Closure of Skin Wounds With Sutures
22
Offic ial repr int f rom UpToDate ® www.uptodate.com ©201 2 UpT oDat e ® Author David deLemos, MD Section Editors Anne M St ack, MD Allan B Wolfson, MD Deputy Editor James F Wiley, II, MD, MPH Closure of skin wounds with sutures Disclosures All topics are up dated as new ev idence becomes av ailable an d our peer review process is complete. Literature revie w curr ent throug h: Sep 2012. | This topic last updated: oct 19, 2011. INTRODUCTION — The basic principles of laceration repair have not changed significantly in the last century, but the therapeutic options now available are more innovative and rigorously studied. The development of topical anesthetics, tissue adhe sives, and fa st -ab sorbing sutures has made the management of lacerations less traumatic fo r the patient. In addition, the use of procedural sedation for difficult lacerations or for the extremely anxious child has made the experience more tolerable for the patient, family, and physician. The goals of wound management are simple: to avoid wound infection, assist in hemostasis, and to provide an esthetically pleasing scar [ 1]. The majority of studies now are focusing on the esthetic nature of wound healing rather than infection rates, because infection rates remain low, regardless of management. Laceration repair with sutures will be discussed here. Information concerning wound preparat ion and irrigation, topical and infiltrativ e anesthesia, and tiss ue adhesive an d st aples is found separately. (See "Closure of minor skin wounds with staples" and "Minor wound preparation and irrigation" and "Superficial wound repair with tissue adhesives" .) WOUND PH YSIOLOGY A ND HE ALING — The epidermis, dermis, subcutaneous layer, and deep fascia are the tissue layers of concern in wound closure [ 2]: The epidermis and dermis are tightly adhered and clinically indistinguishable, and together constitute the skin. Dermal approximation provides the strength and alignment of skin closure. T he subcutaneous layer is mainly comprised of adipose tissue. Nerve fibers, blood vessels, and hair f ollicles are located here. Although this layer provides little strength to the repair, sutures placed in the subcutaneous layer may decrease the tension of the wound and impro v e the c osmetic result. The deep fascial layer is intermixed with musc le and occ asionally require s repair in deep lacerations. The healing process of skin occurs in several s tages [ 3]: Coag ulation begin s immediately follow ing the injury. Vasos pasm as well as platelet aggre gation and fib rous clot for mation occ ur. During the infla mmatory phase, pro teolyti c enzymes relea sed by neutro phils and macrophag es break down damaged tissue. Epithelializati on occurs in the epidermis, which is the only layer capable of re gene ration. Complete bridg ing of the wound occurs within 48 hours after suturing. New blood vessel growth peaks four days after the injury. Collagen formation is necessary to restore tensile strength to the wound. The process begins within 48 hours of the injury and peaks in the first week. Collagen production and remodeling continue for up to 12 months. Wound contraction occurs three to four days following the injury, and the process is poorly understood. The full wound thickness moves toward the center of the wound, which may affect the final appearance of the wound. Systemic disturbances can influence wound healing. These host factors include renal insufficiency, diabetes mellitus, nutritional
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Transcript of Closure of Skin Wounds With Sutures
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