Chapter 45

The major goal of wound closure is to restore the skin’s integrity in order to reduce the risk of infection, scarring, and impaired function. This may be achieved by one of three methods. With primary closure, the wound is immediately closed by approximating its edges. The main advantage of primary closure is a reduction in healing time in comparison with other closure methods. Rapid wound closure also may reduce bleeding and discomfort often associated with open wounds. Secondary wound closure, in which the wound is left open and allowed to close on its own, is particularly well suited for highly contaminated or infected wounds as well as in patients at high risk of infection. Although this method may reduce the risk of infection, it is relatively slow and uncomfortable and leaves a larger scar than primary closure. Delayed primary (or tertiary) closure combines the advantages of both primary and secondary closure. With this method, the wound is initially cleansed and then packed with dry sterile gauze followed by a sterile covering. The dressing is left undisturbed unless signs of infection develop: fever, purulent exudate, or spreading cellulitis. After 4 to 5 days, the dressing is removed and the wound edges can be closed if no infection has supervened. This may be useful for highly contaminated wounds and animal bites, especially with extensive wounds.

A small study of simple hand and finger lacerations challenges the principle of primary closure for all lacerations.1 Small (<2 cm) uncomplicated hand wounds randomized to conservative treatment with antibiotic ointment and gauze dressing (“secondary closure”) healed as fast and with no notable differences in appearance or function as those closed primarily with sutures.1 However, as this study was limited to short, superficial hand lacerations, it cannot be widely recommended for larger lacerations and in other sites.

Lacerations may be closed by one of four commonly available methods or devices: sutures, staples, adhesive tapes, or tissue adhesives. Each method has advantages and disadvantages (Table 45-1). Choice of the wound closure method and timing should take into account both patient and wound characteristics (Table 45-2). Cosmetic outcome is more closely related to practitioner technique and the patient’s own healing characteristics than to any specific closure method or device.

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