Surgical wound closure

What is surgical wound closure?

Surgical wound closure refers to a spectrum of techniques used to close wounds — whether inflicted by trauma or surgery — and minimise complications such as dehiscence, infection, and poor cosmesis.

The most common approach is primary closure (or healing by primary intention), which directly approximates wound edges using sutures, surgical staples, or adhesives.

Reconstructive surgeons often consider the ‘reconstruction elevator’ (previously the ‘reconstructive ladder’), which outlines wound closure options from simple to complex, moving up the hierarchy only as necessary:

For information on skin flaps and skin grafting, see their respective pages.

Defect after skin cancer excision 

An advancement flap wound closure 

What are the indications and contraindications for wound closure?

Clinicians should consider wound depth and the potential for damage to underlying structures (eg, nerves, joints, tendons, fascia, major vessels) before proceeding with closure. Concerns regarding function, sensation, or local blood supply should prompt referral to the appropriate speciality.

Wound closure concerns in the community setting may require referral to tertiary care eg, emergency medicine or plastic surgery.

Simple clean wounds

Most simple clean wounds can be approached with primary closure or healing by secondary intention.

Primary closure

• Indicated for uncontaminated wounds with minimal tissue loss and where the edges can be easily approximated (ie, can be pinched together with ease).
• Contraindicated for contaminated wounds, defects with extensive tissue loss, and wounds where the edges cannot be approximated without undue tension.
• Sutures are preferred for cosmetically sensitive areas, whereas surgical staples can be used on cosmetically insensitive areas, such as the scalp and abdomen. 



Secondary intention healing

• Indicated for small, superficial abrasions and lacerations as well as certain concave facial structures eg, nasolabial fold, nasal alar crease, medial canthus, conchal bowl.
• Contraindicated for mobile areas (eg, joints) and flat facial areas, as this can result in unacceptable scarring and contractures.

Contaminated wounds

Traumatic wounds are often contaminated as a result of the injury. This can be due to direct trauma from foreign objects, environmental debris, or pathogen-contaminated implements, such as teeth and animal claws.


Preparatory steps

• Contaminated wounds should not be closed directly, as this can seal in pathogens and cause infection.
• Contaminated wounds must be cleaned before closure eg, irrigation, removal or debridement of visible contaminants and foreign bodies.
• Tetanus status should be assessed in a patient with tetanus-prone wounds:
  • Contamination with soil, dust, or manure
  • Penetrating or puncture-type wounds eg, nails, needles, animal bites, thorns
  • Wounds with devitalised tissue eg, burns, crush injuries, contusions.

Delayed primary closure

Following decontamination, the wound can undergo delayed primary closure. This involves leaving the wound open for a brief waiting period (often 3–5 days) before the wound edges are surgically approximated. The delay allows for natural host defences to reduce bacterial load and for non-viable tissue to declare itself for debridement.

Secondary intention healing

Abscess cavities or other purulent wounds are purposely left open to heal by secondary intention to facilitate ongoing drainage.

How is surgical wound closure performed?

Important principles should be adhered to during wound closure for optimal outcomes:

• There should be minimal tension on the wound to prevent tensile forces pulling on both the sutures and healing skin.
  • A 2-layer closure approach can prevent this: dissolvable sutures are placed in the deeper dermal layer to bear tension, and superficial sutures approximate the epidermis under minimal tension.
• If the wound remains under tension or the skin is fragile, tension can be distributed over a larger area with horizontal mattress sutures.
• An elliptical excision pattern avoids bunching of skin at either end of the wound (a standing cone, or 'dog-ear') and produces a straight-line scar.
• Wound edge eversion is traditionally recommended as this is thought to counteract the contractile nature of the healing scar and prevent depression of the final scar.
• If the wound edges cannot be opposed without undue tension, other techniques can be employed eg, skin grafting or flaps.
• Vacuum-assisted closure (VAC) can promote granulation and prepare a wound bed for closure.

For more information, see: suturing techniques.

What are the benefits of surgical wound closure?

• Primary closure is a simple, cost-effective procedure that reduces healing time and avoids the donor-site morbidity associated with flaps and grafts.
• Primary closure typically produces a thinner, neater scar than leaving a wound to heal by secondary intention.
• Skin glue and adhesive strips, unlike sutures and staples, do not require local anaesthetic and can be applied quickly, making them particularly useful on young children.
• Skin tension can be adjusted to prevent unacceptable healing outcomes eg, a contraction scar on a sensitive area such as the eyelid.
• Coverage over underlying tissues prevents contamination and infection.

What are the disadvantages of surgical wound closure?

Selecting the suboptimal closure technique can lead to complications with the wound itself:

• Primary closure on wounds with inadequate recruitable tissue can result in unsatisfactory scarring or wound breakdown.
• Closure of a contaminated wound can result in infection.

Secondary intention healing has its own disadvantages:

• Wounds take considerably longer to heal than with primary closure.
• Resultant scarring is often larger than surgically closed wounds.
• It can be labour-intensive, requiring frequent dressing changes and good wound care to prevent infection.

What are the side effects and risks of surgical wound closure?

• Wound infection
• Wound dehiscence
• Pain and bleeding
• Scarring and cosmetic concerns
• Occasional allergic contact dermatitis to acrylate adhesives in glues and adhesive strips

Risk factors for wound infection and dehiscence:

• Closure under tension
• Advanced age or malnutrition
• Smoking
• Use of topical or systemic steroids
• Immunosuppressive drug therapy
• Diabetes mellitus
• Peripheral arterial disease.