Closing surgical wounds: how is it done?

[Josephine]

Wounds are closed in 'layers' each with several stitches meaning
1. the joint capsule is closed then
2. the muscle
3. the fascia - which is a white, fibrous outside layer of the muscle
4. the fat
5. the sub-dermal layer of the skin - meaning the 2-3mm immediately below the skin
6. and finally the outside skin

As a recap:
2, 3 are the main anchors that holds the wound closed
5 is the one that holds the skin closed.
6 is mostly cosmetic, probably unnecessary, and may either be further closed with surgical glue, sutures, staples or Steristrips

Also
1-4 are closed with absorbable sutures
5 is closed with a single long stitch that runs the length of the wound called either subdermal or subcuticular.

Skin staples
These are made of inert wire, usually titanium, about 0.5mm thick. With the correct applicator and removal instrument they are easily formed for insertion and removal.

The construction of the staple is a unique design that folds up and ultimately makes a box shaped 'stitch' which holds the skin edges together but slightly elevated from the natural level (see image)

When they are removed, a special instrument is used bends the staple into an M shape, thus making the legs open up and be at right angles to the skin. They can then be lifted out without pain or discomfort. However, occasionally, when the wound swells, they can be a little buried and this can be a bit painful.

Subcuticular stitch
Here you can see the stitch being place after which the surgeon will pull both ends and the skin edges will be drawn together. Mostly an absorbable suture material is used so there's nothing to be taken out. But once in a while, a surgeon might choose to use a fine monofilament nylon which has to be removed. For many, many years, once the skin was closed with this stitch, we'd do nothing more, not even a dressing! Just a spray of plastic skin to seal it, specially for heart and chest surgery.

Here is another version where the stitch is of monofilament nylon and is knotted at each end. The ridge of skin is made by the surgeon when he stitches the wound closed. For removal, the knots are each end have to be removed and the nylon thread gently pulled out.

This is the removed subcuticular suture

Nowadays, the closed wound gets covered with Steristrips either straight away or after suture or staple removal.

I've seen people get blisters from Steristrips but this is usually due to improper application of them. They are supposed to be simply laid on the wound and patted into place but sometimes staff will stick one end down and apply traction before sticking the other end down, in the mistaken attempt to hold the wound closed. All this does is cause blistering of the skin similar to this

Interrupted sutures
A variant on this is that the surgeon may either not use fat stitches at all or only a few interrupted (single) stitches.

Glue closure of skin
Skin can also be closed with a 'glue' called Dermabond (Cyanoacrylate).

another new type of wound closure is the “Zip” Surgical Skin Closure which means no stitches and no staples! It's very flexible but the big downside to me is the adhesive. Some people's skin doesn't take kindly to this stuff - mine for example!

Open or infected stitches

Should a stitch/staple or two come out too soon, it may well result in open patch of the wound which may even become inflamed, bloody or infected looking but it will usually be superficial and look a lot worse than it really is. Anything up to the size of the end of your little finger is really nothing at all to be concerned about. Keep clean, cover with a sterile dressing gauze (not cotton wool (which can leave fibres that can exacerbate risk of infection) and no creams that haven't been prescribed by your OS). Get to see your OS as soon as you can and he'll effect a temporary closure with some Steristrips. Simple!

Emerging stitches
Another small complication is the emergence of a stitch end from the wound. People get very alarmed about this but like the stitch abscess, it's really a minor issue.

When it happens, it's just because an internal suture hasn't been cut as short as it should have been (and we're talking below 5mm here) so though the long bit might be tucked down inside the wound at first, it gradually straightens out and peeps out of the wound. If that should happen, the patient will be aware of the thread, which feels stiff and prickly because it's soaked with dried blood and feels like the end of a guitar string! Treatment is to have a nurse or PA snip the end off with sterile scissors so the wound can heal or to remove the stitch completely.

Here is a close up of a stitch showing in a wound - it's the white fabric marked with the red arrow