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Alternative Methods of Wound Closure
Steri-Strips
Wound closure tapes, or Steri-Strips, are reinforced microporous surgical adhesive tape. Steri-Strips are used to provide extra support to a suture line, either when running subcuticular sutures are used or after sutures are removed.
Wound closure tapes may reduce spreading of the scar if they are kept in place for several weeks after suture removal. Often, they are used with a tissue adhesive. Because they have a tendency to fall off, they are used mainly in low-tension wounds and rarely for primary wound closure.
Staples
Stainless steel staples are frequently used in wounds under high tension, including wounds on the scalp and trunk. Advantages of staples include quick placement, minimal tissue reaction, low risk of infection, and strong wound closure. Disadvantages include less precise wound edge alignment and cost.
Tissue adhesive[13, 14, 15]
Superglues that contain acrylates may be applied to superficial wounds to block pinpoint skin hemorrhages and to precisely coapt wound edges. Because of their bacteriostatic effects and easy application, they have gained increasing popularity.[16] They have demonstrated either cosmetic equivalence or superiority to traditional sutures in various procedures, including sutureless closure of pediatric day surgeries, saphenous vein harvesting for coronary artery bypass, and blepharoplasty.[17] [18, 19] The most commonly used adhesive, 2-octyl cyanoacrylate (Dermabond), has also been used as a skin bolster for suturing thin, atrophic skin.[20] Advantages of these topical adhesives include rapid wound closure, painless application, reduced risk of needle sticks, no suture marks, and no removal. Disadvantages include increased cost and less tensile strength (compared to sutures).
The use of tissue adhesives in dermatologic surgery is still evolving. It appears that using high viscosity 2-octyl cyanoacrylate in the repair of linear wounds after Mohs micrographic surgery results in cosmetic outcomes equivalent to those of epidermal sutures.[21]
Greenhill and O'Regan reported on the use of N-butyl 2-cyanoacrylate (Indermil) for closure of parotid wounds and its relationship to keloid and hypertrophic scar formation versus using sutures.[22] Their results indicated a simpler technique and a comparable result. In a related area, Tsui and Gogolewski report on the use of microporous biodegradable polyurethane membranes, which may be useful for coverage of skin wounds, among other things.[23]
Barbed sutures
A barbed suture has been developed and is being evaluated for its efficacy in cutaneous surgery. The proposed advantage of such a suture is the avoidance of suture knots. Suture knots theoretically may be a nidus for infection, are tedious to place, may place ischemic demands on tissue, and may extrude following surgery.
A randomized controlled trial comparing a barbed suture with conventional closure using 3-0 polydioxanone suture suggests that a barbed suture has a safety and cosmesis profile similar to the conventional suture when used to close cesarean delivery wounds.[24]
Barbed sutures have also been used in minimally invasive procedures to lift ptotic face and neck tissue.[25] In a recent study, average patient satisfaction 11.5 months after a thread lift was 6.9/10.[25] By 3 months postprocedure, the skin of the neck and jawline relaxed and the final results became apparent. Overall, the barbed suture lift was determined to provide sustained improvement in facial laxity.[25] However, painful dysesthesias and suture migration distant to insertion site have been reported.[26, 27] Although the long-term efficacy of barbed suspension sutures remains unclear, they may allow for a minimally invasive facial lift with few adverse effects.[28]
Novel punch biopsy closure[29]
Placing sutures lateral to a punch biopsy causes the defect to taper, allowing for a more linear closure and improved cosmetic outcomes. A simple interrupted stitch is placed 1-3 mm lateral to a wound edge, a second stitch is placed 1-3 mm lateral to the opposite wound edge, and a final stitch is placed at the center of the wound. Sites greater than 4 mm may require additional interrupted stitches. Disadvantages include extended procedure time and increased risk of suture marks.
