Continuous Subcuticular Running Sutures Are Preferable to Simple Interrupted Sutures for Skin Closure
Use continuous subcuticular absorbable monofilament sutures (4-0 poliglecaprone or polyglactin) rather than simple interrupted sutures for skin closure to significantly reduce superficial wound dehiscence while achieving comparable or superior cosmetic outcomes. 1
Key Evidence from Guidelines
The 2020 World Society of Emergency Surgery (WSES) guidelines provide clear direction based on meta-analysis of 5 RCTs with 827 participants 1:
Wound Dehiscence (Primary Advantage)
- Continuous subcuticular sutures dramatically reduce superficial wound dehiscence (RR 0.08; 95% CI 0.02 to 0.35) 1
- This represents a 92% relative risk reduction—a clinically significant benefit for patient morbidity
- The mechanism: absorbable subcuticular sutures retain 50-75% tensile strength after 1 week, providing extended wound support beyond the typical 7-9 day period when interrupted sutures are removed 1
Surgical Site Infection (Equivalent)
- No significant difference in superficial SSI rates between techniques (RR 0.73; 95% CI 0.40 to 1.33) 1
- Both methods are equally safe regarding infection risk
Hospital Stay (Equivalent)
- No difference in length of hospital stay between techniques 1
Cosmetic Outcomes (Superior with Continuous)
Recent research supports superior cosmetic results with continuous subcuticular technique:
- Both objective and subjective assessments favor continuous absorbable intradermal sutures 2
- POSAS scores significantly better for continuous technique in patient (p=0.032) and observer scales (p=0.001) 2
- VAS scores superior (p=0.002) 2
- Smaller scar surface area with continuous technique (p=0.002) 2
Practical Implementation Algorithm
Suture Selection
- Material: 4-0 poliglecaprone (Monocryl) or 4-0 polyglactin (Vicryl) 1
- Technique: Subcuticular continuous running suture
- Key advantage: No suture removal required, reducing patient visits and maintaining wound support longer
When to Use Continuous vs Interrupted
Favor Continuous Subcuticular When:
- Clean, clean-contaminated, or contaminated surgical wounds
- Abdominal or groin operations
- Patient compliance with follow-up uncertain
- Desire to minimize postoperative visits
- Cosmetic outcome is important
Consider Interrupted When:
- Extremely high tension wounds where individual suture adjustment needed
- Surgeon unfamiliar with continuous technique
- Specific anatomical constraints
Important Caveats and Pitfalls
Technical Considerations
- Avoid excessive tension: Continuous sutures pulled too tightly can strangulate wound edges 1
- The continuous technique provides better wound seal against bacterial invasion but requires proper tension management 1
Evidence Quality Limitations
The guidelines acknowledge "high grade of uncertainty remains" due to moderate evidence quality 1. However, the consistency of findings across multiple trials and the magnitude of dehiscence reduction support the recommendation.
Adjunctive Measures Not Recommended
- Steri-strips: Do not improve cosmetic outcomes or reduce complications when added to subcuticular sutures 1
- No significant difference in scar width, infection, or dehiscence rates with adhesive strip addition
Suture Spacing
For interrupted subcuticular sutures (if used), spacing of 1 cm vs 2 cm shows no significant cosmetic difference 3, allowing 2 cm spacing for efficiency without compromising outcomes.
Clinical Bottom Line
The evidence strongly supports continuous subcuticular absorbable sutures as the preferred technique. The dramatic reduction in wound dehiscence (92% relative risk reduction), elimination of suture removal visits, comparable infection rates, and superior cosmetic outcomes make this the optimal choice for most surgical closures. The technique requires proper training to avoid excessive tension, but once mastered, provides superior patient outcomes with reduced healthcare utilization.