What suturing techniques should be used for different skin lacerations based on tension, edge eversion, and cosmetic outcome?

Suturing Techniques for Skin Lacerations

Use continuous subcuticular sutures with absorbable material (4-0 poliglecaprone or polyglactin) for most skin closures to minimize wound dehiscence while achieving equivalent infection rates and superior cosmetic outcomes compared to interrupted techniques.

Primary Recommendation Based on Strongest Evidence

The 2020 WSES guidelines provide clear, evidence-based direction for wound closure technique selection 1. Continuous subcuticular sutures significantly reduce superficial wound dehiscence (RR 0.08; 95% CI 0.02 to 0.35) compared to interrupted sutures, with no difference in surgical site infection rates or hospital stay 1. This represents Grade 1B evidence (strong recommendation, moderate-quality evidence from RCTs with some limitations).

Key Technical Specifications

Suture Material Selection:

• Use 4-0 poliglecaprone or 4-0 polyglactin for continuous subcuticular closure 1
• These materials retain 50-75% tensile strength after 1 week in situ 1
• This extended support period is the primary mechanism preventing dehiscence 1
• For optimal scar suppression, polydioxanone (3-month tension maintenance) outperforms polyglactin acid (1-month maintenance) at 6 months 2

Avoid nonabsorbable sutures like polyester despite their prolonged tension maintenance—they induce enhanced local inflammation that neutralizes anti-scarring benefits 2.

Algorithm for Technique Selection

Step 1: Assess Wound Tension

Low-Tension Wounds (face, scalp, areas with good tissue mobility):

• Continuous subcuticular suture with 4-0 absorbable material 1
• Alternative: Tissue adhesives are acceptable and faster, with equivalent cosmetic outcomes 3, 4
• Tissue adhesives show similar infection/dehiscence rates but significantly reduced closure time 4

High-Tension Wounds (trunk, extremities, areas under mechanical stress):

• Mandatory: Buried dermal sutures first to approximate edges and reduce tension 3
• Then: Continuous subcuticular closure for skin 1
• Critical pitfall: Avoid tightly pulled continuous sutures—they strangulate wound edges and compromise outcomes 1

Wounds with Poor Edge Approximation:

• Place interrupted deep sutures to achieve edge approximation
• Follow with continuous subcuticular closure 3
• May require temporary interrupted sutures removed after adhesive application 3

Step 2: Anatomic Location Considerations

Facial Lacerations:

• Continuous subcuticular technique with layered closure produces favorable aesthetic outcomes 5
• Tissue adhesives are particularly effective for facial wounds with low tension 4
• Mean satisfaction scores of 8.65/10 achieved with proper technique 5

Trunk and Extremities:

• Subcuticular closure demonstrates superior aesthetic outcomes versus simple interrupted or running sutures 6
• 12 of 15 studies in systematic analysis confirmed subcuticular superiority 6

Evidence on Edge Eversion

Do not prioritize wound eversion as a primary goal. A prospective randomized split-scar trial found no significant difference in observer POSAS scores between everted (13.59 at 3 months, 12.26 at 6 months) versus planar closures (12.91 at 3 months, 12.98 at 6 months) 7. Patient assessments similarly showed no benefit. This contradicts traditional teaching but represents high-quality prospective evidence.

What NOT to Do

Steri-strips and tissue adhesives as adjuncts:

• Do not add steri-strips over buried dermal sutures—they provide no benefit for cosmetic outcomes or scar width (both methods: 1.1mm scar width, P=0.89) 1
• No reduction in infection, dehiscence, or abscess formation 1
• Grade 1B evidence against routine use 1

Interrupted transcutaneous sutures:

• Inferior to subcuticular technique for dehiscence prevention 1
• Require removal at 7-9 days, eliminating wound support during critical healing phase 1
• Use only when continuous technique is technically impossible

Tissue adhesives alone for high-tension wounds:

• Low-quality evidence shows sutures significantly better than adhesives for preventing dehiscence (RR 3.35; 95% CI 1.53-7.33) 1
• Reserve adhesives for low-tension wounds or as adjunct after tension-reducing sutures 3

Critical Technical Points

1. Tension management is paramount: Prolonged tension reduction (3 months) produces superior scar suppression compared to shorter duration (1 month) 2

2. Avoid inflammatory suture materials: Polyester's inflammation neutralizes anti-scarring benefits despite maintaining tension 2

3. Layered closure technique: For wounds under tension, place deep sutures first, then superficial continuous subcuticular layer 3, 5

4. Infection rates are equivalent: SSI rates show no significant difference between continuous (RR 0.73; 95% CI 0.40-1.33) and interrupted techniques 1

5. Scar management adjuncts: Silicone therapy adherence independently predicts satisfaction (OR 5.42; 95% CI 1.10-26.81) 5

Quality of Evidence Considerations

The guideline evidence is Grade 1B (strong recommendation, moderate quality) based on Cochrane meta-analysis of 5 RCTs with 827 participants 1. While most studies involved pediatric appendectomy patients, the principles apply broadly to surgical wound closure. The evidence has "high grade of uncertainty" per the meta-analysis authors 1, but represents the best available data and forms the basis for international surgical society recommendations.

The split-scar study on eversion 7 provides higher-quality evidence (prospective randomized design, validated POSAS instrument) specifically addressing cosmetic outcomes, though from a single center.