What are the alternatives to sutures for wound closure?

Alternatives to Sutures for Wound Closure

While tissue adhesives (cyanoacrylates) and staples exist as alternatives to sutures, sutures remain the superior choice for most wound closures due to significantly lower dehiscence rates and equivalent cosmetic outcomes. 1

Primary Alternatives Available

Tissue Adhesives (Cyanoacrylates)

• 2-octyl cyanoacrylate (Dermabond) is the most commonly used tissue adhesive alternative, offering advantages of no suture removal, water resistance, and faster application time 2, 3
• However, tissue adhesives carry a significantly higher risk of wound breakdown (RR 3.35; 95% CI 1.53-7.33), meaning you must treat 43 patients with sutures instead of adhesives to prevent one additional dehiscence 1
• Cosmetic outcomes are equivalent between tissue adhesives and sutures when assessed by both patients and surgeons in most studies 4, 5
• Application time is faster with adhesives, and patients report higher satisfaction due to easier wound care and no suture removal 5

Staples

• Staples represent another alternative but demonstrate inferior outcomes compared to subcuticular sutures, with one study showing 10.0% SSI rate with stapling versus 1.8% with continuous subcuticular sutures (P < 0.01) 6
• Staples are faster to apply but require removal and generally produce less favorable cosmetic results 6

Adhesive Strips (Steri-Strips)

• Adhesive strips do not reduce SSI incidence when used alone or as adjuncts to sutures 6
• Adding steri-strips to subcuticular sutures shows no improvement in scar width (mean 1.1 mm for both methods, P = 0.89) or cosmetic outcomes 7

When Sutures Are Mandatory

You must use sutures in the following clinical scenarios:

• High-tension wounds where mechanical forces are significant, as tissue adhesives consistently fail in these areas 1
• Contaminated or infection-prone wounds, where triclosan-coated antimicrobial sutures reduce SSI risk (OR 0.72; 95% CI 0.59-0.88) 1
• Deep wounds requiring subcutaneous closure, as adhesives only work for superficial approximation 3
• Total ankle arthroplasty and similar high-risk orthopedic procedures, where Dermabond Prineo showed significantly higher wound complication rates including allergic contact dermatitis and progression to deep infection 8

When Tissue Adhesives Are Acceptable

Tissue adhesives may be considered for:

• Small, superficial lacerations under minimal tension in patients with normal wound healing capacity 4, 3
• Pediatric patients who readily accept being "glued" and benefit from avoiding suture removal 3
• Wounds where subcutaneous sutures have already been placed for deep closure, with adhesive used only for final skin approximation 3
• Patients requiring water-resistant coverage who need early return to activities 2

Critical Pitfalls to Avoid

• Never use tissue adhesives alone in emergency laparotomy or abdominal wall closures, as these require proper suture technique with 4:1 suture-to-wound length ratios 1
• Do not apply adhesives to wounds under significant tension, as the dehiscence rate becomes unacceptably high 1
• Avoid adhesives in areas prone to moisture or movement where the bond may fail prematurely 3
• Be aware of allergic contact dermatitis risk with cyanoacrylate products, which can progress to deep infection 8
• Recognize that rapidly absorbable sutures increase incisional hernia rates compared to slowly absorbable materials retaining 50-75% tensile strength after one week 1

Optimal Technique When Using Sutures

When sutures are chosen (which should be most cases):

• Use continuous subcuticular technique, which significantly reduces superficial wound dehiscence (RR 0.08; 95% CI 0.02-0.35) compared to interrupted sutures 6, 1
• Select slowly absorbable monofilament sutures such as 4-0 poliglecaprone or 4-0 polyglactin that retain 50-75% tensile strength after one week 6, 1
• Maintain a suture-to-wound length ratio of at least 4:1 to minimize incisional hernia and wound complications 1
• Avoid tightly pulling continuous sutures, as this can strangulate wound edges and compromise healing 6, 7

Post-Closure Monitoring Requirements

• Monitor all closures for signs of infection including increasing pain, redness, swelling, or discharge regardless of closure method 1, 7
• Watch for wound dehiscence particularly in the first 7-10 days, which is the critical period for wound support 1, 9
• Remove non-absorbable sutures or staples within 7-10 days to prevent suture track scarring 9