How to manage a laceration that is too wide for sutures (stitches)?

Management of Wide Lacerations

For lacerations too wide for primary suture closure, use undermining of wound edges combined with deep dermal sutures to reduce tension, followed by either delayed primary closure, tissue adhesives for low-tension areas, or allowing healing by secondary intention if closure remains impossible. 1, 2

Initial Assessment and Preparation

• Ensure adequate lighting and anesthesia before attempting any repair—use local infiltration with lidocaine (with or without epinephrine up to 1:100,000 concentration for digits) or consider regional/general anesthesia for extensive wounds 3, 4
• Thoroughly irrigate the wound under pressure with potable tap water or sterile saline to remove debris and reduce bacterial load 4, 5
• Examine the wound depth to identify involvement of deeper structures (muscle, tendon, nerve, or bone) that may require specialized repair 1, 5
• Obtain radiographs if foreign body retention is suspected, though not all foreign bodies are radiopaque 1, 5

Techniques for Wide Lacerations

Undermining and Tension Reduction

• Perform wide undermining of the wound edges at the dermal-subcutaneous junction to mobilize tissue and allow approximation of edges that initially appear too far apart 1, 2
• The dermis provides the skin's greatest tensile strength, so accurate approximation of the entire dermal depth is critical for wound integrity 1
• Undermining is particularly effective for wounds on the trunk, extremities, and scalp where tissue mobility exists 2

Deep Dermal (Buried) Sutures

• Place deep dermal sutures using absorbable monofilament material (poliglecaprone or polyglyconate) to reduce surface tension and support the wound infrastructure 3, 1
• Lay buried sutures beside the wound without tying until surface approximation is achieved—this ensures adequate support without excessive tension 2
• Deep sutures should approximate the full thickness of the dermis to dermis, as fat and muscle do not hold sutures reliably 1

Pulley Sutures

• Use pulley (far-far-near-near) sutures for wounds with significant tension to mechanically advantage the closure and bring distant edges together 2
• This technique is particularly useful for scalp lacerations and wounds over convex surfaces 2

Alternative Closure Methods

Tissue Adhesives

• For low-tension areas where edges can be approximated to within 5mm, tissue adhesives (cyanoacrylate) provide equivalent cosmetic outcomes with less pain and faster application time compared to sutures 3, 4
• Tissue adhesives are contraindicated in high-tension areas, over joints, or where edges cannot be manually approximated 4, 6
• Application time averages 2.29 minutes versus 7.88 minutes for suturing (P<0.001) 3

Partial Closure

• When complete closure creates excessive tension, perform partial closure of the deep layers and allow the remaining superficial defect to heal by secondary intention 2
• Partial closure decreases wound size, shortens healing duration, and keeps scars within single cosmetic units 2
• This approach is preferable to forcing closure under tension, which increases dehiscence and infection risk 2

Secondary Intention Healing

• Allow wounds to heal without closure when: located in concave areas (medial canthus, nasolabial fold), contaminated/infected, or when closure would distort free margins 2, 5
• Apply occlusive or semi-occlusive dressings to maintain moist wound environment and accelerate healing 4

Timing Considerations

• No definitive "golden period" exists—wounds may be safely closed up to 18+ hours after injury depending on location, contamination level, and vascularity 4
• Well-vascularized areas (face, scalp) tolerate longer delays before closure 4
• Heavily contaminated wounds or those in poorly vascularized areas should be considered for delayed primary closure (3-5 days after injury) 5

Common Pitfalls

• Avoid placing full-thickness sutures except on palmar and plantar surfaces—these increase infection risk and cause unnecessary pain 1
• Do not attempt to close wounds under excessive tension, as this leads to tissue ischemia, necrosis, and dehiscence 3, 2
• Epidermis-only sutures provide cosmetic benefit but no tensile strength—always secure the dermis first 1
• Fat and muscle layers do not hold sutures and should not be relied upon for wound support 1

Post-Repair Management

• Immobilize wounds near joints or extensive repairs with splints or slings to reduce tension during early healing 1
• Examine wounds 2-3 days post-repair for signs of infection (increasing pain, erythema, purulent drainage) 1, 5
• Provide tetanus prophylaxis if indicated based on immunization history and wound characteristics 4, 5
• Consider prophylactic antibiotics only for high-risk wounds (human/animal bites, heavily contaminated, or involving cartilage) 6, 5