Wound closure is an important step in wound healing. Proper closure techniques help aid the body’s natural process and promote faster healing.
There are three types of wound closure methods to consider based on how the wound is presented. These include primary intention, secondary intention, and tertiary intention. Primary closure is the most rapid wound healing and usually results in a good cosmetic result. It occurs when the edges of a wound are closely approximated and this ensures that keratinocytes and new blood vessels travel across the linear wound very quickly. This type of healing is best with wound closure where the edges are able to be approximated by sutures, staples, skin adhesive or Steri-Strips. These methods lower the risk of infection and help the wound to heal more rapidly and with less scarring. Wounds where the edges cannot be approximated by sutures or staples, such as pressure wounds or those with curved or uneven margins, often need to be healed by secondary intention. This involves a wound which is left open for a period of time and then filled with granulation tissue to contract the wound edges and epithelialization occurs. This is the most common method of wound closure in surgical procedures. It is also used for some wounds caused by trauma where the wound edges have become too inflamed, colonized or necrotic to be re-approximated by sutures or staples. Wounds are often closed by doctors using staples, sutures or adhesive glue to bring the wound edges together. This reduces the amount of tissue that is lost and enables the body to focus on healing over a smaller area. However, there are some wounds that cannot be stitched. These are called secondary wounds. Doctors may also leave a wound open to allow the body to heal naturally in these cases. In wounds that are left open by secondary intention, a granulation tissue matrix is created to fill the gap between the dermal edges of the wound. This process is slow and involves an intense inflammatory phase. The wound contraction that occurs in 2nd intention wounds originates from modified smooth muscle cells (myofibroblasts) that contain actin and myosin and act to decrease the space between the dermal edges. This contraction is then followed by the migration of epithelial cells to fill the defect. Surgeons rely on 2nd intention healing to close many challenging wounds. These include moderate-sized wounds involving the trunk, and smaller problematic wounds that involve the extremities. The tertiary intention of wound closure is when the physician leaves the wound open to granulate and heal before closing it with sutures or staples. This may be done when there is a traumatic injury that involves deeper lacerations, or if there is an infection expected or suspected. In this type of wound, there is a large amount of tissue loss in the area and a granulation tissue matrix must be built to fill the wound. The healing process takes longer than in wounds that are healed by primary intention. These wounds also need to undergo a process called wound contraction which helps lessen their size. This can be difficult for certain types of wounds, like a pressure ulcer or diabetic foot, whereas it is an important part of the healing process. In this type of wound, the skin needs to heal through a process called full thickness wound healing which includes granulation, contracting, and epithelialization. This is a slower process that requires daily attention to help the skin heal properly.
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