Background Information:

What are the other Names for the Procedure?

• Second Intention Healing
• Suturing a Wound Closed

What is Wound Closure surgical procedure?

• Wound Closure is a procedure used to get an open skin wound closed
• Closing a traumatic wound or a surgically induced wound speeds healing time, can help lower the infection rate and generally leads to better cosmetic outcomes
• Flaps and grafts are also used to close wounds. In certain circumstances, Second Intention Healing is used instead of an active closure process

Second intention uses the natural process of wound healing that takes place in injured animals and healed human wounds, before primitive medical/surgical interventions. At times, Second Intention Wound Healing is preferable to active methods of Wound Closure.

What part of the Body does the Procedure involve?

The Wound Closure procedure involves any wound on the body surface.

Why is the Wound Closure surgical procedure Performed?

There could be a variety of reasons for performing the Wound Closure procedure. Some of these include:

• To close a traumatic injury of the skin
• To close a surgical incision of the skin
• For deeper traumatic and surgical wounds, involving bone, muscles, and internal organs - these injuries take precedence. After repairing the deeper injuries, the skin is addressed

What are some Alternative Choices for the Procedure?

Some of the alternative choices for Wound Closure include:

• Skin grafting
• Flap closure
• Second intention wound healing

What are the Recent Advances in the Procedure?

Some of the recent advances include new suture materials, as well as the use of staples and methacrylate glues instead of sutures.

What is the Cost of performing the Wound Closure surgical procedure?

The cost of the Wound Closure procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Wound Closure procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.aad.org/ (accessed on 05/16/2021)

Prior to Wound Closure surgical procedure:

How is the Wound Closure surgical procedure Performed?

The Wound Closure procedure is performed in the following manner:

• Suturing a wound closed, whether a traumatic defect or as a result of surgery, should be done in a sterile manner
• Certain traumatic wounds have a high risk of infection, so they should not be sutured shut until they are clean and clear of foreign matter. This would include human bites, animal bites, and any other significantly contaminated wound
• Bleeding must be controlled with electrocautery or sutures, as bleeding into the deep wound space inhibits healing and increases the risk of infection
• Besides infection, deeper tissue damage, and bleeding considerations, the wound is evaluated regarding the ultimate functional and cosmetic aspect of the closure
• Defects in thicker skin are repaired in two layers
  • First, sutures are placed deep in the dermis and tied. These sutures are made of material that will be digested by the body’s healing process
  • These are called absorbable sutures and are not removed. These absorbable sutures perform the majority of the process of restoring the skin to its proper original position
  • A superficial layer of sutures is placed to finesse the fine orientation of the skin surface
• Depending on the circumstances evaluated by the healthcare provider, sterile methacrylate skin glue or staples may also be used

It is important to keep all appointments for wound care.

Second Intention Wound Healing is a process of informing the patient or caregiver of the optimal manner of promoting rapid healing.

• Each individual surgeon might have variations in their Second Intention Healing protocol
• In principle, moist healing is faster and preferable to leaving wounds open to develop a dry crust, or ‘scab’
• Petrolatum or a similar substitute is often used to keep the living cells on the surface moist, so they continue growing upward to fill the defect
• “If It Dries Out, It Dies Out”, and so a dressing is applied over the moistening layer
• The duration between opening, cleansing, and redressing the wound will be prescribed
• Topical antibiotics are not often used, because the percentage of people allergic to the antibiotic component is high. Allergic reactions inhibit healing

Where is the Procedure Performed?

The Wound Closure procedure is usually performed in a clinic, urgent care center, hospital emergency department, outpatient or inpatient surgical procedure suite.

Who Performs the Procedure?

The Wound Closure procedure is usually performed by a qualified physician, physician assistant, advanced practice nurse, or other trained personnel.

How long will the Procedure take?

The Wound Closure procedure usually takes variable times, depending on the extent of the wound to be closed. For a small, planned dermatology procedure, for example, after excisional biopsy of a cyst or s mole (nevus), the closure takes about 15 minutes.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• For traumatic injuries, provide an accurate and honest report regarding the circumstances
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• Any medical or family history of bleeding disorders or blood clots
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• Any unusual effects of anesthesia from prior surgery
• A list of all previous surgical procedures you have undergone, like for example - removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Avoid application of any deodorant or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the procedure
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications being taken) with their attending physician well in advance
• For individuals with diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

Pregnant women and individuals with severe underlying sicknesses are informed to advise the surgical team of their status.

What is the Consent Process before the Procedure?

The physician will obtain permission for the Wound Closure procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Wound Closure surgical procedure?

In many cases, no tests are typically necessary prior to the Wound Closure procedure. However, if required, the healthcare provider may recommend the following tests such as:

• Blood and urine tests
• Imaging studies 
• Other tests and exams as indicated in the situation

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

• What is a Wound Closure procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Wound Closure surgical procedure:

What kind of Anesthesia is given, during the Procedure?

• Local anesthesia by injection is used for small Wound Closure procedures
• For Wound Closure after trauma, anesthesia will be tailored to the individual circumstances

How much Blood will you lose, during the Procedure?

There is not much blood loss during an uncomplicated Wound Closure procedure.

What are the possible Risks and Complications during the Wound Closure surgical procedure?

There are general factors that increase one’s risk of getting complications during the Wound Closure procedure, which include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during a Wound Closure procedure include:

• Infection
• Bleeding
• Injury to the neighboring structures
• Pain
• Discomfort
• Anesthetic complications
• Need for further procedures
• Heart problems

Please note that the complication and risks that may arise during the surgery is governed by factors such as the underlying health of the patient.

What Post-Operative Care is needed at the Healthcare Facility after the Wound Closure surgical procedure?

• At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise
• However, immediately following the surgery, the patient will be observed until they are able to ambulate and return home

After the Wound Closure surgical procedure:

What are the possible Risks and Complications after the Wound Closure surgical procedure?

The risks and complications that may arise after Wound Closure include:

• Excessive bleeding that may sometimes require an additional surgical procedure
• Any symptom that causes uneasiness such as nausea and dehydration
• Low-grade fever
• Infection of the surgical wound
• Poor functional or cosmetic outcomes

What is the Prognosis after the Surgery?

In many cases, the prognosis after a Wound Closure procedure is typically excellent.

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Fever and chills
• Severe pain
• Shortness of breath
• Bleeding or fluid discharge from the surgical wound
• Nausea and vomiting
• Signs of infection
• Severe fatigue
• Dizziness

What Post-Operative Care is needed at Home after the Wound Closure surgical procedure?

At home, the following post-operative care is recommended after a Wound Closure procedure:

• Use a cold pack over the dressing to relieve pain due to the incision
• Follow the written wound care instructions given by the surgeon
• Take the prescribed medications following the procedure
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue old prescribed medications after checking with your healthcare provider
• Avoid sex until complete healing has taken place (under advice by the physician)
• Do not sign any legal documents post-procedure for a period of 24 hours
• Return for suture removal or other wound healing appointments

Consult with your surgeon before deviating from their instructions. Advice from non-professionals is meant well but at times may be incorrect.

How long does it normally take to fully recover, from the Procedure?

The recovery time usually depends on the extensiveness of the surgery. Simple procedures have shorter recovery periods. 

• Sutures are removed at different times based on location of the wound. The ultimate wound strength brought about by new collagen production is generally at 4 weeks
• Second Intention Healing takes weeks to two months, depending on the depth and extent of the defect. Initial healing is slower, with more rapid, notable improvements observed later

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

The procedure does not involve the surgical removal of any tissue.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is removed during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Wound Closure surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The dermatologist
• An anesthesiologist (if anesthesia was administered)

The patient is advised to inquire and confirm the type of billing before the Wound Closure procedure is performed.