Non-invasive skin closure alternatives can provide proper wound closure without penetrating the epidermis and dermis, provide surgeon satisfaction and also be cost effective
David Gorsulowsky MD FAAD
Associate Clinical Professor Department of Dermatology,
University of California San Francisco,
Guy Talmor BS, California, USA
The most commonly used methods of skin closure are sutures and staples. However, there are viable alternatives such as tapes and adhesives that can be used as well. The choice of a skin closure modality after surgery involves several considerations. Most importantly, patients and surgeons need to be satisfied with the final result.
Surgeons seek practical, simple modalities that can quickly achieve quality closure. Staples are the standard of practicality, as they are easy to use and allow for rapid closure. Sutures, however, are time-consuming and may require more skill to apply.1
Patient satisfaction is extremely important as well. The shift from fee-for-service based care to value-based care in some countries increases the importance of recognising patient satisfaction. Such satisfaction is based largely upon comfort following surgery. In addition to comfort, adverse events such as excessive discharge, erythema, infection and dehiscence have a negative impact upon patient satisfaction. Secondary factors include cosmetic outcomes, which can affect satisfaction as well. Scar width, wound edge step-off, contour irregularity and wound edge inversion all have prominent negative effects on the overall cosmetic result. Generally, subcuticular sutures may produce the most favourable cosmetic results following surgery. They are also regarded to yield favourable patient satisfaction. Staples are not considered to produce favourable cosmetic results or particularly positive patient satisfaction.2
Lastly, infection rates are a highly influential factor in the choice of a wound closure modality. Healthcare providers today are especially concerned about the incidence of surgical site infection (SSI). Because of an increased length of stay, medication costs and staff time, SSIs have become extremely costly. For example, a recent study found the mean treatment cost for a single SSI following pacemaker procedures to be 146,000 USD.3
In some countries insurance providers no longer offer reimbursement for expenditures related to post-operative infections, further bolstering the drive to reduce infection rates. The choice of wound closure modality has a demonstrable effect on SSI rates and can therefore be used as a means of reducing infection. In reality, neither sutures nor staples are the optimal modalities to reduce SSIs as they are both invasive. They penetrate the epidermis and dermis, forming pathways by which bacteria can penetrate subcutaneous tissue and cause infection. The drive to reduce infection likely requires the consideration of alternative, non-invasive skin closure methods.
Non-invasive wound closure
There are non-invasive alternatives that can provide proper wound closure without penetrating the epidermis and dermis. They include adhesives and tape-based devices that hold the skin together. Studies dating back to the 1960s have validated the notion that non-invasive closure methods can reduce the rate of infection following surgery.4,5 From both a financial and patient welfare standpoint, reduced SSI rates are a significant advantage of non-invasive skin closure modalities. However, these modalities require further analysis before they can be labelled as practical for widespread use. They may be able to reduce SSI rates, but it is important to determine whether non-invasive alternatives can achieve optimal patient and surgeon satisfaction. Staples are fast and sutures provide a high rate of positive outcomes. Can these alternative, non-invasive modalities measure up to the speed and outcome standards set by staples and sutures?
Analysis of non-invasive skin closure methods
The first aspect of non-invasive closure modalities to be analysed is surgeon satisfaction. Surgeons seek a quick and effective skin closure modality that can limit the time spent in the operating room (OR). A shorter operating time frees surgeons to attend to other duties such as post-operative care. Not all non-invasive skin closure modalities yield the same level of surgeon satisfaction, but in general their ease of use and closure speed is between sutures and staples.6 Although tapes and adhesives are significantly faster than sutures, they do not close wounds as quickly as staples.4,7 They can also be more expensive, putting their eligibility for widespread use into question.
However, the cost effectiveness of these non-invasive modalities does appear more favourable once SSIs and suture- or staple-removal visits are considered. Staples lead to a higher rate of costly SSIs and, like sutures, are time-consuming to remove. Ultimately, the costly nature of infections and post-operative visits may make staples just as expensive as some higher priced tapes and adhesives. Upon analysis, non-invasive modalities do appear feasible for use by surgeons. It is imperative to ensure that they can achieve optimal patient satisfaction as well.
Among the traditionally used closure modalities, sutures yield optimal patient satisfaction, while staples seem to fall short of that standard. Satisfaction results for non-invasive modalities vary but are nonetheless promising. Studies show that patients find tapes to be more comfortable than subcuticular sutures and are overall more satisfied with them.8,9
Another study comparing adhesives to sutures reported equivalent patient comfort ratings between the two modalities.10 Since sutures have set the standard for optimal patient satisfaction, non-invasive modalities are clearly acceptable in this regard.
Another important consideration is that staples and non-absorbable sutures require a removal visit. Patients can find these interventions painful and anxiety inducing, leading to lessened satisfaction.11 Most non-invasive closure modalities do not require an uncomfortable removal procedure, an advantage in producing favourable satisfaction outcomes. Surgical tapes can be simply peeled off while skin adhesives slough naturally over time. Indeed, some non-invasive closures may not even require a post-operative visit for removal at all.
Cosmetic results are another important aspect of patient satisfaction. The primary cosmetic benefit of some non-invasive modalities is that they can spread force evenly throughout the wound rather than apply specific point-forces as staples and sutures do. The application of point-forces can produce ischaemia, a contributor to scarring. Point-forces are also naturally stronger than evenly spread forces, meaning that non-invasive modalities may be gentler on wounds.
Gentler handling of wounds reduces the risk of necrosis and strangulation of tissue. Lastly, staples and sutures puncture the skin. With staples in particular, needle puncture marks can lead to a poor overall cosmetic result, putting staples among the modalities that yield the poorest cosmetic outcomes. Suture canal scarring is also possible.12 Although tapes and adhesives have limited ability to affect wound eversion, a factor often attributed to favourable cosmetic results, they do not pierce the skin or leave permanent track marks. These factors ultimately contribute to an equivalent cosmetic result between most non-invasive closure methods and sutures, the standard for favourable cosmetic outcomes.9,13 Of course, not all non-invasive modalities produce the same results, prompting further analysis of which specific products are best suited for widespread use by surgeons.
Methods of non-invasive skin closure
There are many non-invasive skin closure modalities available, with a wide range of cost and efficacy observed. Some products with optimal efficacy are not feasible for widespread usage due to their higher cost, but some effective modalities are quite cost-effective. Commonly used tape-based products include the Steri-Strip™ Skin Closure products.
They are inexpensive and relatively simple to apply. Similar to most non-invasive methods of skin closure, Steri-Strip™ products reduce the risk of SSI compared to invasive modalities and are ideal for use on patients at high risk of infection.14 Their quick application and removal serves to further reduce costs. They are also effective when used in combination with other modalities to enforce proper closure.
However, they do have some disadvantages. Since Steri-Strip™ products are applied as discreet, narrow strips of tape, they do not necessarily distribute wound closure and extrinsic forces evenly. They also have limited adhesive strength, requiring the application of adhesion-promoting products to extend their use beyond a few days. The application of these strips to hairy or oily skin areas as well as high drainage wounds is not recommended. Most importantly, Steri-Strip™ tapes cannot cover large incisions or high-tension wounds, nor can the tension applied to the wound be adjusted once the Steri-Strip™ is applied.
Surgical glues such as Dermabond (Ethicon US, Cincinnati, OH) are similarly easy to apply. Compared to sutures, they reduce application time by 20–50%.4 Use of surgical glues reduces the risk of needle stick injury to staff and enhances time savings by eliminating lengthy removal visits. However, these adhesives do not have the same breaking force on day 1 as sutures and they cannot reliably close long lacerations over skin creases. Other limitations of these adhesives include the risk that they will wash off if frequently exposed to water and may weaken upon repeated patient movement.
Given the limitations of some adhesives and tapes, they are often used in combination so as to produce more reliable closure. The combined use of multiple modalities can achieve better quality closure but also increases costs. As the above-mentioned information indicates, no current skin closure modality, invasive or non-invasive, is without disadvantages. Recognising that little innovation has been introduced into the field of skin closure for some time, some companies have recently introduced new products for non-invasive closure.
Among recent entrants into the non-invasive closure market are the Zip® Surgical Skin Closure devices (ZipLine Medical, Campbell, CA, USA). Following the notion that intact human skin is an effective barrier against infection, Zip® devices do not pierce or compromise the skin and produce SSI benefits similar to other non-invasive skin closure modalities. Once the devices are placed over the affected area, they apply uniform stress throughout the wound. The surgeon can also subsequently adjust the tension administered to the wound, a considerable advantage of the Zip® devices.
Like Steri-Strips™, these devices are quick to apply and similarly uncomplicated to remove. Unlike Steri-Strips™, these devices do not occlude the wound and therefore allow exudate to be absorbed by a dressing placed over the region. In terms of applicability, the Zip® devices can be placed upon larger incisions as well as wounds that are under considerably higher tension. The primary disadvantage is cost since the Zip® devices are more expensive than Steri-Strips™ and other non-invasive modalities. However, given the reduced rate of costly SSIs as well as reduced time expenditures on removal visits and operating time, Zip® devices appear to be cost-effective. Preliminary data regarding the practicality and cosmetic result of the Zip® devices has been encouraging. The Zip® devices produce cosmetic results equivalent to sutures while closing wounds at a significantly shorter time.14
Other recent entrants into the skin closure market are the TopClosure® systems (IVT Medical Ltd., Ra’anana, Israel). Unlike the Zip® products, these devices are more applicable for pre-surgical skin stretching and traumatic injuries. Their ease of use is satisfactory and comparable to the Zip® devices. Swift, simple removal makes these systems ideal for wounds that are likely to be reopened for additional surgery. Furthermore, the TopClosure®’s ability to keep stress away from wound edges aids in producing acceptable cosmetic results. However, this system is only non-invasive as long as wounds are not under considerably high tension. Once wound tension becomes too high, the TopClosure® systems must be stapled to the skin. The system becomes invasive at that time, and the SSI advantages of non-invasive wound closure are no longer applicable.
Little innovation has been introduced into the field of skin closure for several decades. Despite their considerable disadvantages, staples and sutures remain the most commonly used closure modalities. As invasive methods of skin closure, neither is ideal for reducing SSI rates. Non-invasive modalities may serve as promising alternatives. With the rising cost of infection treatment, any wound closure modality that can limit SSIs provides immediate benefits to healthcare providers.
Patients appear satisfied with the non-invasive modalities as well, an increasingly important consideration in healthcare. They do hold some disadvantages, such as an inability to close long or high-tension wounds. New technologies, such as the Zip® products and Topclosure® systems, have been able to overcome some of these disadvantages. They can achieve swift closure with wounds that are under considerably higher tension. The current reality is that every skin closure modality is inherently imperfect. Rapid closure time often comes at the expense of favourable outcomes and vice versa. New technology has the potential to provide the balance of applicability, favourable outcomes and ease of use that traditional skin closure modalities lack.
- Clay FSH et al. Staples vs subcuticular sutures for skin closure at cesarean delivery: a metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2011;204(5):378–83.
- Smith TO et al. Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis. BMJ 2010;340:c1199.
- Greenspon AJ et al. 16-year trends in the infection burden for pacemakers and implantable cardioverter-defibrilators in the United States. J Am Coll Cardiol 2011;58(10):1001–6.
- Autio L et al. The four S’s of wound management: staples, sutures, Steri-Strips, and sticky stuff. Holist Nurs Pract 2002;16(2):80–8.
- Schauerhammer RA et al. Studies in the management of the contaminated wound: VII. Susceptibility of surgical wounds to postoperative bacterial contamination. Am J Surg 1971;122:74–7.
- Livesey C et al. Skin closure after total hip replacement. J Bone Joint Surg Br 2009;91:725–9.
- Quinn J et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. J Am Med Assoc 1997;277(19):1527–30.
- Webster DJ et al. Closure of abdominal wounds by adhesive strips: a clinical trial. Br Med J 1975;3(5985):696–8.
- Chen HH. Prospective study comparing wounds closed with tape with sutured wounds in colorectal surgery. Arch Surg 2001;136(7):801–3.
- Matin SF. Prospective randomized trial of skin adhesives versus suture for 217 laparoscopic port-site incisions. J Am Coll Surg 2003;196(6):845–53.
- Foster D et al. Efficacy and safety of a fibrin sealant for adherence of autologous skin grafts to burn wounds: Results of a Phase 3 clinical study. J Burn Care Res 2008;29:293–303.
- Pepicello J et al. Five year experience with tape closure of abdominal wounds. Surg Gynecol Obstet 1989;169(4):310–4.
- Singer AJ et al. Prospective, randomized, controlled trial of tissue adhesive (2-Octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Acad Emerg Med 1998;5(2):94–9.
- Hirshman HP et al. Penetration of Staphylococcus aureus into sutured wounds. J Orthop Surg Res 1984;2:269–71.
- Khorasani H. Preliminary study data presented at 16th Annual Mount Sinai Winter Symposium on Advances in Medical and Surgical Dermatology, New York. Dec. 6–8, 2013.