If You Weren't Convinced About Sewing Wounds - Here's More

Previously, I published an article called "Which is Best - Sew It, Tape It, or Glue It?" that discussed various ways to treat wounds. You may remember; that's the one with the Hibachi cartoon where the chef misses and his knife ends up in his hat. At the time I thought that I was amazing everyone with the idea that sometimes it might be better to let cuts heal without suturing them up. However, I did forget one thing; dermatologists and some other surgeons frequently allow certain types of skin procedures to heal by second intention, which is leaving them open without sutures. I was reawakened to that method when I read an article in the August 10th 2002 BMJ by Quinn and associates called "Suturing Versus Conservative Management of Lacerations of the Hand: Randomized Controlled Trial." Here at last was a real test of my old professor's idiosyncrasy; allowing wounds of the fingers to heal without sutures.

What they did in this trial was to compare 91 consecutive patients with 95 uncomplicated lacerations of the hand that would normally require sutures, in a randomized controlled fashion to decide which heals better, sutures or no sutures. Of the total, 41 suture patients and 40 non-suture patients completed the study. An uncomplicated laceration was determined to be less than 2 cm in thickness and without tendon, joint, fracture, or nerve involvement. The object was to see which approach gave a better cosmetic result after 3 months, took less time to treat, caused less pain during treatment, took less time for patients to get back to normal routines, and pleased patients better. Cosmetic appearance was rated on a visual analogue scale that had been previously proven to work well.

You guessed it: it turns out that leaving a laceration of the hand alone is better because you get about the same cosmetic and functional result without the pain of sewing it up. Treatment time is shorter, and the ability to get back to a normal routine is about the same. Doctors who evaluated the cosmetic appearance without knowing which method was used found no difference. Although this study didn't evaluate infection, it is already known that suturing leads to more of it.

Readers may recall that the method used by my old professor of surgery was to avoid sutures, but he did approximate the wound edges, and held them in place using gauze placed directly on the open wound followed by an outer bandage. Furthermore, mine was a knife cut so it was easy to bring the edges together. The technique used in this study was to leave the wound edges open and let the tissues fill in by themselves even if there was a definite aperture. This method of healing by second intention, as I noted above, is nothing new. My own experience with the technique has been quite favorable, if used for the right sort of wounds or surgical procedures. I am pleased to see the study indicated that this approach is not only acceptable but actually may be preferable if properly utilized.

There is another advantage to avoiding sutures. The use of any surgical technique like suturing is always a good deal more expensive. Furthermore it involves two procedures; application of the sutures and removal afterward. These are traumatic procedures and probably do not present a cosmetic hazard to the average individual, as noted in this study, but many individuals, in particular those with darker skin pigmentation, do risk the formation of thickened scars called keloids following injury to the skin. On the hand this is unlikely to occur on the palmar surface, but does occur sometimes on the dorsum. It would be interesting to run a study comparing suturing to healing by second intention on a series of keloid prone individuals. The question to be solved is whether allowing a wound to heal in from its edges creates more of a keloid-provoking trauma than the placing of sutures through the skin layers plus the resultant tension on the wound edges when the sutures are closed. The fact that patients differ individually in their capacity to heal with minimal cosmetic damage does create a problem when evaluating studies such as this one. It would be better to compare two separate wounds on the same individual. However, obviously, this is not usually feasible.

Another question to be solved is whether allowing free flow of sanguino-serous discharge from a wound is preferable to closing it off. This is especially important when dealing with individuals with a tendency to have poor cosmetic healing. Furthermore, results obtained with wounds of the hands cannot be justifiably extrapolated to wounds elsewhere on the body.

Cartoons and Poems following each article are created and copyrighted by Dr. Ackerman and cannot be copied or reproduced without his permission. Copyright © 2007 by Marvin Ackerman, M.D.

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