Alternatives to Sutures for Skin Closure

Types of Suture Alternatives for Skin Closure

Each closure alternative serves specific surgical needs based on wound characteristics, anatomical location, tension requirements, and desired outcomes. Understanding the distinct advantages and limitations of each method enables optimal selection for individual surgical scenarios.

Surgical Staples

Surgical staples are mechanical fasteners that rapidly approximate skin edges using metal devices, typically constructed from stainless steel or titanium.

The stapler mechanism drives U-shaped staples through both sides of the wound, bending the legs to create a bridge that holds tissue together.

Staples provide external closure through full-thickness skin penetration, remaining visible on the skin surface. They require removal 7-14 days post-procedure, contrasting with absorbable alternatives that work internally and disappear naturally.

Clinical Applications:

• Scalp wounds where hair conceals staple marks
• Trunk incisions on the back, abdomen, or chest
• Orthopedic procedures including total knee and hip arthroplasty
• Long linear incisions where speed is critical
• Emergency trauma situations requiring rapid closure

Advantages: Staples offer significant speed advantages, with wound closure significantly faster than sutures in orthopaedic surgery. They provide strong wound edge approximation and reliable tensile strength for high-tension areas. The application technique requires minimal technical skill compared to suturing, making staples accessible for various surgical team members.

Limitations: Cosmetic concerns represent the primary limitation. Percutaneous metal staples create "train track" scarring and trigger higher inflammatory responses in the early postoperative period compared to subcuticular closures.

Patients report greater discomfort during wear and removal. Staples are generally contraindicated for facial and cosmetically sensitive areas. Contrary to assumptions, using staples was three times more expensive than subcuticular Vicryl sutures when including applicator and removal costs.

Tissue Adhesives (Skin Glue)

Tissue adhesives are liquid cyanoacrylate-based compounds—most commonly octyl-2-cyanoacrylate (Dermabond)—that chemically bond skin edges through rapid polymerization.

Upon contact with skin moisture, these adhesives form a flexible plastic film that bridges wound edges and creates a protective barrier.

Adhesives create a topical seal without penetrating tissue—a fundamental difference from staples or sutures that pass through skin layers. The polymerized film sloughs off naturally as the wound heals beneath it, typically within 5-10 days, requiring no removal procedure.

Clinical Applications:

• Low-tension wounds that can be easily approximated
• Pediatric lacerations to avoid needle anxiety
• Facial wounds where cosmesis is priority
• Small surgical incisions under 5 cm
• Areas where waterproof barriers benefit healing

Advantages: For facial and neck wounds, tissue adhesives offer better cosmetic outcomes than sutures in the short term (≤1 month). Application is significantly faster than suturing, with octyl-2-cyanoacrylate significantly reducing closure time in maxillofacial surgery. The adhesive creates a waterproof barrier that protects against contamination while eliminating removal appointments and associated patient anxiety.

Limitations: A major limitation is higher wound dehiscence rates compared to sutures, particularly in areas subject to tension. Avoid use in high-tension areas, joints, mucosal surfaces, infected wounds, and areas with dense hair or regular moisture exposure.

The formaldehyde released during degradation creates histotoxicity concerns, though long-chain formulations like octyl-2-cyanoacrylate minimize this risk.

Adhesive Strips and Tapes

Adhesive strips (Steri-Strips, butterfly closures) are topical wound closure devices using strong adhesive backing to hold wound edges together externally. These porous strips allow moisture vapor transmission while providing mechanical support across the incision line.

Strips provide external reinforcement without any tissue penetration, making them the least invasive closure option. They're frequently used as adjunct support following suture or staple removal, or as standalone closure for very superficial wounds.

Clinical Applications:

• Superficial lacerations with minimal depth
• Surgical incision reinforcement after primary closure
• Low-tension wounds that approximate easily
• Patients with bleeding disorders where tissue penetration poses risks
• Supplementary support following suture/staple removal

Limitations: Adhesive strips have the lowest tensile strength among closure techniques, making them unsuitable for wounds under significant tension. They cannot adhere effectively in hairy areas, lose adhesion in moist environments, and risk premature detachment with patient movement. Avoid use where adhesion cannot be obtained due to exudate, skin oils, or moisture.

Bioabsorbable Subcuticular Fasteners

Bioabsorbable subcuticular fastener systems are mechanical devices that place absorbable fasteners beneath the skin surface for dermal layer approximation.

Systems like SubQ It! use pre-loaded staplers that deploy U-shaped fasteners made from polylactic-co-glycolic acid (PLGA) into the subcuticular tissue layer.

These systems uniquely combine the rapid mechanical placement of staplers with subcuticular positioning and bioabsorbable materials. The fasteners engage dermal tissue beneath the surface—never piercing external skin—while eliminating the need for manual needle passes and knot tying.

Clinical Applications:

• Small and laparoscopic incisions (SubQ It! handles incisions up to 25 cm)
• Abdominal procedures including laparoscopic cholecystectomy
• Thoracic and gynecologic surgeries including cesarean sections
• Orthopedic procedures requiring cosmetic closure
• Plastic and reconstructive surgery where both speed and aesthetics matter

Advantages: Bioabsorbable dermal staplers are four times faster than standard suture closure, reducing closure time by over 10 minutes per case in breast reconstruction. SubQ It! deploys fasteners in 7 seconds each—approximately 7X faster than manual sutures. The subcuticular placement eliminates "train track" scarring while the bioabsorbable material removes the need for follow-up removal appointments. PLGA fasteners maintain 80% strength for 21 days before being naturally absorbed.

Limitations: Surgeons navigate a learning curve when adjusting to the unique placement technique, though training studies with 20 surgeons demonstrated near-perfect performance. Cost considerations exist compared to traditional methods, though time savings often offset device expenses. Very high-tension areas may require supplementary deep layer closure for optimal results.

Absorbable Sutures

Modern absorbable sutures are synthetic materials—including polyglycolic acid (Dexon), polydioxanone (PDS), and poliglecaprone (Monocryl)—that maintain strength during critical healing periods then degrade naturally through hydrolysis.

These materials replaced older catgut sutures with more predictable absorption profiles and reduced inflammatory responses.

Absorbable sutures eliminate the removal step required for permanent sutures while still using traditional suturing technique. Surgeons maintain complete control over tissue approximation and tension, but patients avoid follow-up removal appointments.

Clinical Applications:

• Deep tissue closure and layered closure techniques
• Internal suturing where removal is impossible
• Pediatric patients to eliminate removal trauma
• Areas where removal access is difficult
• Subcuticular skin closures requiring precise approximation

Absorption timelines:

Limitations: Absorption timeline variability means some materials lose strength before healing completes in slow-healing tissues. Potential for inflammatory response exists, though synthetic materials minimize this compared to natural fibers.

Absorbable sutures are unsuitable for long-term wound support beyond their degradation timeline and typically cost more than non-absorbable alternatives.

How to Choose the Right Closure Method for Your Surgical Procedure

Assess Wound Characteristics First

Begin selection by evaluating fundamental wound properties:

Tension levels: High-tension wounds over joints or in areas subject to movement require closure methods with robust tensile strength. Traditional sutures, staples, or deep layer closure with superficial reinforcement work best.

Tissue adhesives alone are inappropriate for high-tension sites and lead to increased dehiscence rates.

Depth and layers: Superficial wounds may require only topical closure. Deeper wounds need layered approaches addressing fascia, subcutaneous tissue, and skin separately.

Match closure method to the specific layer being addressed.

Length and location: Small laparoscopic incisions (5-10 mm) benefit from rapid closure methods like bioabsorbable fasteners. Extensive linear incisions may justify staples for speed.

Contamination status influences selection—infected wounds require delayed closure or methods minimizing foreign material.

Anatomical Considerations

Once you've assessed wound characteristics, anatomical location determines which methods deliver optimal results.

Facial and cosmetic areas: For facial lacerations, 6-0 nylon or polypropylene sutures provide precise alignment. Tissue adhesives offer excellent alternatives for low-tension facial wounds. Metal staples are contraindicated due to scarring risks.

Scalp and trunk: Staples work well for speed in these areas where hair conceals marks or scarring is less concerning. 3-0/4-0 polypropylene or polyglactin sutures are effective alternatives when cosmesis matters.

High-moisture areas: Wounds in the axilla, perineum, or near mucosal surfaces experience adhesive failure with strips or glues. These locations require sutures or staples for reliable closure.

Joints and mobile areas: Areas subject to constant movement need closure methods that handle tissue dynamics without dehiscence. Sutures with appropriate tension distribution or deep layer support deliver the best results.

Practical Factors

Time constraints: When operative efficiency is paramount, staples and tissue adhesives are significantly faster than suturing. Bioabsorbable fastener systems like SubQ It! offer the best balance—delivering staple-like speed with suture-quality cosmetic outcomes.

Cost-benefit analysis: Consider total cost of care, not just device price. While staples appear economical, removal appointment costs often exceed savings.

In breast reconstruction, bioabsorbable fasteners saved $220 per case despite higher device costs due to time efficiency.

Surgeon experience: Leverage techniques within your skill set while remaining open to training on alternatives that offer clear advantages. Most modern alternatives require minimal learning curves with proper instruction.

Patient Factors

Pediatric considerations: To avoid trauma of suture removal, absorbable sutures or tissue adhesives work best for pediatric patients. Fast-absorbing gut or Monocryl work well for children who may not tolerate removal procedures.

Activity level: Active patients or those unable to restrict movement may require more robust closure methods than adhesives alone. Consider supplementing adhesives with deep sutures for adequate support.

Cosmetic expectations: Discuss scarring expectations preoperatively. Patients prioritizing aesthetics benefit from subcuticular techniques or tissue adhesives over staples, even if this extends operative time slightly.

Follow-up compliance: Patients with limited access to follow-up care are ideal candidates for absorbable alternatives that eliminate removal requirements.