Introduction
Every surgical closure presents a critical choice: sutures, metal staples, or bioabsorbable fastener systems. The decision affects closure speed, infection risk, cosmetic outcomes, and patient recovery.
Surgeons weigh these factors with each procedure, knowing the wrong choice can compromise results.
The stakes are considerable. In cesarean sections alone, staples are associated with a four-fold increase in wound separation compared to sutures02445-4/fulltext). This drives wound complications, readmissions, and patient dissatisfaction.
The global wound closure market is projected to reach $28.34 billion by 2034, fueled by demand for technologies that minimize scarring and eliminate removal visits.
Surgeons now choose from traditional sutures, metal staples, adhesive strips, and bioabsorbable subcuticular fasteners. Each has distinct advantages based on wound characteristics, anatomical location, and patient risk factors.
This article examines the evidence behind each method and provides a framework for selecting the optimal approach.
TL;DR
- Bioabsorbable subcuticular fasteners close 7X faster than sutures with superior cosmesis
- Sutures offer maximum precision but demand more time and technical skill
- Metal staples work fastest for long incisions yet increase scarring and removal pain
- Choose based on wound location, tension, patient needs, and OR efficiency
- Factor removal visits, OR time, and complication costs into total analysis
Quick Comparison: Skin Clips vs Sutures vs Staples
Selecting the right wound closure method requires balancing speed, cosmetic outcomes, and patient comfort. This comparison breaks down how traditional methods stack up against newer bioabsorbable technologies.
| Feature | Subcuticular Sutures | Metal Surgical Staples | Bioabsorbable Fasteners |
|---|---|---|---|
| Closure Speed | Slowest—adds 5-8 minutes vs staples | Fastest for trauma/emergency | 7X faster than manual sutures |
| Infection Risk | 50% lower wound complications in C-sections vs staples | Higher risk in obstetrics; equivalent in ortho/abdominal | Low—no percutaneous tracks |
| Cosmetic Outcomes | Superior long-term POSAS scores | "Train track" scarring common | Comparable to subcuticular sutures |
| Tensile Strength | Variable—technique dependent | High—reliable eversion | Maintains 80% strength for 21 days |
| Patient Comfort | High—absorbable options need no removal | Low—removal causes significant pain | High—absorbed naturally |
| Removal Required | No (absorbable) or Yes (non-absorbable) | Yes—painful procedure | No—bioabsorbable |
| Total Cost | Low material/high OR time | Medium material/high removal costs | Higher material/no removal costs |
| Ideal Use Cases | Facial wounds, complex geometry | Scalp, trunk, high-tension areas | Laparoscopic, MIS, cosmetically sensitive areas |
Sutures hold approximately 39% market share and remain the gold standard for precision. Staples save 5-8 minutes of OR time but carry specific risks in obstetrics.
Bioabsorbable fasteners eliminate the speed-versus-cosmesis trade-off. Systems like SubQ It! deliver stapler-speed closure without metal's drawbacks, combining rapid application with subcuticular placement that avoids external skin puncture.
What are Skin Clips and Bioabsorbable Fasteners?
Skin clips traditionally refer to external metal fasteners that approximate wound edges through surface penetration. However, modern bioabsorbable subcuticular fastener systems represent a fundamental evolution in closure technology.
Traditional Metal Clips:
Metal surgical staples have been the standard for rapid wound closure for decades. They penetrate the external skin surface, creating immediate wound approximation with minimal technical skill required.
While efficient, they leave characteristic "train track" scarring and require removal procedures.
Bioabsorbable Subcuticular Fastener Systems:
In contrast, modern systems like SubQ It! work beneath the skin surface rather than piercing it. These devices use disposable applicators pre-loaded with bioabsorbable dermal fasteners made from PLGA (polylactic-co-glycolic acid)—a medical-grade polymer that safely dissolves in the body.
The fasteners are inserted below the skin via small surgical needles that immediately retract, leaving barbed fastener legs embedded in the dermal tissue.
How They Work:
The mechanism differs fundamentally from traditional staplers:
- Fasteners engage tissue away from the incision edge, not at the surface
- Barbed legs spread angularly within the dermis for secure anchoring
- A bridge connecting the legs holds the incision together through distributed strength
- Tissue damage is minimized—no pinching or compression that restricts blood flow
This approach reduces tissue ischemia (restricted blood flow) and inflammatory response compared to traditional methods.
FDA Clearance and Clinical Evidence:
This validated technology has gained regulatory approval for diverse surgical applications. SubQ It! received FDA 510(k) clearance (K131563) in April 2014 for closing incisions in abdominal, thoracic, gynecologic, orthopedic, plastic and reconstructive surgery.
The system maintains ISO 13485 certification, validating manufacturing quality standards.
Core Benefits:
- External skin never pierced—eliminates surface scarring
- No removal required—fasteners maintain 80% strength for 21 days, then absorb naturally
- 7X faster than manual sutures with deployment in seconds
- Reduced infection risk—no percutaneous tracks for bacterial entry
Use Cases for Bioabsorbable Fasteners
Bioabsorbable fasteners address closure needs across multiple surgical specialties, offering particular advantages where cosmetic outcomes and patient comfort matter most.
Minimally Invasive and Laparoscopic Surgery
Small trocar incisions (5-15mm) in MIS procedures benefit from rapid, cosmetic closure without removal visits. SubQ It! is specifically designed for laparoscopic port sites in:
- Cholecystectomy and other abdominal procedures
- Hernia repair (ventral and inguinal approaches)
- Gynecologic laparoscopic surgery
General and Abdominal Surgery
The subcuticular placement provides excellent cosmetic outcomes across open abdominal procedures:
- Ventral and inguinal hernia repair
- Exploratory laparotomy closures
- Complex abdominal wall reconstruction
Gynecologic Applications
Cesarean sections and hysterectomy closures demonstrate particularly strong patient satisfaction. Case studies show minimal scarring at 6-week follow-up, with significant benefits from eliminating staple removal during the postpartum period.
Cosmetic and Reconstructive Procedures
When scar appearance is paramount, subcuticular placement with no external skin penetration minimizes visible scarring compared to traditional staples or percutaneous sutures. FDA clearance covers plastic and reconstructive surgery as well as orthopedic procedures where elimination of removal visits benefits patients with mobility limitations.
Clinical Performance Data:
Clinical studies involving 50 patients across 16 different procedures with seven surgeons demonstrated 2% infection rates and 17% bleeding incidence. Training validation studies with 20 surgeons showed near-perfect performance, indicating the system's ease of use across varying experience levels.
What are Sutures?
Sutures are thread-like materials used to bring wound edges together. They remain the most versatile closure method in surgery.
These materials offer maximum control over tissue approximation and adapt to virtually any wound geometry or tissue type.
Suture Types and Variations
Absorbable vs Non-Absorbable:
- Absorbable sutures (Monocryl, Vicryl) break down naturally over weeks to months, eliminating removal needs
- Non-absorbable sutures (Nylon, Prolene) provide extended tensile strength but require removal
Placement Techniques:
- Subcuticular sutures run beneath the skin surface, providing superior cosmetic results
- Percutaneous sutures pass through the skin, offering stronger closure for high-tension wounds
- Interrupted sutures place individual stitches along the wound
- Continuous sutures use a single running thread, significantly reducing dehiscence risk (OR 0.16)
These varied techniques give surgeons flexibility to match closure method to wound characteristics and healing requirements.
Core Advantages of Sutures
- Maximum precision for complex wound geometries
- Ability to manage varying tissue tension along wound length
- Versatility across all anatomical locations and tissue types
- Option to use antimicrobial-coated sutures to reduce SSI risk
Use Cases for Sutures
Complex and Irregular Wounds
Sutures remain unmatched for wounds with irregular geometry, multiple tissue layers, or areas requiring precise tissue approximation. Their flexibility allows surgeons to adjust tension and placement for optimal healing.
Facial and Cosmetically Sensitive Areas
For facial lacerations, systematic reviews show no significant difference in cosmetic outcomes between absorbable and non-absorbable sutures. This validates absorbable options that eliminate removal trauma while maintaining excellent aesthetic results.
Deep Tissue Layers
Sutures are essential for closing fascial layers, muscle, and subcutaneous tissue before addressing skin closure. Multi-layer closure with absorbable sutures provides structural support throughout healing.
Contaminated or High-Risk Wounds
Beyond structural considerations, sutures provide infection control advantages in certain clinical scenarios. In contaminated wounds or patients with infection risk factors, CDC guidelines suggest considering triclosan-coated absorbable sutures to reduce surgical site infection risk.
High-Tension Areas
Wounds requiring controlled tension distribution benefit from suture-based closure:
- Incisions over joints or mobile anatomical areas
- Areas with significant tissue tension or movement
- Sites where retention sutures can reduce stress on primary closure
- Wounds requiring graduated tension adjustment during healing
Evidence for Technique Selection
Research comparing continuous vs interrupted sutures demonstrates that continuous subcuticular technique produces superior cosmetic scores and lower dehiscence rates, making it the preferred approach when time permits.
What are Surgical Staples?
Surgical staples are metal fasteners (typically stainless steel or titanium) that rapidly bring wound edges together through external skin penetration. They represent the fastest closure method available.
Staples work by penetrating both sides of the wound and bending to create a bridge that holds edges together.
The primary advantage is speed—meta-analyses confirm wound closure is significantly faster with staples than sutures, saving 5-8 minutes of OR time per procedure.
Key Benefits and Limitations
Why surgeons choose staples:
- Minimal technical skill required compared to manual suturing
- Accessible to less experienced practitioners
- Valuable in emergency settings where speed is critical
**Key disadvantages:
- "Train track" scarring—external penetration creates visible scar patterns
- Removal pain—patients report significantly higher pain scores during staple removal compared to suture removal
- Not suitable for all locations—cannot be used on face, hands, or areas where cosmetic appearance is a priority
Use Cases for Surgical Staples
Scalp Lacerations:
- Excellent blood supply requires fast hemostasis control
- Hair coverage minimizes cosmetic concerns
- Speed of application critical in high-bleeding scenarios
Trunk and Extremity Wounds:
Orthopedic meta-analyses show no significant difference in infection rates between staples and sutures for hip/knee arthroplasty. Key advantages:
- Comparable outcomes to sutures in large orthopedic closures
- Faster application when speed matters
- Acceptable cosmetic results where appearance is less critical
Emergency and Trauma Settings:
- Fastest definitive closure method for unstable patients
- Minimizes anesthesia time in critical scenarios
- Reduces time to stabilization in trauma cases
Important Exception—Obstetrics:
While staples work well in many surgical applications, they have a significant contraindication. Evidence is conclusive that sutures should be used instead of staples for cesarean sections. C-section data shows:
- Two-fold higher wound infection risk with staples
- Four-fold increased wound separation compared to sutures
- Particularly problematic in obese patients
Choosing the Right Wound Closure Method: Decision Framework
Selecting the optimal closure method requires systematic evaluation of multiple factors.
Wound Characteristics Assessment
Incision Length:
- <10cm: Bioabsorbable fasteners or sutures
- 10-25cm: Bioabsorbable fasteners (SU-25 model) or continuous sutures
- >25cm: Continuous sutures or staples for speed
Tissue Tension:
- Low tension wounds accept any closure method. Moderate tension requires sutures or bioabsorbable fasteners. High tension demands deep dermal sutures plus surface closure—avoid adhesives alone.
Contamination Level:
- Clean: All methods appropriate
- Clean-contaminated: Prefer sutures with antimicrobial coating
- Contaminated: Delayed primary closure or loose sutures; avoid staples
Anatomical Location Guidelines
Beyond wound characteristics, anatomical location significantly influences closure method selection.
Face and Neck:Use absorbable subcuticular sutures—research confirms comparable cosmesis to non-absorbables without removal trauma.
Scalp:Staples or non-absorbable sutures provide rapid closure with adequate cosmetic results given hair coverage.
Abdomen:
- Cesarean sections: Sutures mandatory—50% reduction in composite wound complications vs staples
- Other abdominal: Bioabsorbable fasteners or sutures based on incision length and surgeon preference
Extremities:Choice depends on location visibility and patient activity level. Consider bioabsorbable fasteners for areas where removal visits would be burdensome.
Patient-Specific Factors
Patient characteristics add another layer to the decision process.
Obesity (BMI >30):In cesarean sections, sutures significantly reduce wound complications in obese populations compared to staples.
Diabetes or Immunocompromised:Consider antimicrobial-coated sutures. Avoid methods that create tissue ischemia.
Pediatric Patients:Absorbable sutures or bioabsorbable fasteners eliminate removal visit trauma and anxiety.
Follow-up Reliability:For patients unlikely to return for removal (rural areas, international travel), use absorbable methods exclusively.
Procedural Efficiency Considerations
Operational factors often determine practical closure method selection.
OR Time Constraints:When throughput is critical, bioabsorbable fasteners provide staple-comparable speed (7 seconds per fastener) without subsequent removal costs.
Surgeon Experience:Staples require minimal training. Sutures demand technical proficiency. Bioabsorbable fasteners show near-perfect performance after basic training.
Multiple Closures:In procedures requiring numerous small incisions (laparoscopic surgery), bioabsorbable fasteners optimize efficiency while maintaining cosmetic outcomes.
Total Cost Analysis
Direct material costs tell only part of the story:
- Sutures: Lowest ($)
- Staples: Medium ($$)
- Bioabsorbable fasteners: Highest ($$$)
However, indirect costs shift the equation. OR time valued at $60-$100/minute means 5-8 minute savings with staples/fasteners vs sutures justifies higher material costs. Staples require clinic time for removal, supplies, and patient time off work. Staple-associated wound complications in C-sections create costs that exceed OR time savings.
When all factors are included, bioabsorbable fasteners often prove most economical for appropriate use cases by eliminating removal visits while providing staple-comparable OR efficiency.
Real World Applications and Case Studies
Clinical Performance in Gynecologic Surgery
A cesarean section case documented with SubQ It! demonstrated practical advantages in postpartum care. The abdominal incision was closed using bioabsorbable subcuticular fasteners.
Six-week follow-up documentation showed:
- Minimal visible scarring with excellent cosmetic outcome
- No staple removal appointment needed during demanding postpartum period
- Eliminated patient discomfort associated with removal procedures
Laparoscopic Procedure Efficiency
This application demonstrates the system's advantages for minimally invasive procedures. A 10mm trocar incision from laparoscopic cholecystectomy was closed with just 2 SubQ It! fasteners.
Follow-up documentation showed progressive healing with minimal scarring at 22 days, becoming increasingly less visible at 45 days as fasteners were absorbed. Closure time was reduced by approximately 85% compared to manual subcuticular suturing.
Multi-Surgeon Clinical Validation
Building on individual procedure success, broader clinical evaluation validated consistent performance across multiple surgeons and procedure types. A study involving 50 patients across 16 different procedures with seven surgeons at Northern Vermont Regional Hospital examined real-world outcomes.
The study documented infection rates of only 2% and bleeding incidence of 17%—comparable or superior to traditional methods while delivering the speed and convenience advantages.
High-Volume Surgical Setting
Training validation with 20 surgeons using skin-like surrogate material showed near-perfect performance, indicating the system's ease of adoption in busy surgical practices.
Surgeons reported that the 7-second deployment time per fastener (compared to 42 seconds for manual interrupted stitches) created meaningful efficiency gains when performing multiple procedures daily.
Key Takeaway
Modern bioabsorbable fastener systems address the historical trade-off between speed, cosmesis, and patient convenience. In high-volume surgical settings performing laparoscopic and minimally invasive procedures, these systems deliver stapler-comparable efficiency with suture-comparable cosmetic outcomes while eliminating removal visits entirely.
For questions about integrating bioabsorbable closure systems into your surgical practice, SubQ It!'s surgical specialists are available at rob@subq-it.com.
Frequently Asked Questions
Are bioabsorbable fasteners as strong as traditional sutures or staples?
Yes. SubQ It! fasteners maintain 80% of their strength for 21 days—the critical healing period—with studies showing equivalent or superior wound healing compared to traditional methods. They reduce tissue ischemia by engaging tissue away from the cut edge rather than pinching it tightly.
What is the cost difference between skin clips, sutures, and staples?
Material costs vary (sutures lowest, bioabsorbable fasteners highest), but total cost of ownership differs. When factoring in OR time ($60-$100/minute), staple removal visits, and complication management, bioabsorbable fasteners often prove most economical despite higher upfront costs.
Which closure method results in the best cosmetic outcomes?
Research consistently shows subcuticular techniques produce superior cosmetic results compared to percutaneous staples or sutures. Both absorbable sutures and bioabsorbable fasteners deliver better long-term POSAS scores by avoiding external skin penetration, eliminating "train track" scarring.
How do I choose between absorbable and non-absorbable sutures?
Choose absorbable sutures for deep tissue layers, pediatric patients, or areas where removal is difficult. Systematic reviews show no difference in cosmetic outcomes between types for facial wounds. Use non-absorbable sutures when extended tensile strength is needed (over joints) or minimizing inflammatory response is critical.
Can bioabsorbable fasteners be used for all types of wounds?
No. Bioabsorbable fasteners are FDA-cleared for clean surgical incisions in abdominal, thoracic, gynecologic, orthopedic, plastic and reconstructive surgery up to 25cm. Contraindications include contaminated wounds, wounds under extreme tension, and areas with insufficient subcutaneous tissue.
What are the infection risks with different closure methods?
Meta-analyses show no significant SSI difference between sutures and staples in most surgeries, except obstetrics where sutures reduce wound complications by 50%. Subcuticular techniques theoretically lower infection risk by eliminating percutaneous tracks.
