Introduction
Surgeons face mounting pressure to reduce operative time while delivering superior cosmetic outcomes and minimizing patient discomfort. Traditional suturing requires meticulous technique, consumes valuable OR minutes, and often results in visible scarring that patients find unacceptable.
Sutureless skin closure techniques address these challenges directly. These systems eliminate needle-and-thread suturing entirely, replacing manual closure with bioabsorbable fasteners and adhesive systems that reduce application time by up to 7× compared to traditional methods.
The benefits extend beyond speed: no suture removal appointments, reduced needlestick injury risk, and improved aesthetic results. These advantages have driven rapid adoption across general surgery, plastic surgery, gynecology, orthopedics, and emergency medicine.
TL;DR
- Sutureless closure delivers faster application and better cosmetic outcomes than traditional sutures
- Choose from adhesive tapes, tissue adhesives (cyanoacrylate glues), or bioabsorbable subcuticular devices
- Match closure method to wound tension, anatomical location, and cosmetic requirements
- Tissue adhesives save 5.6 minutes per wound versus suturing
- Bioabsorbable subcuticular systems combine stapler speed with superior cosmesis
What Is Sutureless Skin Closure?
Sutureless skin closure refers to wound approximation methods that achieve secure tissue closure without traditional needle-threaded sutures. Rather than manually stitching tissue edges together with needle and thread, these techniques use adhesive bonding, chemical polymerization, or subcuticular mechanical fastening to hold wound edges in alignment during healing.
This approach has found applications across surgical specialties:
- General surgery: Hernia repairs and abdominal incisions
- Plastic surgery: Facial lacerations requiring optimal cosmetic outcomes
- Dermatology: Excision closures
- Gynecology: Cesarean sections
- Orthopedic surgery: Arthroscopic port sites
- Emergency medicine: Rapid laceration management in high-volume settings
Sutureless closure addresses real surgical challenges. It solves problems inherent to traditional suturing: time consumption, occupational hazards, patient anxiety, and scarring complications.
Why Is Sutureless Skin Closure Important in Wound Management?
Sutureless techniques directly improve critical surgical outcomes across four key dimensions: operative efficiency, infection prevention, cosmetic results, and patient satisfaction.
Operative Efficiency Gains
Traditional suturing is time-intensive, averaging 5.2 minutes for facial lacerations compared to 2.9 minutes with tissue adhesives. For cesarean sections, adhesive closure took just 55 seconds versus 408 seconds for sutures—an 86% time reduction.
These minutes compound across surgical schedules. The result? Significant cost savings and increased surgical capacity.
Occupational Safety
Suture needles cause 43.4% of all sharps injuries in surgical settings, with 52% of surgical resident needlestick injuries occurring specifically during suturing.
Sutureless methods eliminate this occupational hazard entirely, protecting surgical teams from bloodborne pathogen exposure.
Improved Cosmetic Outcomes
Percutaneous sutures create permanent "train track" scarring when tied too tightly or left in place too long. Meta-analyses show tissue adhesives deliver better cosmetic outcomes than sutures at one month post-procedure, with outcomes remaining comparable at three months. Subcuticular bioabsorbable devices eliminate external scarring entirely by never piercing the skin surface.
Enhanced Patient Experience
Patients report consistently higher satisfaction with sutureless methods. Pain scores are lower with tissue adhesives (VAS 6.8) compared to sutures (VAS 8.28) on day zero.
Eliminating suture removal visits reduces patient anxiety—particularly valuable in pediatric populations where removal procedures cause significant distress.
What Goes Wrong with Traditional Suturing
Traditional suturing carries inherent limitations that sutureless techniques address:
- Time consumption: Manual suturing requires meticulous technique, consuming valuable operative time
- Needlestick injuries: Repeated needle passes create continuous exposure risk for surgical personnel
- Suture marks: Percutaneous sutures leave cross-hatching scars if tension is excessive or removal delayed
- Patient discomfort: Suture removal causes pain and anxiety, requiring dedicated follow-up appointments
- Follow-up burden: Non-absorbable sutures require return visits, increasing healthcare system costs and patient inconvenience
Types of Sutureless Skin Closure Techniques
Sutureless closure is not one-size-fits-all. Three distinct categories exist, each optimized for specific wound characteristics, anatomical locations, and clinical goals. Understanding these differences enables clinicians to match technique to clinical scenario, maximizing outcomes while minimizing complications.
Adhesive Tape Closure Systems
Description
Adhesive tape closures use specialized medical-grade adhesive strips (such as Steri-Strips) applied across wound edges to maintain approximation during healing. These porous, non-woven backings are coated with pressure-sensitive adhesive that bonds to the skin surface.
Strips bridge wound edges externally, applying gentle tension to hold tissue in alignment without penetrating the skin.
How It Differs
Unlike sutures that pierce tissue or adhesives that chemically bond wound edges, tapes work entirely through external adhesion to the skin surface. Unlike sutures that pierce tissue or adhesives that chemically bond wound edges, tapes rely entirely on adhesive bonding to the skin surface rather than tissue integration. They function as external splints rather than tissue fasteners.
Best Suited For
- Low-tension wounds with minimal static or dynamic stress
- Clean, linear lacerations in non-mobile areas
- Superficial wounds without significant depth
- Pediatric patients where needle-free closure reduces anxiety
- Emergency department settings prioritizing rapid wound management
- Adjunctive reinforcement over subcuticular sutures
Key Strengths
Adhesive tapes yield the lowest infection rates of any closure method, with contaminated wounds showing 3.8% infection rates versus 14% for sutured wounds. Clinicians can apply them non-invasively without anesthesia. Removal is painless—tapes simply peel off or slough naturally. When properly applied to appropriate wounds, scarring is minimal.
Limitations
Tapes perform poorly on high-tension wounds, frequently detaching before adequate healing occurs. They're ineffective on hairy skin (poor adhesion), oily surfaces, or areas exposed to moisture.
Tapes cannot approximate deeper tissue layers, limiting use to superficial wounds. Premature detachment risk is high in mobile anatomical areas or when exposed to body fluids.
Tissue Adhesives (Cyanoacrylate-Based Glues)
Description
Tissue adhesives are liquid or gel formulations—typically 2-octyl cyanoacrylate compounds—that polymerize on contact with wound edges to create a bonded seal. Application involves manually approximating wound edges, applying adhesive topically along the wound line, and allowing polymerization within seconds.
The resulting flexible bond creates a waterproof barrier over the wound.
How It Differs
These adhesives create chemical bonds through rapid polymerization rather than mechanical fastening. Unlike tapes that stick to skin surfaces or devices that insert fasteners, tissue adhesives create molecular bonds between the adhesive polymer and tissue proteins. The polymerized film forms a protective, waterproof seal.
Best Suited For
Tissue adhesives excel in emergency medicine, plastic surgery, and pediatric surgery for:
- Small, clean, low-tension lacerations (typically <5cm)
- Facial wounds where cosmetic outcome is critical
- Pediatric lacerations requiring needle-free closure
- Areas difficult to bandage (scalp, forehead)
- Wounds where waterproof coverage provides value
Closure time for inguinal hernia repair was 1.4 minutes with adhesive versus 2.4 minutes for sutures.
Key Strengths
Clinical evidence shows tissue adhesives reduce closure time by 5.6 minutes compared to sutures, with some procedures completed in under two minutes. Cosmetic outcomes are superior to sutures at one month post-procedure. The waterproof seal allows immediate showering. Cyanoacrylate adhesives possess inherent bacteriostatic properties against Gram-positive organisms.
Application is painless, and the adhesive naturally sloughs as the wound heals—no removal required.
Limitations
Tissue adhesives are contraindicated for high-tension wounds, joints, or areas subject to repeated movement. They should not be used on mucosal surfaces or mucocutaneous junctions.
Allergic contact dermatitis occurs in 0.5-14% of patients, with a 71% relative increase in reaction rates upon repeated exposure. Material costs are higher than sutures. Dehiscence risk is higher with adhesives compared to sutures (RR 3.35), making proper case selection critical.
Bioabsorbable Subcuticular Closure Devices
Description
Bioabsorbable subcuticular devices are mechanical fastening systems that place absorbable fasteners beneath the skin surface—in the subcuticular layer—to approximate dermal edges without external skin penetration. Specialized delivery devices insert bioabsorbable fasteners (staples, clips, or anchors) into subcutaneous tissue.
Fasteners hold tissue approximation during healing, then gradually absorb over weeks to months, eliminating removal procedures.
How It Differs
What sets these devices apart is subcuticular placement that combines mechanical fastening with bioabsorption. Unlike adhesive tapes that work externally or tissue adhesives that bond the skin surface, these devices place fasteners between the dermis and epidermis. The external skin surface remains unpierced—fundamentally different from percutaneous metal staples that penetrate through the epidermis, leaving visible puncture marks.
Best Suited For
General surgery, gynecology, and plastic surgery show highest adoption, particularly for:
- Surgical incisions requiring secure closure with optimal cosmesis
- Laparoscopic port sites and minimally invasive surgery closures
- Cesarean sections and gynecologic procedures
- General surgical incisions (hernia repairs, abdominal procedures)
- Plastic and reconstructive surgery where scarring must be minimized
- Situations where elimination of removal visits provides significant value
These devices excel when both speed and cosmetic outcome are priorities.
Key Strengths
Bioabsorbable subcuticular devices deliver closure speeds comparable to metal staplers—significantly faster than manual suturing. Systems like SubQ It! achieve closures averaging 7X faster than traditional sutures, with each fastener deploying in approximately 7 seconds.
The subcuticular placement eliminates "train track" scarring entirely since the external skin is never pierced. Patients experience superior comfort—no percutaneous foreign material and no removal procedure required.
Studies show absorbable sutures have significantly lower surgical site infection rates than skin staplers (OR 0.77) and non-absorbable sutures (OR 0.62)00205-6/pdf). The bioabsorbable fasteners maintain 80% of strength for 21 days before natural absorption eliminates all removal-related costs.
Limitations
Higher upfront device costs compared to sutures represent the primary barrier. Devices require specific training on proper operation technique, though learning curves are generally minimal.
Incision length is limited by device capacity—most systems accommodate incisions from 10-25cm depending on the model. Extremely high-tension closures or severely compromised tissue may not be suitable. Minor fastener extrusion during absorption occasionally occurs but is typically self-limiting.
How to Choose the Right Sutureless Skin Closure Technique
The right technique depends on wound characteristics, clinical context, and desired outcomes. Proper selection requires systematic evaluation—not defaulting to what's most familiar.
Consider these factors when evaluating closure options:
Wound characteristics:
- Size and depth (superficial vs. deep tissue involvement)
- Anatomical location and tension (high-tension joints vs. low-tension facial areas)
- Contamination level and infection risk
Patient considerations:
- Age (pediatric patients benefit from needle-free methods)
- Skin condition (fragile skin requires gentler approaches)
- Ability to return for follow-up visits
Clinical priorities:
- Operating room time constraints
- Desired cosmetic outcome (especially for visible areas)
- Total cost-of-care (material costs plus time savings and elimination of removal visits)
Practitioner factors:
- Training and comfort level with specific devices
- Available equipment and inventory
Decision-Making Framework:
| Clinical Scenario | Recommended Approach | Key Considerations |
|---|---|---|
| Low-tension superficial wounds | Adhesive tapes or tissue adhesives | Ideal for clean lacerations <3cm; excellent for pediatric patients (needle-free) |
| Cosmetically sensitive areas (face, neck, visible skin) | Tissue adhesives or bioabsorbable subcuticular devices | Subcuticular placement eliminates external scarring; avoid through-the-skin methods that leave suture marks |
| Surgical incisions requiring rapid closure | Bioabsorbable subcuticular devices | Combines speed (7X faster than sutures) with superior cosmesis; eliminates removal visits and reduces total cost-of-care |
| High-tension wounds (joints, back) | Deep dermal sutures + subcuticular reinforcement | Tissue adhesives alone contraindicated; subcuticular devices must provide adequate tissue engagement |
| Contaminated or infected wounds | Adhesive tapes (minimize foreign material) | Tapes show lowest infection rates; avoid buried absorbable materials in actively infected tissue |
For surgical incisions where speed and cosmetic outcomes are equally important, bioabsorbable subcuticular devices like SubQ It! offer a compelling alternative. These systems combine the procedural efficiency of traditional staplers with the superior cosmetic results of buried closures—without requiring removal appointments.
Common Mistakes When Selecting Sutureless Closure Techniques
Selecting the wrong closure technique can compromise wound healing and patient outcomes. Common errors include:
Choosing complex methods when simpler techniques suffice — Selecting advanced bioabsorbable devices for straightforward, low-tension lacerations that would heal perfectly with adhesive tape adds unnecessary cost and procedural complexity. Match technique sophistication to wound complexity.
Ignoring wound-specific limitations — Using tissue adhesives alone on high-tension wounds led to 8% dehiscence rates in clinical trials, with 75% requiring re-suturing. Applying adhesive tapes to hairy or moist skin results in premature detachment.
Using tissue adhesives on joints or mucosal surfaces violates fundamental contraindications. Each technique has specific limitations that must be respected.
Selecting based on familiarity rather than optimal fit — Defaulting to the technique you know best rather than the technique the patient needs most compromises outcomes. A surgeon comfortable with sutures who uses them exclusively—even when tissue adhesives would deliver better cosmetic results in half the time—serves neither efficiency nor patient satisfaction.
Applying adhesives below the epidermal layer — Placing tissue adhesive into the wound depth rather than topically on approximated edges causes foreign body reactions and tissue toxicity. Adhesives must remain on the surface.
Using subcuticular devices in inadequate tissue — Attempting to place subcuticular fasteners in extremely thin skin (such as scalp) can result in asymmetric engagement and insufficient holding strength, leading to potential failure.
Conclusion
Sutureless skin closure techniques play an increasingly vital role in modern wound management across surgical specialties, driven by demonstrated improvements in operative efficiency, patient outcomes, and satisfaction.
Three distinct types exist—adhesive tapes, tissue adhesives, and bioabsorbable subcuticular devices—each optimized for different clinical scenarios based on wound tension, location, depth, and cosmetic priorities.
Understanding these differences and applying appropriate selection criteria leads to better surgical efficiency, reduced complications, superior cosmetic results, and enhanced patient satisfaction.
Bioabsorbable subcuticular systems like SubQ It! represent the evolution of closure technology—combining stapler-speed efficiency with superior cosmetic outcomes while eliminating removal procedures. As clinical evidence grows and adoption increases, these sutureless techniques will continue expanding their role in surgical wound closure, offering surgeons practical alternatives that balance speed, outcomes, and patient comfort.
Frequently Asked Questions
Are sutureless skin closure techniques as strong and secure as traditional sutures?
Ex vivo testing shows staples provide strongest closure, followed by 2-octyl cyanoacrylate, then adhesive strips. Clinical studies demonstrate comparable outcomes for appropriately selected cases, with bioabsorbable devices showing infection rates lower than traditional sutures.
What are the main advantages of sutureless closure over traditional suturing?
Key benefits include faster application (up to 7X faster), superior cosmetic results with no suture marks, no removal required, reduced patient discomfort, and elimination of needlestick risk. Total cost-of-care often favors sutureless methods despite higher material costs.
Can sutureless techniques be used on all types of wounds and surgical incisions?
No—proper case selection is critical. Sutureless methods are contraindicated for high-tension wounds without tissue support, infected wounds, and certain anatomical locations. Dehiscence risk increases significantly when inappropriately applied.
Do sutureless closure methods cost more than traditional sutures?
Material costs are higher (adhesives ~$22.63 vs. sutures ~$11.70), but total cost-of-care often favors sutureless methods when accounting for reduced operative time, eliminated removal visits, and fewer complications.
What training is required for surgeons to use sutureless closure devices?
Basic techniques (tapes, adhesives) require minimal training in wound preparation and application. Specialized bioabsorbable devices require manufacturer instruction with hands-on practice. Learning curves are minimal, with most surgeons achieving proficiency quickly.
What complications can occur with sutureless skin closure techniques?
Complications include wound dehiscence, allergic dermatitis (0.5-14% incidence with cyanoacrylates), and material failure in moist environments. Bioabsorbable devices show 2% infection rates and 17% bleeding, comparable to traditional methods.
