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The Importance of “Just Right” Wound Closure

“Ahhh, this porridge is just right."

It’s probably been a while since you’ve heard the fairytale, but that’s Goldilocks, after having tried one bear's porridge that was too hot, and one that was too cold. The concept of finding just the right balance can be applied to many things, however, especially in the medical field. One area I believe that absolutely requires this sort of precision is operative incision care.

As a surgeon specializing in knee preservation and cartilage restoration for over 20 years, I’ve observed several changes in nearly all aspects of patient care. However, the wonders of biology never cease to amaze me. What I continue to find intriguing after all these years is the body’s ability to heal given the right environment, whether a planned orthopedic procedure or a traumatic injury. As soon as our skin is compromised, our bodies initiate a healing cascade response. 

The first phase occurs as platelets initiate a fibrin clot. As they degranulate, they release over 1,500 biologically active proteins that coordinate tissue repair efforts through a variety of cell types and healing factors (e.g., cytokines and chemokines). The cells then lay down collagen in a proliferative phase in an attempt to bring the disrupted tissues back together. For minor wounds, our bodies can accomplish this on their own. But for larger wounds, they often require the assistance of a wound closure method, such as sutures, staples, tapes, or glues. But these methods of wound closure need to be “just right” in order to assist our bodies while allowing them to perform to their own natural abilities. Ultimately, surgeons want to minimize post-operative wound healing complications and allow the patient to heal with the best possible cosmetic result. These are elements that, to a certain extent, I believe are within our control as surgeons.

Common Wound Closure Methods

Today, surgeons have more wound closure options than ever before, whether it’s following a planned procedure or for emergency situations, but each of these methods have unique effects on biology.

Sutures

The oldest method of wound care, absorbable and non-absorbable sutures offer a variety of trade-offs between strength, knot security, and handling. Sutures can be time-consuming to apply, can result in scarring, infection, and or needlestick injuries. In addition, sutures do cause microtrauma to the tissue which may compromise wound healing. Most of us have seen “suture reactions” as bioabsorbable sutures create small nodules at the incision line that often mimic an infection. Sutures can also leave long-standing unsightly “hole” scars even for very small incisions as seen below.

Suture track scarImage courtesy of ScienceDirect, not a patient of Dr. Farr.

Staples

New to the scene in the 1960s, staples are used when an incision must be closed quickly and securely. While faster than suturing, staples tend to leave “track” scarring, require the hands of two experienced people, and are limited to the areas of the body in which they can be applied. If left too long, the puncture sites become inflamed and can lead to permanent marks in the skin adjacent to the incision healing site. The photo below shows permanent track scarring due to the use of staples.

Leslys staple scar on footImage courtesy of patient with staple scarring, not a patient of Dr. Farr.

Surgical Tapes

While great for small cuts and wounds, surgical tapes tend to lose grip over time and can be severely weakened by contact with water. They often lack the strength and stability to hold wound edges securely in place long enough for the healing process to begin. 

Adhesives

Noninflammatory surgical glue has been around since the 1970s and is generally used in conjunction with sutures as a sealant to support closure rather than the primary means of closure. It’s not often used as the only means of wound closure.

An Alternative to Wound Closure

I’ve already described some of the limitations of using common methods of wound closure, and now it’s time to go back to Goldilocks. Sutures and staples can be applied too tightly, which may compromise blood flow and result in localized healing problems. Both methods may leave portions of the wound partially exposed, potentially allowing air germs to enter, which can delay recovery and lead to possibly higher levels of post-operative pain and infection. On the other hand, tapes and glues can be too loose, eroding over time or splitting apart if they experience tension. Moisture can also cause them to lose their grip, resulting in wound dehiscence.

For these reasons, we have added BandGrip as an option to my practice at OrthoIndy. In the words of Goldilocks, BandGrip is “just right,” closing incisions precisely without sutures or staples. Differing from surgical tapes, BandGrip uses micro-anchors to keep wounds closed without additional tapes or glues. Unlike other tapes and sticky adhesives, BandGrip is hypoallergenic and not made from silicone which can cause many patients to have an adverse inflammatory reaction in the skin.

The efficacy and efficiencies that this non-invasive skin closure product brings to our surgical suite benefits both surgeon and patient. It saves operative time (i.e., it is about 70% faster to close a wound with BandGrip compared to traditional sutures) and thus patients spend less time under anesthesia and potentially recover with less scarring compared to other wound closure techniques. Patients also appreciated that they can move about and shower just 24 hours following BandGrip’s application. Finally, patients can often remove the BandGrip without otherwise requiring an time-consuming postoperative visit with the surgeon or advanced practice providers. Check out the more seamless healing abilities with BandGrip below.

Screen Shot 2019-06-25 at 1.27.30 PMImage courtesy of patient receiving BandGrip wound closure treatment.

I encourage you to view the brief video here to see the difference BandGrip can make within your practice. 

Dr. Farr-1Dr. Farr is a leader in U.S. cartilage restoration advances and is an active staff member at OrthoIndy Hospital and Community Hospital South. He is a member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Society of Sports Medicine, Arthroscopy Association of North America, the International Cartilage Repair Society, International Patellofemoral Study Group, International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine and the European Society of Sports Traumatology, Knee Surgery & Arthroscopy.