Principles of Wound Closure

Michael Hussey, MD, and Mark Bagg, MD

Methods of wound closure have advanced over the last decade with the addition of newer
techniques but the fundamental principles of wound management remain unchanged and
must be understood to achieve a stable wound that can be successfully closed. This article
reviews the basic science of wound healing and the clinical principles of wound management with respect to timing and assessment of the wound, and finally, the principles of
irrigation and debridement that one must understand to obtain a stable wound prior to any
soft tissue closure. Once a stable wound has been achieved, some of the newer advancements in wound dressings and soft tissue coverage techniques that are discussed in this
article can be applied to any open wound to achieve a stable durable wound closure that
will ultimately lead to improved form and function.
Oper Tech Sports Med 19:206-211 2011 Elsevier Inc. All rights reserved.
KEYWORDS wound closure, healing, surgical debridement, wound management

Skin Anatomy

Wound Healing

Our skin has many important roles and functions that

allow us to carry out our daily activities. In addition to its
ability to regulate body temperature, receive external stimuli, and aid in the synthesis of vitamin D, perhaps its most
valuable role lies in its ability to protect the body against
injury, microbial invasion, and desiccation.1,2 The 2 layers
of skin, epidermis and dermis, work in concert to carry out
these functions. The epidermis, through its rapid mitotic
activity and thick layer of keratin at its surface, allows
quick wound healing and provides a highly resistant barrier to foreign invasion and desiccation.1,2 The dermis,
however, provides a base for hair growth, sweat and oil
production, thermoregulation, and sensation to be effectively carried out. Also very important is the subcutaneous
layer (hypodermis), which separates the skin from fascia
and provides a supporting framework so that the skin can
perform its functions.1,2 When either accidental or surgical trauma causes a disruption to the skin, its functions are
lost in that localized area of injury. It is the goal of the
surgeon to achieve reconstitution of skin integrity at the
site of injury or incision by using the full armamentarium
of medical and surgical techniques currently available.

For us to have a full understanding of wound closure and

healing, we first have to appreciate the underlying biological
mechanisms in place. After injury to the skin occurs, the
body responds by going through 3 stages of healing: inflammatory, proliferative, and remodeling.3,4
The inflammatory stage begins with platelet aggregation
and formation of the fibrin clot,3 which reestablishes hemostasis and provides an extracellular matrix for cell migration.4
After the coagulation pathway is activated, numerous cytokines (eg, transforming growth factor-, platelet derived
growth factor, fibroblast growth factor, interleukin-1)3,4 are
released, which trigger the bodys inflammatory cells to infiltrate the wound to begin repair.5 Neutrophils and macrophages work together to cleanse the wound by removing
bacteria, matrix, and nonviable host cells.3,4 Mast cells are
also present and release granules containing histamine and
other enzymes that cause the characteristic signs of inflammationredness, heat, swelling, and pain.3
Next, the proliferative stage begins by reepithelialization of
the wound. Epidermal cells migrate laterally across the free
edge of the wound and begin to dissect across the extracellular matrix through secretion of collagenase and plasmin.4
Epidermal cells behind the leading edge of migration start to
proliferate and continue to do so until the epithelial bridge is
complete.4 With progression of wound repair, increasing demands for oxygen and nutrients are made at the wound site.
As a result, cytokines are secreted, which stimulate the regeneration of a new blood supply to the area, a process termed
neovascularization.1,3-5 The presence of these new blood ves-

University of Texas Health Science Center at San Antonio, San Antonio, TX.
Address reprint requests to Mark Bagg, MD, Hand Center of San Antonio, 21
Spurs Lane, Ste 310, San Antonio, TX 78240. E-mail: mbagg@
satx.rr.com

206

1060-1872/11/$-see front matter 2011 Elsevier Inc. All rights reserved.

doi:10.1053/j.otsm.2011.10.004

Principles of wound closure

207

sels in combination with growth factors produced by macrophages allows fibroblasts in the wound to begin production
of the new extracellular matrix, which will restore structure
and function to the injured tissue.5 This fibroblast-rich granulation tissue is composed mostly of type I collagen and other
supporting structural proteins.3 Finally, around the second
week of wound healing, remodeling begins, as the myofibroblast becomes predominant in the granulation tissue, providing compaction and contraction of the wound through
attachments and crosslinks with collagen.1,3,4 This reinforcement of the wound provides sufficient strength to allow suture removal around the second week in most cases. The
developing scar continues to remodel and strengthen over
the coming weeks and months, but it only regains about 80%
of its original breaking strength.6

tension lines also need to be considered, as incisions that run

parallel to lines of tension generally produce a better cosmetic
scar than those running perpendicular to skin tension lines.9

Classification of Wounds

Polyglactin 910 (Vicryl, Ethicon Inc.) is a synthetic absorbable braided suture made of glycolide and lactide. It is also
available with an antimicrobial coating called triclosan (Vicryl Plus).8,13 Polyglactin 910 retains 75% of its tensile
strength at 2 weeks and only 25% at 4 weeks, with complete
resorption by hydrolysis within 90 days.14,15 It has the advantages of strong knot security, good initial 2-week strength,
and relatively fast absorption.13 Disadvantages of polyglactin
910 include increased potential for wound infection because
of microbial ability to hide within its multifilament braid.
Avoidance of use in the cutaneous region is recommended
because slower absorption time in this area sometimes leads
to the knot being extruded from the healed wound, compromising the appearance of the scar and causing patient anxiety.8
Surgical gut (plain, chromic, fast absorbing) is a purified,
collagen-based absorbable suture derived from the small intestine of sheep or cattle.8,13,15 It retains only 40% of its tensile
strength at 7 days and is completely absorbed by 2 weeks.8
Treating it with chromium salts increases its holding time to
14 days and delays absorption to 3 weeks.13,15 In contrast,
heat treating the plain gut causes loss of tensile strength and
faster absorption. Surgical gut has the advantage of fast absorption without need for removal; however, this also leads
to high tissue reactivity and rapid loss of tensile strength,
which are considered to be disadvantages of using this suture.13
Poliglecaprone 25 (Monocryl) is a synthetic absorbable
monofilament suture made of glycolide and -caprolactone.
It maintains about 50% of its original tensile strength at 1
week and 0% at 3 weeks, with complete absorption by hydrolysis within 120 days. Poliglecaprone 25 has the advantages of minimal tissue reactivity and strong initial tensile
strength.15 Disadvantages include a fast loss of tensile
strength and a significantly higher cost compared with other
absorbable sutures.
Polydioxanone (PDS) is a synthetic absorbable monofilament suture made from polyester p-dioxanone. It maintains
about 70% of its tensile strength at 2 weeks and 50% at 4
weeks, with complete absorption by hydrolysis within 6
months. It has the advantages of long-lasting tensile strength,
integrity maintenance in presence of infection, and minimal

As no 2 wounds are the same, one of the first steps is to

mentally assess and classify the wound preoperatively to develop a plan for wound closure. A common mistake is to
forget about wound closure until the very end of the case.
This often leads to operating room personnel scrambling to
locate what the surgeon needs, thereby wasting precious time
and placing the patient at greater surgical risk. Preparing
ahead of time promotes efficiency and ensures that all available resources are available when needed.
The first step in classification is determining whether the
wound is clean or contaminated. This will help determine
whether the wound can be closed primarily or may need
delayed closure to limit risk of wound infection.7 It will also
have bearing on the type of suture used, with avoidance of
braided or nonabsorbable suture in contaminated wounds,
as these are more likely to continue to harbor infection after
the wound is closed.8
The location of the wound is also important and will aid in
selection of closure technique. Obviously, wounds that are in
highly visible locations deserve meticulous closure to minimize scarring, as do wounds in areas of touch or manipulation, such as the hands and feet.9 With regard to joint arthroscopy, there have been recent studies showing that leaving the
portals open or using adhesive tape results in a slightly lower
complication rate than closing portals primarily with suture.10,11 However, in our practice, we have not found this to
be the case and continue to perform a single-level nylon skin
closure, which results in improved wound cosmesis.
The size and depth of the wound should be considered as
well, with larger defects and those with exposed tendon/bone
possibly needing skin flap/graft coverage. Deeper wounds
will also likely need a layered closure to prevent dead space
with subsequent hematoma/seroma formation, which could
serve as a nidus for infection.7,9,12
Also of importance are the static and dynamic forces that
produce tension on the skin, such as bony prominences and
joint motion, respectively. Incisions and wounds over areas
of less tension and dynamic forces usually result in better
cosmetic results, whereas those with increased tension and
dynamic forces tend to result in a worse cosmetic result. Skin

Suture Material
Important in the understanding of wound closure is also
knowing what closure material is available. Most operating
rooms have a suture cart with many different types of suture
material. The following is a brief summary of the most common types of suture used for orthopedic wound closure today, including an explanation on their advantages/disadvantages and biomechanical characteristics (Table 1).

Absorbable

M. Hussey and M. Bagg

208
Table 1 Suture Material
Suture
Absorbable
Vicryl (polyglactin 910)
Surgical gut
Plain
Chromic
Fast-absorbing
Monocryl
(poliglecaprone 25)
PDS II (polydioxanone)
Nonabsorbable
Ethilon (nylon)
Prolene
(polypropylene)

Composition

Tensile Strength
Retention

Absorption Rate

Tissue
Knot
Reaction Security*

Glycolide and lactide

75% at 2 weeks
25% at 4 weeks

Complete absorption
within 90 d

Minimal

Collagen-based submucosa
of sheep or cattle
Treated with chromium
salts
Heat treated
Glycolide and caprolactone
Polyester p-diozanone

40% at 1 week

Complete absorption
by 2 wks
Complete absorption
by 3 wks
Faster than plain
Complete absorption
within 120 d
Complete absorption
within 6 mo

Moderate

Moderate

Moderate
Minimal

Slight

N/A

Minimal

N/A

Minimal

Polyamide polymer
Polymer of propylene

Greater than plain

Less than plain
50% at 1 week
0% at 3 weeks
70% at 2 weeks
50% at 4 weeks
Loses 15% per
year
No loss

*A subjective measure of relative knot strength.

tissue reactivity; however, its stiff and less pliable nature

make it difficult to handle.13,15

Nonabsorbable
Nylon (Ethilon) is a synthetic nonabsorbable monofilament
composed of a polyamide polymer.13,15 It displays high elasticity, memory, and tensile strength and loses only about
15% of its tensile strength per year by hydrolysis.8 Another
important characteristic of nylon is that it can be made more
pliable and easier to handle by wetting the suture. Advantages of nylon include the following: it is an inexpensive
suture material, causes minimal tissue reactivity, and has
long-lasting tensile strength.13,15 Its disadvantages include
need for eventual removal, as well as poor knot security secondary to its high memory.8,13
Polypropylene (Prolene) is a synthetic nonabsorbable
monofilament suture made of an isostatic crystalline hydrocarbon polymer, making it relatively inert and resistant to
enzyme degradation.8,15 It easily passes through tissue because of its nonadherence properties.8,13 Similar to nylon,
advantages of polypropylene include high tensile strength
and minimal tissue reactivity. Because polypropylene has
high plasticity and is able to accommodate wound edema, it
is less susceptible to cut out of tissue.13 Disadvantages of
polypropylene include poor knot security, need for eventual
removal, and increased cost, which is almost double the cost
of nylon.8,15
Surgical staples have become increasingly popular over
recent years, likely because of quickness and ease of use.
Most staples are made of 316L-grade stainless steel and cause
minimal tissue reactivity. They have the advantage of being
easy to use, allowing rapid closure, and promoting good skin
apposition. Surgical staples have a lower incidence of infection compared with sutures when closing contaminated
wounds.15 Disadvantages of surgical staples include need for

eventual removal, which can be painful, and they can leave

permanent tracks along the wound edges.7,9

Needle Selection
In addition to suture selection, the surgeon is frequently
questioned regarding the particular type of needle he or she
would like to use. Often, we rely on our surgical technicians
to know what type of needle we need, as we are unknowledgeable about the different types of needles that are available. As with all aspects of surgery, proper needle selection
can promote efficiency and decrease confusion in the operating room.
A general understanding of needle anatomy, shape, and
type is crucial in all aspects of wound closure. Suture needles
are composed of 3 basic components: eye, body, and point.14
The eye of modern needles is almost always of the swaged
type, in which the suture is manufactured into the eye.15 The
needle is matched to the suture caliber, which makes it less
traumatic upon exit. The shape of the needle is also important, with a 3/8 circle needle being the most commonly
used for wound closure. A 1/2 circle needle can also be used
to facilitate closure of deeper wounds, although this requires
more pronation/supination of the wrist. Another important
feature used in many modern needles today is longitudinal
ribbing along the body, which provides added needle control
by way of a crosslocking action with the needleholder.14
Although there are many different types of needle points
currently in use, the most commonly used are of the cutting
and tapered type. Cutting needles have 3 cutting edges,
allowing for excellent penetration into tough tissues such as
skin. They can also be subcategorized into either standard or
reverse cutting, with the difference depending on which way
the third edge points. Standard cutting needles have the third
edge pointing toward the wound edge. Reverse cutting nee-

Principles of wound closure

209

Table 2 Common Needle Codes

CODE

MEANING

BN
CE
CFS
CP
CPX
CT
CTB
CTX
EN
FS
FSL
LH
MH
MO
OS
PS
RH
SH

Bunnell
Cutting edge
Conventional for skin
Cutting point
Cutting point extra large
Circle taper
Circle taper blunt
Circle taper extra large
Endoscopic needle
For skin
For skin large
Large half
Medium half (circle)
Mayo
Orthopedic surgery
Plastic surgery
Round half (circle)
Small half (circle)

dles have the third edge pointing away from the wound edge,
which helps avoid the possibility of cut-out through the
wound. Tapered needles, however, have a body that is round
and tapers smoothly to a point. Unlike cutting needles, they
spread through the tissue without cutting it. They are most
commonly used in less resistant tissue such as fascia and
subcutaneous fat.15
In an attempt to simplify and abbreviate needle selection,
needles are often categorized by acronym and number, corresponding to design and size, respectively (eg, PS-1, FS-2,
CT-3). A list of the most commonly used acronyms in needle
selection are listed in Table 2.14

Wound Management
Timing
Classically, the golden period for managing acute wounds
has been defined as 6 hours. This has been supported by
clinical and research studies, which show an increased risk of
infection if debridement is not carried out within this window. However, practical realities, such as lack of operating
room time and delayed presentation, often impede early
wound management, which has resulted in newer techniques
to optimize this period and thus challenge the 6-hour rule.
Some of these newer techniques, such as silver-coated dressings and negative-pressure wound therapy, have leveraged
newer technologies to optimize wound care.

Assessment
Before closure, all wounds require a systematic assessment. Skin and subcutaneous tissue need to be carefully
evaluated, paying particularly close attention to the vascularity. Nonviable skin is dusky and without capillary refill.
It does not bleed when excised. Subcutaneous fat, when
necrotic, is dull and grayish brown to black. Probably, the
most consistent adjunct in determining skin viability is

flourecin. Other adjuncts rarely used are ultrasound

Doppler flowmeters, laser temperature readings, photoplesthymography, and transcutaneous PO2 monitors. Enlarging the wound to allow better visualization and exposure should be a high priority.
Muscle viability is determined by assessing its contractility,
color, and whether it bleeds when cut. Necrotic muscle does
not contract when stimulated with electorcautery or pinched
with forceps, is a dark red color, and does not bleed when
debrided. Compartment syndrome should always be at the
forefront of any acute wound assessment, with rapid and
aggressive fasciotomies performed if the compartments are
tight or the muscle is found to bulge significantly after incising the fascia. Blood vessels and nerves should be carefully
preserved if possible. It is debatable whether these structures
should be tagged, as often this only causes greater tissue
damage. Finally, bone should be carefully assessed for vascularity and only be selectively debrided if it is devoid of softtissue attachments and stripped of periosteum.

Wound Debridement
Wound debridement remains the most fundamental principle in the successful management of open wounds. After a
thorough assessment of the wound, abscess cavities require
drainage, elevated compartment pressures should be decompressed, and devitalized, infected, or necrotic tissue requires
excision from the wound. Probably, the best determinant to
guide the surgeon on the extent of debridement is whether
the tissue in question bleeds. This generally will provide a
useful end point regarding the extent of debridement. However, there are specialized tissues, such as cartilage, tendon,
and bone, which require the judgment of the surgeon on
whether to debride the tissue. In many cases, it may require a
second or third debridement to achieve a stable wound that is
ready for closure. Sequential debridement is necessary when
tissue viability and the extent of debridement are not predictable. The viable margins of the wound can then be identified
and borderline tissue may be preserved without the risk of
infection by early wound closure.

Wound Irrigation
Wounds should be cleansed with a sufficient volume of irrigant to reduce or eliminate particulate matter and bacterial
loads from the wound. There is some debate as to the proper
pressure that is ideally required in the delivery of the irrigant.
High-pressure delivery has been shown to initially decrease
bacterial burden on the surface of tissues; however, it may
drive bacteria deeper into the tissues, which results in a rebound of bacterial colonization after several days. Therefore,
delivery through a bulb syringe may be the ideal method of
irrigating contaminated wounds. Generally, normal saline is
the most appropriate irrigant when available; however, when
tap water has been used, rates of infection have remained the
same. Povidoneiodine, hydrogen peroxide, and detergents
should be avoided because of their tissue-toxic properties.

210

Negative-Pressure
Wound Therapy
The goal of any surgical dressing covering an open wound is
to provide a barrier to contamination and infection, to decrease edema within the wound by actively or passively eliminating fluid exudates, and, finally, to reduce pain and discomfort by preventing desiccation of tissues. Negativepressure wound therapy exposes the wound bed to
mechanically induced negative pressure, resulting in active
removal of fluid from the extravascular space, improving circulation, enhancing the proliferation of granulation tissue,
and decreasing the burden of bacteria. The following are
indications in which negative-pressure wound therapy may
be appropriate: infected open wounds after debridement;
open fracture wounds; acute soft-tissue wounds with exposed white tissue, such as bone, nerve, tendon, and joints;
wounds with exposed shiny tissue, such as hardware; fasciotomy wounds after compartment release; surgical wounds
that are difficult to close because of tension; and surgical
wounds weeping serous fluid. Generally, pressure settings of
125 mm Hg are used for most wound types, with the exception of weeping surgical incisions that have already been
closed, in which the pressure setting is lowered to 50 mm
Hg. Generally, the wound vac is an intermediate step before
obtaining definitive wound coverage. Because of its use in
accelerating wound healing by promotion of granulation tissue, flap coverage of a wound is enhanced and sometimes
altogether circumvented. The wound vac has become a very
popular method of wound coverage; however, it is absolutely
not a substitute for a thorough surgical debridement. When
negative-pressure wound therapy is chosen as a method to
cover an open wound, negative pressure should be continuously applied to the wound bed. If negative pressure is not
being delivered to the wound bed, wound infections may
occur or worsen. Essentially, a sealed wound without negative pressure equates to closing a contaminated wound.
Therefore, it is important that the wound vac dressing be
carefully monitored to ensure that negative pressure is continuously delivered to the wound. For chronic nonhealing
wounds, the wound vac was shown to be superior to moist
saline dressings.

Wound Closure Techniques

During the evaluation of the injury and after initial debridement, a wound closure plan should be constructed. There are
many options for wound closure, and generally, the simplest
method with the least risk, which will result in a stable healed
wound, is chosen. Typically, the reconstructive ladder of
wound closure options has been useful in planning the closure of any wound. It should only be used as a guideline, as
each wound needs to be assessed individually, taking into
consideration a multitude of factors, such as size and depth of
the wound, vascularity of the surrounding tissue, and type of
tissue exposed.
Beginning at the bottom rung of the reconstructive ladder

M. Hussey and M. Bagg

is allowing the wound to heal by secondary intention. Typically after draining an abscess in the hand, the wound is
allowed to spontaneously heal by secondary intention, that
is, from the inside out to ensure bacteria are not trapped
under the closed wound. The advantages of this type of
wound closureare its relative ease of use and avoidance of
wound infection. Of course, the disadvantages are the increased length of time to wound closure and the possibility of
a suboptimal scar.
Going to the next rung of the ladder is primary closure.
This is obviously the preferred method to close a wound, if at
all possible, if the wound is clean and straightforward. It is
simple and is the most cosmetically acceptable. However,
there is the potential for wound infection.
If there is tension on the wound edges and the defect
cannot be closed primarily, a skin graft can be harvested to
cover the open wound. A skin graft has no intrinsic blood
supply and requires capillary in-growth from the wound bed.
Therefore, the wound must be meticulously clean, and hemostasis is required to prevent a hematoma from forming
under the graft. There are many types of dressings that have
been advocated to protect the skin graft to prevent shearing.
If the wound bed is convex, a simple moist adaptic dressing
with a circumferential wrap to prevent shearing of the graft is
probably all that is required. If the wound bed is concave or
the vascularity is questionable, a wound vac may increase the
survival rate of the graft. Skin grafting is relatively simple;
however, it does require meticulous wound preparation and
may leave an unsightly scar. In addition, a skin graft is not a
durable type of wound coverage that will allow repair or
reconstruction of underlying tissues.
When there are exposed white tissues, such as bone,
tendon, nerves, and joints, the wound will require coverage
with a flap, which is defined as a tissue with an intrinsic blood
supply. The simplest flaps are local soft-tissue arrangements,
such as Z-plasties, that do not have a defined blood supply.
This type of closure is the next rung on the reconstructive
ladder. There are more advanced local flaps, such as fasciocutaneous flaps and musculocutaneous flaps, that have a defined axial circulation that must be protected while raising
the flap. Using a local flap provides similar tissue, is durable,
and generally does not require microvascular expertise or an
operative microscope.
Muscle and fasciocutaneous flaps are both optimal flaps
for coverage of large soft-tissue defects, obliterate dead space,
and serve as a delivery system of leukocytes, oxygen, and
antibiotics. Each of these flaps can be rotated on a pedicle or
can be transferred as a free-tissue transfer. Free-tissue transfer is the most complex type of procedure on the reconstructive ladder. As microvascular techniques have improved over
the years, the indications for free-tissue transfer have increased. In some instances, it is more appropriate to directly
perform free-tissue transfer as the preferred method for
wound closure. Certainly, if there are tissues other than skin
and muscle required for reconstruction (ie, bone, nerve, and
tendon), a free flap will be the best option. The advantage of
free-tissue transfer is that it allows for reconstruction of a
multitude of different tissues if local tissue is not available.

Principles of wound closure

The disadvantages are the need for microvascular expertise,
specialized surgical and monitoring equipment, operative
microscope, and increased surgical time, with the potential of
vascular compromise to the graft.

Summary
Today, almost any wound of any complexity can now be
successfully closed. Some of this success can be attributed to
the newer methods that have evolved over the past decade,
such as the advancements in wound dressings and advanced
surgical techniques, including free-tissue transfer. However,
for these new methods of wound closure to be successful, the
principles of meticulous surgical debridement and wound
management must be continually emphasized, as they remain unchanged.

References
1. Strecker-McGraw MK, Jones TR, Baer DG: Soft tissue wounds and
principles of healing. Emerg Med Clin North Am 25:1-22, 2007.
2. Gartner LP, Hiatt JL: Epithelium and glands. Philadelphia, PA: Saunders, Color Textbook of Histology, 2001, pp 85-108
3. Diegelmann RF, Evans MC: Wound healing: An overview of acute,
fibrotic and delayed healing. Front Biosci 9:283-289, 2004

211
4. Singer AJ, Clark RA: Cutaneous wound healing. N Engl J Med 341:738746, 1999
5. Hunt TK: Basic principles of wound healing. J Trauma 30(suppl 12):
S122-S128, 1990
6. Levenson SM, Geever EF, Crowley LV, et al: The healing of rat skin
wounds. Ann Surg 161:293-308, 1965
7. Lloyd JD, Marque MJ 3rd, Kacprowicz RF: Closure techniques. Emerg
Med Clin North Am 25:73-81, 2007
8. Kudur MH, Pai SB, Sripathi H, et al:. Sutures and suturing techniques in skin closure. Indian J Dermatol Venereol Leprol 75:425434, 2009
9. DeBoard RH, Rondeau DF, Kang CS, et al: Principles of basic wound
evaluation and management in the emergency department. Emerg Med
Clin North Am 25:23-39, 2007.
10. Fairclough JA, Moran CG: The use of sterile adhesive tape in the
closure of arthroscopic puncture wounds: a comparison with a single layer nylon closure. Ann R Coll Surg Engl 69:140-141, 1987
11. Maffulli N, Pintore E, Petricciuolo F: Arthroscopy wounds: to suture or
not to suture. Acta Orthop Belg 57:154-156, 1991
12. Hollander JE, Singer AJ: Laceration management. Ann Emerg Med
34:356-367, 1999
13. Bloom BS, Goldberg DJ: Suture material in cosmetic cutaneous surgery.
J Cosmet Laser Ther 9:41-45, 2007
14. Dunn D: Ethicon Wound Closure Manual, Ethicon Inc., 2004, pp
1-12715
15. Hochberg J, Meyer KM, Marion MD: Suture choice and other methods
of skin closure. Surg Clin North Am 89:627-641, 2009