Direct approximation of the wound margins is required for healing by primary intention. This is preferred when possible. However, if infection or excessive tension is present, then healing by secondary intention (spontaneous contraction and epithelialization) or tertiary intention (delayed surgical closure) will most likely be necessary. The following surgical axioms are important to remember in the goal of obtaining a fine-line scar that compromises neither function nor appearance:
Critical elements include the obliteration of dead space, layered tissue closure, and eversion of skin margins. Deep dermal sutures align the skin edges and help decrease tension on the skin closure. Everting skin sutures are placed by encompassing a larger amount of deep dermis than epidermis in the closure. The suture is tied under the minimal tension necessary to appose the skin margins. Because nonabsorbable synthetic monfilament sutures (nylon, Prolene) are minimally reactive, they are preferred for skin closure when cosmesis is essential. Absorbable synthetic braided sutures (Vicryl, Dexon) are ideal for deep dermal closure, acting as transient but necessary skin splints. Absorbable natural sutures (catgut, chromic catgut) induce inflammation as they are degraded by phagocytosis. Still they are useful where suture removal is difficult and cosmesis is not critical (in the mouth, inside the nose, and non-facial wounds in children).