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Skin suturing and suture removal are essential skills that support safe wound closure, promote healing, reduce the risk of infection, and optimize functional and cosmetic outcomes. Although the perioperative nurse may not always perform suturing independently, they play a critical role in preparing equipment, assisting the provider, anticipating procedural needs, maintaining aseptic technique, monitoring patient comfort, and recognizing when wound findings require modification of the planned approach or escalation for further medical evaluation.

This module provides the knowledge and practical skills required to understand the principles of skin suturing and safe suture removal. Learners will develop an understanding of wound assessment, suture materials, needle selection, closure techniques, wound healing, postoperative care, and the safe removal of sutures. The module also emphasizes sound clinical judgment, patient safety, accurate documentation, and practical adaptations for low-resource environments.

This module is intended for perioperative nurses and other clinicians involved in assisting with wound closure and postoperative wound management. Learners are expected to possess fundamental knowledge of aseptic technique, basic anatomy and physiology of the skin, infection prevention, and routine wound care. The module builds on these foundational competencies to develop the knowledge, clinical reasoning, and psychomotor skills required to safely assist with skin suturing, perform suture removal when indicated, and recognize situations requiring referral or escalation.

By the end of this module, you will be able to:

• Describe the indications, contraindications, and clinical principles of skin suturing and suture removal.
• Perform a systematic assessment to determine whether a wound is appropriate for suturing or suture removal.
• Identify the instruments, equipment, and materials required for skin suturing and suture removal.
• Differentiate common suture materials and needle types, including their characteristics, indications, advantages, and limitations.
• Select appropriate wound closure methods based on wound characteristics, anatomical location, tissue tension, and healing requirements.
• Explain the principles of atraumatic tissue handling, wound edge approximation, knot security, and tension management.
• Describe the phases of wound healing and recognize normal and abnormal healing findings.
• Explain appropriate postoperative wound care, patient education, documentation, and follow-up after suturing and suture removal.
• Describe the principles and technique of safe suture removal, including wound support and recognition of complications.
• Identify practical adaptations that maintain safe practice in low-resource environments.

Skin suturing is one of the most common methods of wound closure and is performed to restore tissue continuity, promote healing, reduce the risk of infection, preserve function, and optimize cosmetic outcome. Although perioperative nurses may not always perform wound closure independently, they play a critical role in preparing the patient and equipment, assisting the proceduralist, maintaining aseptic technique, anticipating procedural needs, and recognizing findings that influence wound management. Safe wound closure begins long before the first suture is placed. Careful assessment of both the patient and the wound establishes whether suturing is appropriate and guides every subsequent decision.

Successful skin closure depends on sound clinical judgment rather than technical skill alone. Appropriate wound selection, meticulous preparation, atraumatic tissue handling, and proper approximation of wound edges all contribute to optimal healing. Conversely, closing an unsuitable wound or failing to recognize features that require alternative management can increase the risk of infection, wound dehiscence, poor cosmetic outcome, and patient harm. Throughout this module, these assessment principles form the foundation upon which the remaining topics build.

Skin suturing is performed to approximate wound edges so that healing can occur by primary intention. Proper wound closure restores tissue continuity, protects underlying structures from contamination, minimizes bleeding, supports functional recovery, and improves cosmetic outcome.

The objective of suturing is not simply to close a wound but to create the conditions that allow normal healing to occur. Successful closure depends on careful wound assessment, appropriate preparation, gentle tissue handling, correct suture selection, and proper wound edge approximation. Excessive tissue tension, poor alignment, contamination, or inadequate preparation increase the likelihood of infection, delayed healing, wound separation, and excessive scar formation.

Perioperative nurses contribute to successful wound closure by preparing appropriate instruments and supplies, maintaining aseptic technique, anticipating the provider's needs, monitoring patient comfort, and recognizing situations in which routine closure should be modified or delayed.

Skin suturing is indicated for a variety of wound types, including clean surgical incisions, sharp lacerations, and avulsion injuries in which viable tissue remains attached and satisfactory approximation can be achieved.

Before suturing, however, every wound must be assessed to determine whether immediate closure is appropriate. Common contraindications include:

• Heavily contaminated or infected wounds.
• Deep puncture wounds or wounds containing retained foreign bodies.
• Animal or human bites that have not undergone appropriate irrigation and debridement.
• Devitalized or crushed tissue with poor perfusion.
• Delayed presentation (generally more than 12–18 hours after injury, or more than 24 hours for facial wounds, depending on local practice).
• Poorly controlled diabetes or significant peripheral vascular disease.
• Systemic sepsis.
• Clotting disorders or anticoagulant therapy requiring additional assessment.
• Known allergy to planned local anaesthetic agents.

Recognition of these conditions allows the perioperative nurse to anticipate additional wound management requirements such as further irrigation, debridement, delayed primary closure, specialist consultation, or alternative methods of wound management.

Safe wound closure begins with a systematic assessment of both the patient and the wound. Patient history should be reviewed for bleeding tendencies, previous wound healing complications, allergies, immunization status where appropriate, and medications such as anticoagulants or corticosteroids that may affect bleeding or healing.

The wound itself should then be assessed carefully to determine:

• Anatomical location.
• Length, depth, and orientation.
• Tissue viability.
• Degree of contamination.
• Presence of foreign material.
• Bleeding and haemostasis.
• Tissue loss or dead space.
• Relationship to underlying structures such as tendons, nerves, joints, cartilage, or major blood vessels.

Taking time to assess the wound before beginning preparation is a critical step in determining procedural appropriateness. A wound that initially appears suitable for closure may require referral if contamination cannot be adequately controlled or if injury to deeper structures is suspected.

Assessment also identifies anatomical factors that influence closure planning. Wounds crossing joints must withstand increased tension during movement. Facial wounds require meticulous edge alignment to optimize cosmetic outcome. Deep wounds frequently require layered closure to eliminate dead space and reduce wound tension. These findings help the perioperative nurse anticipate equipment needs and prepare appropriate suture materials before closure begins.

The wound bed must be thoroughly irrigated and, when necessary, debrided before any suturing begins. A wound that appears clean may still harbour debris or devitalized tissue, making meticulous inspection under good lighting and appropriate patient positioning essential.

Following wound cleansing, the wound edges should be handled gently using toothed tissue forceps, such as Adson forceps, to avoid crushing viable tissue. Excessive tissue trauma compromises local blood supply and increases the likelihood of infection, delayed healing, and poor scar formation.

Throughout preparation, aseptic technique should be maintained to minimize contamination before closure. The perioperative nurse should also ensure that all necessary instruments, suture materials, local anaesthetic, irrigation supplies, and dressings are readily available before the procedure proceeds.

Successful suturing depends upon accurate approximation rather than excessive compression of the wound edges. Proper approximation restores normal tissue alignment while preserving tissue perfusion and minimizing wound tension.

Leaving dead space beneath the wound, placing sutures too tightly, creating irregular edge alignment, or allowing wound edges to invert predisposes the wound to infection, tissue ischemia, wound dehiscence, delayed healing, and poor cosmetic outcome.

The goal is to achieve symmetrical wound edge alignment with gentle eversion and balanced tension across the wound. These principles remain constant regardless of the specific closure technique selected, which will be discussed in a later topic.

Completion of wound assessment and preparation should always be followed by a final decision regarding the appropriateness of wound closure.

This decision should consider:

• The degree of contamination.
• Tissue viability.
• Anatomical location.
• Functional requirements.
• Wound tension.
• Cosmetic considerations.
• Risk of infection.
• Availability of appropriate closure materials.

Not every wound should undergo immediate closure. The perioperative nurse should recognize findings that require reassessment by the provider or modification of the planned management, including extensive contamination, devitalized tissue, uncontrolled bleeding, involvement of deeper structures, or evidence of established infection.

Sound clinical judgment at this stage prevents inappropriate closure and supports safer patient outcomes.

• Successful wound closure begins with careful patient and wound assessment.
• Not every wound is suitable for immediate suturing.
• Patient history and wound characteristics both influence management decisions.
• Thorough irrigation and debridement prepare the wound for safe closure.
• Gentle tissue handling preserves tissue viability and promotes healing.
• Successful suturing depends on approximation rather than excessive tension.
• Anatomical location influences closure planning and anticipated equipment needs.
• Early recognition of wounds requiring referral or alternative management improves patient safety.

Having established the principles that determine whether and how a wound should be closed, the next topic examines the suture materials, needles, instruments, and equipment used to perform skin suturing safely and effectively.

Self-Assessment

Please complete the following: Wound Assessment and Principles of Skin Suturing Quiz

Once a wound has been assessed and determined to be suitable for closure, the next step is selecting and preparing the appropriate materials and equipment. Appropriate selection of suture material, needle type, instruments, and supplies allows the wound to be closed safely, efficiently, and with the least possible tissue trauma. The perioperative nurse plays a central role in anticipating these needs, organizing the sterile field, and ensuring that all required equipment is immediately available before wound closure begins.

No single suture or needle is suitable for every wound. Material selection depends on the tissue being repaired, the amount of wound tension, the desired duration of wound support, the risk of infection, and the anticipated cosmetic outcome. Understanding these principles enables the perioperative nurse to prepare appropriate options in advance and anticipate changes to the procedural plan if wound characteristics differ from those initially expected.

Suture materials fall into two broad categories: absorbable and non-absorbable.

Absorbable sutures are commonly used for deep tissue or subcutaneous closure where later removal is not feasible. Common examples include Vicryl and Chromic Gut. Vicryl maintains tensile strength for approximately two to three weeks while producing minimal tissue reaction, making it suitable for many deep tissue closures. Chromic Gut is generally less expensive but loses tensile strength more rapidly and may produce a greater inflammatory response.

Non-absorbable sutures are typically selected for skin closure when later removal is planned. Common examples include Nylon and Prolene. Nylon maintains tensile strength for prolonged periods but may produce mild tissue reactivity. Prolene causes very little tissue reaction and is often preferred when minimizing scarring is an important consideration.

Selection of suture material should always consider the tissue being repaired, expected healing time, wound tension, risk of infection, and patient factors identified during wound assessment.

Suture materials are also classified according to their structural configuration as either braided or monofilament, and these characteristics influence handling, knot security, tissue passage, and infection risk.

Braided sutures, such as Silk and Vicryl, consist of multiple woven strands. They offer excellent handling characteristics and superior knot security because the individual strands grip one another effectively. However, their multifilament structure may harbor microorganisms and increase the risk of infection, particularly in contaminated wounds.

Monofilament sutures, including Nylon and Prolene, consist of a single smooth strand. They pass through tissue more easily, reduce tissue drag, and are less likely to retain microorganisms. Their smooth surface makes them advantageous for skin closure and contaminated wounds, although they possess greater memory and require careful knot tying to prevent knot loosening.

Braided sutures are commonly selected for elective procedures such as bowel anastomosis or fascial closure where secure knot holding is particularly important. Monofilament sutures are generally preferred for skin closure and contaminated traumatic wounds because they reduce bacterial retention and tissue trauma.

Selecting the appropriate needle is equally important to selecting the suture itself.

Cutting and reverse cutting needles are most commonly used for skin closure because their triangular cross-section penetrates dense skin efficiently while minimizing unnecessary tissue trauma.

Tapered needles are intended for delicate tissues such as bowel, muscle, and vascular structures because they separate tissue fibers rather than cutting through them.

Needle size should also be matched to the wound being repaired. Smaller needles allow more precise placement in delicate tissues, whereas larger needles facilitate closure of thicker or more robust tissues.

The shape of the needle also influences ease of use. Curved needles facilitate suturing in confined or deep operative fields where hand movement is limited. Straight needles may be useful for surface-level wounds in easily accessible locations.

The perioperative nurse should prepare an appropriate selection of needle types, sizes, and suture combinations before the procedure begins. By understanding these principles, the nurse can anticipate procedural needs, recognize potential difficulties, and ensure smooth progression of the wound closure.

The diameter, or gauge, of the suture should correspond to the tissue being repaired.

Fine sutures such as 5-0 and 6-0 are commonly used for facial wounds and other cosmetically sensitive areas because they minimize tissue trauma and scar formation.

Intermediate sizes such as 4-0 are frequently selected for many hand and extremity wounds.

Larger sutures such as 2-0 and 3-0 provide greater tensile strength and are commonly used for scalp, trunk, and other areas subjected to greater mechanical stress.

Appropriate gauge selection balances adequate wound support with minimization of tissue injury. Selecting unnecessarily large sutures increases tissue trauma, whereas sutures that are too fine may not provide sufficient tensile strength for the wound.

Successful wound closure depends upon proper preparation of both the instruments and the sterile field.

Essential equipment commonly includes:

• Needle holder
• Adson or toothed tissue forceps
• Metzenbaum scissors or suture scissors
• Sterile gloves
• Surgical mask
• Sterile gown
• Sterile drapes
• Sterile gauze
• Antiseptic solution
• Local anesthetic with appropriately sized syringe and needle
• Irrigation supplies
• Sharps disposal container
• Appropriate suture materials

Depending on the wound, additional instruments such as skin hooks, small retractors, or other specialized equipment may be required to improve visualization while minimizing tissue trauma.

Before beginning the procedure, package integrity and expiry dates should be verified, and all instruments and supplies should be inspected to ensure they are complete, sterile, and functioning correctly.

Essential suturing supplies should be arranged in a logical and consistent manner to preserve sterility and promote efficient workflow.

The needle holder is typically positioned centrally on the Mayo stand or sterile tray for immediate access. Adson or toothed tissue forceps are placed to one side, with Metzenbaum scissors or suture scissors positioned on the opposite side according to local practice. Sterile drapes should isolate the wound and establish a clearly defined sterile working area.

Antiseptic solution, such as povidone-iodine or chlorhexidine, should be readily available for skin preparation in accordance with local protocol and the principles described in the Skin Preparation and Draping module. Gauze swabs should be stacked neatly to allow rapid access for cleaning, drying, or controlling minor bleeding during the procedure.

Local anesthetic should be prepared using the correct syringe and needle, clearly labeled where required by local policy, and checked to confirm the correct medication, concentration, and expiry date before administration.

The sharps disposal container should remain within arm's reach throughout the procedure to allow immediate disposal of needles and blades after use.

Suture materials should be organized logically, with absorbable and non-absorbable sutures separated and clearly identified according to type and size. Sterile towels, drapes, marking pens, and any additional supplies should be arranged to support the anticipated procedure.

Documentation materials, including any wound assessment or procedural record required by local practice, should also be readily available to facilitate accurate recording of wound characteristics, closure technique, suture material, and the number of sutures placed.

Preparation extends beyond arranging instruments and supplies. Throughout the procedure, the perioperative nurse should continuously anticipate the proceduralist's needs by preparing alternative suture materials, additional needles, replacement instruments, dressings, and other equipment before they are requested.

This proactive approach maintains procedural flow, minimizes unnecessary interruptions, and allows the team to adapt efficiently if wound findings require modification of the planned closure.

A well-organized sterile field allows the nurse to anticipate needs while maintaining sterility throughout the procedure. In contrast, a disorganized field increases the risk of contamination, procedural delays, unnecessary patient discomfort, and avoidable errors. Every instrument and supply has a specific purpose, and systematic organization supports safe, efficient, and precise wound closure.

• Suture selection depends on tissue type, wound tension, healing time, infection risk, and cosmetic requirements.
• Absorbable sutures are generally used for deeper tissues, while non-absorbable sutures are commonly used for skin closure.
• Braided sutures provide excellent knot security but may increase infection risk, whereas monofilament sutures reduce tissue drag and bacterial retention.
• Cutting and reverse cutting needles are used for skin, while tapered needles are used for delicate tissues.
• Curved needles improve access in confined operative fields, while straight needles may be useful for accessible surface wounds.
• Suture gauge should match the tissue being repaired and the expected mechanical forces on the wound.
• Proper preparation and organization of instruments and the sterile field improve safety, maintain sterility, and support efficient workflow.
• Anticipating equipment needs enables the perioperative nurse to support smooth procedural flow and respond effectively to changing clinical circumstances.

With an understanding of how suture materials, needles, instruments, and equipment are selected and prepared, the next topic examines how clinicians choose the most appropriate wound closure technique for different wound types and clinical situations.

Self-Assessment

Please complete the following: Suture Materials and Preparation Quiz

Having assessed the wound and prepared the appropriate materials and equipment, the next step is selecting the most appropriate closure technique. No single suturing method is suitable for every wound. The choice of closure technique depends on the wound's size, depth, anatomical location, tissue tension, cosmetic requirements, and the condition of the surrounding tissue.

Successful wound closure requires more than technical skill. The clinician must select a technique that restores tissue continuity while preserving blood supply, minimizing tissue trauma, distributing tension appropriately, and promoting uncomplicated healing. As discussed in Topic 1, wound assessment forms the foundation of these decisions, while the suture materials and instruments discussed in Topic 2 provide the tools needed to carry them out safely.

Closure technique selection is guided primarily by wound type, tissue tension, anatomical location, and the desired functional and cosmetic outcome. The selected technique should achieve secure wound edge approximation while minimizing tissue trauma and preserving adequate blood supply.

Before selecting a closure method, each wound should be assessed for:

• Wound size and length
• Wound depth
• Anatomical location
• Tissue viability
• Tissue loss
• Bleeding
• Degree of contamination
• Functional status of the involved structures
• Presence of dead space
• Expected tension across the wound
• Cosmetic considerations
• Patient factors that may influence healing

These findings determine whether immediate closure is appropriate and which closure technique will provide the safest and most effective result.

Several suturing techniques are commonly used for skin closure. Each has specific advantages and clinical indications.

The simple interrupted suture is the most versatile and widely used skin closure technique. Each stitch is placed and tied independently, allowing individual adjustment of wound edge approximation and tension.

Because every suture functions independently, failure of one stitch does not compromise the entire wound closure. This technique is particularly useful for irregular wounds, wounds with variable tissue tension, and situations requiring precise adjustment of individual stitches.

The continuous, or running, suture uses a single strand of suture material to close the wound without tying individual knots between each stitch.

This technique can be placed rapidly and distributes tension evenly along long, straight wounds. However, because the closure depends upon a continuous strand, failure of one portion of the suture may compromise the entire closure.

Continuous sutures are commonly selected for clean, low-tension wounds, including long surgical incisions where procedural efficiency and even tension distribution are priorities.

The vertical mattress suture combines deep and superficial tissue bites to provide excellent wound edge eversion while distributing tension away from the wound margins.

This technique is particularly valuable for wounds under high tension, including wounds over joints, areas of thick skin, and wounds at increased risk of edge inversion or separation.

The horizontal mattress suture distributes tension across a broader area of tissue than the simple interrupted suture.

It is particularly useful for fragile or thin skin where concentrated tension may cause sutures to cut through the tissue. It also provides additional reinforcement for wounds subjected to moderate tension.

The blanket, or over-and-over, suture provides continuous closure while adding reinforcement along the wound.

This technique is commonly used for long, straight incisions of the trunk or extremities when additional wound support is desirable.

The subcuticular suture is placed entirely within the dermis, leaving little or no external suture material visible.

Because this technique minimizes surface suture marks, it is frequently selected for cosmetically important areas such as the face and other highly visible parts of the body.

No single closure technique is appropriate for every wound. Technique selection should always be tailored to the wound characteristics identified during assessment.

Clean surgical incisions with well-approximated wound edges are generally closed immediately using simple interrupted, continuous, or subcuticular sutures depending on wound tension and cosmetic requirements.

Contaminated wounds, including traumatic lacerations from dirty environments, frequently require thorough irrigation and debridement before closure. In some cases, delayed primary closure may be the safest approach to reduce the risk of infection.

Traumatic wounds with tissue loss, crush injury, irregular wound edges, or poor tissue perfusion often require reinforced closure using vertical or horizontal mattress sutures to better distribute tension across compromised tissue.

Deep wounds containing dead space require layered closure. Absorbable sutures should first be placed within the deeper tissues to eliminate dead space, restore tissue support, and reduce tension before completing skin closure with an appropriate superficial technique.

Practical examples include:

• A shallow, linear wound with healthy, viable edges is commonly closed using simple interrupted sutures.
• A deep wound with a cavity requires layered closure using absorbable sutures before skin closure.
• An irregular wound may require individually adjusted or staggered simple interrupted sutures to achieve accurate wound edge alignment.
• A high-tension wound may require vertical or horizontal mattress sutures to reduce the risk of wound dehiscence.

Anatomical location has a major influence on closure technique selection because different body regions experience different mechanical forces and cosmetic requirements.

Wounds over joints such as the knee or elbow must withstand repeated movement and increased tissue tension. Vertical or horizontal mattress sutures often provide the additional support required to reduce the risk of wound separation.

Scalp wounds frequently require layered closure using absorbable sutures within the galea followed by simple interrupted skin sutures to restore tissue strength.

Facial wounds require meticulous wound edge approximation using fine 5-0 or 6-0 sutures together with simple interrupted or subcuticular closure techniques to minimize scar formation.

Lacerations crossing natural skin creases or lines of tension require careful alignment to preserve normal anatomical contours and minimize visible scarring. Simple interrupted sutures often provide the flexibility needed to adjust wound edge approximation precisely across these areas.

Long, straight wounds of the forearm or trunk may be closed efficiently using continuous sutures or, when additional reinforcement is needed, blanket sutures.

Deep wounds involving significant dead space, such as thigh lacerations or abdominal wall wounds, require layered closure using absorbable sutures within the deeper tissues before completing skin closure.

The perioperative nurse plays an important role in supporting safe wound closure by anticipating the closure technique likely to be selected based on the wound assessment.

This includes preparing the appropriate suture materials, selecting compatible needle types, and ensuring that additional instruments are immediately available when required.

Examples include:

• Preparing skin hooks or small retractors when wounds over joints require improved visualization.
• Having handheld or self-retaining retractors available for scalp wounds requiring layered closure.
• Preparing fine skin hooks and delicate tissue instruments for facial wounds where precise tissue handling is essential.
• Having Adson toothed forceps available for wounds crossing skin creases or cosmetic units to facilitate accurate wound edge alignment.
• Preparing handheld retractors for deep wounds requiring layered closure and improved visualization of deeper tissues.

The perioperative nurse should also anticipate the need for alternative suture materials or needle types if wound characteristics differ from those initially expected. This proactive preparation minimizes interruptions, supports efficient teamwork, and contributes to safe patient care.

• Closure technique should always be selected according to wound characteristics rather than personal preference.
• Wound assessment should include size, depth, location, tissue viability, contamination, tissue loss, dead space, functional status, and expected wound tension.
• Simple interrupted sutures are the most versatile technique and allow independent adjustment of each stitch.
• Continuous sutures provide rapid closure and even tension distribution for long, low-tension wounds.
• Vertical and horizontal mattress sutures provide additional support for wounds under increased tension.
• Subcuticular sutures are commonly selected when cosmetic outcome is particularly important.
• Deep wounds require layered closure to eliminate dead space and reduce wound tension.
• Anatomical location influences both closure technique and instrument selection.
• The perioperative nurse supports safe wound closure by anticipating the equipment, instruments, and suture materials required for the planned technique.

With an understanding of how wound closure techniques are selected for different wound characteristics, the next topic examines wound healing, postoperative wound care, clinical documentation, and patient education that support uncomplicated healing after wound closure.

Self-Assessment

Please complete the following: Selection of Wound Closure Techniques Quiz

Successful wound closure does not end when the final suture is tied. Appropriate postoperative wound care, patient education, and accurate clinical documentation are essential to promote uncomplicated healing and identify problems early. Understanding the normal process of wound healing allows the perioperative nurse to distinguish expected healing from complications requiring prompt intervention.

The perioperative nurse supports healing by protecting the wound, maintaining a clean environment, managing patient comfort, educating the patient, documenting findings accurately, and monitoring for complications throughout recovery.

Wound healing is a continuous biological process that restores tissue integrity after injury. Although healing progresses as a continuum, it is commonly described in three overlapping phases.

The inflammatory phase begins immediately after wound closure and generally lasts until approximately the third postoperative day.

Blood vessels initially constrict to control bleeding before dilating to allow inflammatory cells to enter the wound. These cells remove bacteria, foreign material, and damaged tissue while initiating tissue repair.

During this phase, mild redness immediately adjacent to the wound edges, slight swelling, mild tenderness, and a small amount of clear or serosanguineous drainage are expected findings. Infection risk is greatest during this period, making meticulous wound care and careful observation particularly important.

The proliferative phase typically extends from approximately day four through the third week after injury.

Granulation tissue develops, new blood vessels form, collagen is deposited, and epithelial cells migrate across the wound surface. Accurate wound edge approximation, adequate blood supply, minimal tissue tension, and protection from further trauma support successful healing during this phase.

Pain and swelling should gradually decrease while wound strength progressively improves.

The remodeling phase begins several weeks after injury and may continue for many months.

During this stage, collagen fibers reorganize and mature, increasing wound strength while the scar gradually becomes flatter, softer, and less visible.

Although the wound becomes progressively stronger, healed skin rarely regains the full strength of uninjured tissue. Careful wound closure and protection during healing contribute to improved long-term cosmetic and functional outcomes.

Many local and patient-related factors influence wound healing.

Local factors include:

• Wound contamination
• Tissue viability
• Adequate blood supply
• Excessive wound tension
• Presence of dead space
• Hematoma or seroma formation
• Repeated trauma or excessive movement

Patient-related factors include:

• Advanced age
• Diabetes mellitus
• Malnutrition
• Smoking
• Poor tissue perfusion
• Obesity
• Immunosuppression
• Corticosteroid therapy
• Chronic medical conditions affecting healing

Recognizing these factors allows the perioperative nurse to anticipate delayed healing, reinforce patient education, and communicate concerns promptly.

Careful wound assessment should begin immediately after wound closure and continue during each dressing change or follow-up assessment.

Within the first 24–48 hours, expected findings include:

• Mild redness confined to the wound edges
• Minimal clear or serosanguineous drainage
• Mild swelling that does not progressively increase
• Pain that gradually improves after the first one to two days
• Well-approximated wound edges

Each wound assessment should be performed under adequate lighting before cleansing or redressing the wound.

Assessment should include evaluation of:

• Wound edge approximation
• Skin color surrounding the wound
• Presence and extent of erythema
• Swelling
• Warmth
• Induration or fluctuance
• Drainage type and amount
• Bleeding
• Wound separation
• Tissue viability
• Condition of the dressing

Drainage should be described using standardized terms such as none, scant, small, moderate, or large, together with its appearance (clear, serosanguineous, sanguineous, or purulent).

If erythema is present, its distribution should be observed carefully. Marking the margin and recording changes over time may help identify progression. Any wound separation should be measured and documented, and the wound edges described as well approximated, partially separated, or separated.

Concerning findings include:

• Increasing redness extending beyond the wound edges
• Thick yellow, green, or foul-smelling drainage
• Increasing swelling or pain after the initial postoperative period
• Wound edge separation
• Dusky or black tissue discoloration
• Fever or other signs of systemic infection
• Red streaking extending away from the wound

These findings require prompt reassessment and communication with the treating clinician.

Following wound closure, an appropriate sterile dressing should be applied according to the wound location, expected drainage, and local protocol.

The dressing protects the wound from contamination, absorbs drainage, maintains a suitable healing environment, and promotes patient comfort.

Pain management should also be addressed. Appropriate analgesia should be provided according to local protocol, and its effectiveness reassessed during follow-up.

The wound should be protected from unnecessary mechanical stress during healing.

Examples include:

• Elevating injured extremities to reduce swelling.
• Supporting abdominal wounds during coughing or movement when appropriate.
• Avoiding unnecessary stretching or tension across the wound.
• Protecting the wound from additional trauma during daily activities.

Maintaining these protective measures supports tissue healing and reduces the risk of wound separation.

Patient education is an essential component of safe postoperative wound care.

Before discharge, patients should receive both verbal and written instructions whenever possible.

Education should include:

• How to keep the wound clean and dry according to local instructions.
• Hand hygiene before touching or dressing the wound.
• When and how dressing changes should be performed.
• Materials required for dressing changes, if performed at home.
• Activities that should be avoided while the wound heals.
• Signs requiring immediate medical review.
• The importance of attending scheduled follow-up appointments.

Patients should be instructed to seek medical attention promptly if they develop:

• Increasing redness
• Thick or foul-smelling drainage
• Increasing pain after the first few postoperative days
• Fever
• Wound separation
• Persistent bleeding
• Progressive swelling

Providing clear instructions improves adherence to wound care recommendations and supports early recognition of complications.

Accurate documentation is an essential component of safe wound management and continuity of care.

Immediately following wound closure, documentation should include, as appropriate:

• Anatomical location of the wound using clear anatomical landmarks
• Wound size and characteristics
• Closure technique performed
• Type, size, and gauge of suture material used
• Number of sutures placed
• Intraoperative findings or challenges, such as friable tissue, excessive bleeding, or the need for tension-relieving techniques
• Type of dressing applied
• Time the dressing was applied
• Patient tolerance of the procedure
• Post-procedure instructions provided
• Planned follow-up

During subsequent wound assessments, documentation should also include:

• Wound edge approximation
• Presence or absence of drainage
• Type and amount of drainage
• Changes in erythema, swelling, or wound appearance
• Presence of wound separation or tissue discoloration
• Pain assessment
• Any interventions performed
• Communication with the treating clinician when concerns are identified

Complete, objective documentation supports continuity of care, facilitates communication among healthcare providers, and provides an accurate legal record of the patient's progress.

Most wounds heal without complication when appropriate wound care is maintained. Nevertheless, ongoing assessment remains essential.

Potential complications include:

• Surgical site infection
• Wound dehiscence
• Hematoma
• Seroma
• Tissue necrosis
• Delayed wound healing
• Excessive scar formation

Escalation should occur promptly if significant concerns develop, including:

• Purulent drainage
• Rapidly expanding redness
• Progressive wound separation
• Tissue necrosis
• Persistent or worsening pain
• Fever or other signs of systemic infection

When escalation is required, documentation should clearly describe the observed findings, interventions performed, and communication with the treating clinician.

• Wound healing progresses through inflammatory, proliferative, and remodeling phases.
• Mild redness, minimal serosanguineous drainage, and decreasing pain are expected during early healing.
• Increasing redness, purulent drainage, wound separation, tissue discoloration, or fever may indicate complications requiring prompt evaluation.
• Appropriate wound protection, pain management, and patient education promote uncomplicated healing.
• Patients should receive clear verbal and written discharge instructions and know when to seek medical attention.
• Accurate documentation should include wound characteristics, closure method, suture details, dressing information, patient response, and follow-up plans.
• Ongoing wound assessment and timely escalation of concerning findings contribute to patient safety and optimal healing.

With an understanding of normal wound healing and postoperative wound management, the next topic examines the principles, timing, and safe technique of suture removal.

Self-Assessment

Please complete the following: Post-Suturing Care Quiz

Suture removal is the final stage of wound management for wounds closed with non-absorbable sutures. The objective is to remove the sutures only after the wound has healed sufficiently to remain closed without mechanical support. Removing sutures too early increases the risk of wound dehiscence, while leaving them in place longer than necessary may increase scarring and make removal more difficult.

The perioperative nurse must determine whether the wound is ready for suture removal, prepare the appropriate equipment, perform the procedure using aseptic technique, and provide appropriate care following removal.

The timing of suture removal depends primarily on the anatomical location of the wound, the amount of tension across the wound, and the patient's healing progress.

Typical removal intervals include:

• Face: 3–5 days
• Scalp: 7–10 days
• Upper extremities: 7–10 days
• Trunk: 10–14 days
• Lower extremities and high-tension areas: 14–21 days

These timeframes are general guidelines. Healing varies between patients and wounds, so the wound should always be assessed before sutures are removed.

Before beginning the procedure, assemble the required equipment and arrange it in a logical order to allow efficient, uninterrupted suture removal.

Equipment typically includes:

• Adson toothed forceps to gently lift each suture knot.
• Fine suture removal scissors to cut the suture close to the skin.
• Sterile gauze for cleansing and maintaining a clear field.
• Antiseptic solution according to local protocol.
• Adhesive skin closure strips (e.g., Steri-Strips) to reinforce the wound if needed.
• An appropriate dressing if indicated after removal.
• Waste and sharps containers.

Good lighting and comfortable patient positioning improve visualization and help minimize unnecessary tissue trauma during the procedure.

Before removing the first suture, confirm that the wound has healed sufficiently to maintain closure without suture support.

The wound edges should remain well approximated without evidence of dehiscence, progressive erythema, purulent drainage, tissue necrosis, or other findings requiring further evaluation.

If these findings are present, routine suture removal should be postponed until the wound has been reassessed by the treating clinician.

Maintain aseptic technique throughout the procedure.

Using Adson toothed forceps, gently grasp and elevate the suture knot without crushing the surrounding tissue.

Position the suture removal scissors beneath the knot and cut the suture on the side closest to the skin. Cutting the suture close to the skin ensures that only the buried portion of the suture passes through the tissue during removal, reducing contamination and minimizing tissue trauma.

Remove each suture with a smooth, controlled motion while observing the wound after each removal.

For long incisions or wounds under moderate tension, every other suture may be removed initially to assess whether the wound remains securely approximated. If the wound remains stable, the remaining sutures may then be removed.

Throughout the procedure, use sterile gauze to remove blood or exudate that obscures visualization. In deep or curved anatomical areas, small skin hooks or retractors may occasionally assist with visualization while minimizing tissue trauma.

After all sutures have been removed, inspect the wound to confirm that the edges remain well approximated and that no separation has occurred.

If additional support is needed, apply adhesive skin closure strips across the wound to reinforce the incision while healing continues. Apply a dressing if indicated by the wound condition or local protocol.

Although the skin surface appears healed, the wound continues to gain strength during the remodeling phase and should be protected from excessive tension.

Following suture removal, document:

• Date and time of suture removal.
• Number of sutures removed.
• Condition of the wound before and after removal.
• Presence or absence of wound separation or drainage.
• Application of adhesive skin closure strips or dressings.
• Patient tolerance of the procedure.
• Additional follow-up or communication with the treating clinician, if required.

Before the patient leaves, provide instructions to:

• Avoid excessive stretching or stress across the wound for the next 24–48 hours.
• Leave adhesive skin closure strips in place until they loosen naturally or are removed according to local protocol.
• Keep the wound clean and dry according to local instructions.
• Return promptly if wound separation, increasing redness, drainage, swelling, or other concerning changes develop.

• Remove sutures only after confirming that the wound has healed sufficiently to remain closed without suture support.
• Suture removal timing depends on wound location, wound tension, and healing progress.
• Always assess the wound before removing the first suture.
• Cut each suture close to the skin so that only the buried portion passes through the tissue during removal.
• Long wounds may require staged removal by removing alternate sutures first.
• Apply adhesive skin closure strips when additional wound support is needed.
• Document the procedure thoroughly and provide clear post-removal instructions.

This completes the knowledge component of the module. The following activities apply these principles through judgment assessments and psychomotor skills practice.

Self-Assessment

Please complete the following: Suture Removal Quiz

Providing safe wound closure and suture removal in low-resource environments often requires careful adaptation of available equipment, supplies, and workflows. Adaptations should always aim to maintain patient safety, preserve aseptic technique, and achieve the best possible clinical outcome with the resources available.

Adaptations should never compromise the fundamental principles of wound management. If appropriate wound assessment, sterile technique, or safe wound closure cannot be achieved, the patient should be referred or the procedure delayed when clinically appropriate.

The principles of wound assessment, wound closure, postoperative care, and suture removal remain the same regardless of the practice environment. When resources are limited, adaptations should focus on achieving these principles safely rather than simply substituting equipment.

Before proceeding, consider whether the available resources allow the procedure to be performed safely. If essential equipment, sterile supplies, or appropriate follow-up cannot be provided, referral to a higher level of care may be the safest option.

Whenever adaptations are necessary, document them clearly and communicate any follow-up requirements to the patient and other healthcare providers.

Limited equipment should be used thoughtfully while maintaining safe technique.

Where multiple suture sizes are unavailable, selecting a versatile mid-range suture such as 3-0 Nylon may provide acceptable closure for many routine wounds. The available suture should always be matched as closely as possible to the wound characteristics and anatomical location.

When absorbable sutures are unavailable, non-absorbable sutures may be used if appropriate, provided that arrangements are made for timely follow-up and suture removal.

If Adson toothed forceps are unavailable, another fine tissue-holding instrument that can securely grasp the suture knot without excessive crushing or slippage may be substituted. In emergency situations where no suitable instrument is available, a sterile gloved hand with sterile gauze may be used to gently elevate the knot while minimizing tissue trauma, although this is less desirable than using an appropriate instrument.

Reusable instruments are appropriate when they have been properly cleaned, disinfected, and sterilized according to local protocols.

Good visualization remains essential. If procedure lighting is limited, repositioning the patient, using portable lighting, or maximizing available natural light may improve visibility while maintaining patient safety.

When commercial dressing materials are unavailable, sterile gauze or other locally available sterile dressing materials may be used, provided they adequately protect the wound, absorb drainage when necessary, and maintain a clean healing environment.

Resource limitations may require modification of the planned approach, but they should not compromise patient safety.

The perioperative nurse should prioritize the equipment and supplies that are essential for safe wound closure and suture removal. Careful preparation of the sterile field and thoughtful organization of available materials become even more important when resources are limited.

Some wounds may exceed the capabilities of the available setting. Complex wounds involving extensive tissue loss, heavy contamination, significant tension, neurovascular injury, or other injuries requiring specialized management should be referred whenever possible rather than attempting closure with inadequate resources.

Clinical judgment should guide adaptation. The goal is always to provide the safest care possible using the resources available while recognizing when referral offers a better outcome for the patient.

Staffing shortages may require one nurse to perform tasks that would normally be shared among several team members.

When this occurs, careful preparation becomes especially important. Instruments should be arranged in the order of use, supplies prepared before beginning the procedure, and documentation forms or wound assessment charts completed as much as possible in advance to reduce interruptions during wound management.

Where follow-up opportunities are limited, discharge planning becomes particularly important. Patients should receive clear verbal and written instructions describing wound care, signs of infection or wound separation, and when to seek urgent medical attention.

If returning for routine follow-up may be difficult because of travel distance or limited healthcare access, arrangements should be made whenever possible for follow-up at a nearby healthcare facility. The anticipated date for suture removal should be communicated clearly to both the patient and the receiving healthcare provider when appropriate.

• Adaptations should maintain patient safety, wound healing principles, and aseptic technique.
• Use the most appropriate available equipment and supplies while preserving safe clinical practice.
• Reusable instruments are acceptable when properly cleaned, disinfected, and sterilized.
• When ideal equipment is unavailable, carefully selected alternatives may be used if they do not compromise patient safety or wound integrity.
• Careful organization of the sterile field and workflow becomes even more important when staffing or equipment is limited.
• Patients with limited access to follow-up require particularly thorough discharge instructions and clearly documented plans for ongoing care.
• When safe wound management cannot be achieved with the available resources, referral or delayed treatment is preferable to performing an unsafe procedure.

This concludes the knowledge component of the module. The following activities apply these concepts through judgment assessments and psychomotor skills practice.

Self-Assessment

Please complete the following: Suturing in Low Resource Environments Quiz

Cumulative Test

Please complete the following: Suturing and Suture Cumulative Assessment

Cumulative Test

Please complete the following: Clinical Decision-Making Assessment Cumulative Assessment