the tissue structure, weakening the repair, and therefore decreasing the capacity to resist infection [3, 9]. Physical and biochemical characteristics of the suture serve as an important factor in the initiation, severity, and persistence of incisional infections [4]. Bacteria have a higher affinity for braided suture compared to monofilament suture [4]. Removal of bacteria by the body’s defense mechanism is slower with braided suture [4]. The use of barbed sutures has been shown to increase the risk of incisional infections [10],
Suture pattern choice can contribute to prolonged edema and erythema from decrease in microvascular flow, resulting in delayed healing, decreased incisional tensile strength, and risk of incisional complications [11].
Suture placement
Sutures that are placed too close to the wound margins risk suture cut‐through due to an initial elevated collagenase activity within 5 mm of the wound edges, leading to an increased risk of suture cut‐through and dehiscence of the wound [5].
Poor knotting technique
A poor knot‐tying technique can result in the knot untying and wound dehiscence [5].
Inappropriate suture material
Selection of an inappropriate suture material with insufficient tensile strength for the given tissues or that significantly decreases in tensile strength (resorption time) faster than tissue healing occurs for the respective tissue, increases the risk of dehiscence [5]. Interactions between the suture material and tissue can alter the characteristics of the suture and lead to suture failure [9]. Barbed sutures have been shown to increase the incidence of postoperative incisional dehiscence and erythema as wound complications [12].
Premature suture removal
Suture removal prior to appropriate wound healing may result in dehiscence [5].
Improper suture needle selection
The type of needle and size in relation to the suture can increase the risk of suture cut‐through, especially when there is tension present or tissues are compromised [5].
Inadequate suture line tension
Loosely placed sutures due to inadequate surgical technique or as a result of anticipated edema formation, as well as a suture line placed in a region of already present edema, increases the risk of wound edge retraction and incisional gapping when the edema resolves [5].
Excessive suture line tension
The use of excessive suture tension or use of an inappropriate suture pattern for mild to moderate tension along a suture line to appose tissues can result in suture cut‐through leading to dehiscence. Excessive suture tension can affect the local blood flow, which increases the inflammatory response resulting in tissue ischemia and pressure necrosis [3, 6, 7]. The use of suture stents or quills in an attempt to diffuse the tension from the suture to a larger surface area can also affect microvascular supply and result in tissue pressure necrosis under the stent or quill, especially when placed under a pressure bandage or cast [3].
Dead space
Dead space is created in some traumatic wounds where tissues have been lost or dissection planes have been created. Dead space is created surgically after tissue debridement, mass removal, or undermining has been performed to relieve tension for the closure. As a result, seroma or hematoma formation may manifest, increasing the risk of incisional infection and possible dehiscence [4].
Suturing of nonviable tissue
The degree of tissue compromise and viability of recently traumatized tissues can be difficult to predict. If a traumatic wound is closed too promptly, without allowing or anticipating the potential ensuing development of tissue necrosis to occur, the development of delayed necrosis may lead to dehiscence [5].
Inappropriate support and immobilization of a suture line
Excessive motion for any given suture line increases the risk of tension on the wound edges and possible dehiscence [5]. The repetitive motion of an incision causes chronic inflammation from microvascular, collagen deposits, and epithelialization disruption [7]. However, complete immobilization can result in disorganized new collagen and decreases incisional tensile strength [7]. Inadequate support and/or immobilization of a suture line as well as inadequate confinement can have detrimental effects on the wound/incision healing process and result in dehiscence.
Prevention
Effective apposition of the wound/incision edges, atraumatic tissue handling, minimal disruption to blood supply, appropriate suture pattern, material, needle, and placement are essential requirements for a positive healing outcome [3, 5]. Adequate perioperative care is also an important factor in incisional healing and appropriate use of antibiotics, NSAIDs, diagnostics, bandaging, and confinement are important. Appropriate bandaging and NSAID uses can prevent excessive edema formation. It is important to inflict the least amount of trauma achievable to obtain the goal of the surgery [9].
The wound strength is more dependent on the tissue’s ability to hold the suture than on the given suture strength [2]. Suture placement from the wound edge is recommended an equal distance from the incision/wound edge as the thickness of the skin edge at that location [3]. Due to the normal inflammatory phase of healing, sutures should be placed at least 5 mm from the wound/incision edge to prevent dehiscence [3]. Spacing between sutures is variable, depending on wound/incision location and relative local tension but it is advised to use the minimum number of sutures necessary to achieve tissue apposition [3]. In general, this corresponds to fewer sutures in thicker skin and areas of low tension and more sutures in regions of thin skin and higher tension [3]. Suture pattern choice can contribute to prolonged edema and erythema, such as with a simple continuous suture pattern when compared to a simple interrupted suture pattern [11]. This edema can result in delayed healing and risk of complications [11].
Physical and biological characteristics should be considered when selecting suture material and size, and the suture material should be compatible with the tissue type being sutured and the anticipated post‐operative incisional tension [5, 9]. The suture should be as strong as the normal tissue through which it is placed [2, 3]. The rate of loss in tensile strength of the suture material and the gain in wound strength of the sutured tissues over time should coincide {2, 3]. Monofilament suture material has the advantages of low tissue drag and low tendency to foster infection [15]. There has been no beneficial effect in the use of antibiotic‐coated suture material in preventing suture‐related complications [16].
Tension forces are converted to shear forces at the suture knot, thus making the knot the weakest point of the suture loop [9]. Secure square knots are important in preventing dehiscence and the appropriate number of throws for good knot security depends on the suture material characteristics and the nature of the suture pattern (interrupted vs. continuous) [3]. A surgeon's throw is only indicated when needed to appose the tissues, otherwise it is contraindicated, especially in deeper layers such
