Patient had his wound sutured with non absorbable material, after 20 days the sutured were removed but now the wound hadn’t healed properly and gaping can be seen.
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This scenario is a classic presentation of secondary suture / delayed primary closure (healing by tertiary intention). Here is a comprehensive breakdown:
What Happened — and Why
The patient's wound was closed primarily with non-absorbable sutures. At day 20, the sutures were removed — but the wound edges separated (gaped), indicating the wound had not achieved sufficient tensile strength by that point.
This now presents as a wound requiring secondary management, classically handled by secondary suture (also called delayed primary closure or tertiary intention).
The Three Intentions of Wound Healing
| Type | Also Called | Description |
|---|---|---|
| Primary intention | Primary closure | Clean wound, edges approximated; seals in ~24 hrs, least scarring |
| Secondary intention | Open healing | Wound left open; heals by granulation, contraction, epithelialization — broader scar |
| Tertiary intention | Secondary suture / Delayed primary closure | Wound cleaned, debrided, observed, then re-closed days later |
"Tertiary intention (delayed primary closure or secondary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure." — Schwartz's Principles of Surgery, 11th Ed.
Why the Wound Gaped After Suture Removal
From the textbooks:
-
Insufficient tensile strength at day 6–7: At 6 days, a wound is held together by only a small amount of fibrin and cells, with minimal tensile strength. Even at 20 days, full wound strength has not been reached (wound tensile strength only reaches ~80% of normal skin at ~6 weeks).
-
Suture removed too early relative to wound strength — particularly a risk in areas with high static/dynamic tension (back, lower extremities, sternal area).
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Possible contributing factors (from Fitzpatrick's Dermatology):
- High wound tension at closure
- Infection or tissue necrosis
- Patient comorbidities: diabetes, malnutrition, immunosuppression, smoking, impaired vascular supply, prior radiation
-
Removing sutures pulls the wound apart if done incorrectly (pulling away from the wound line rather than toward it).
Management of the Gaping Wound
Based on Fitzpatrick's Dermatology and Roberts & Hedges' Clinical Procedures:
If dehiscence occurred > 48 hours after initial closure:
- Excise ~1 mm of normal skin at both wound edges before re-suturing (to refresh the wound bed and allow proper healing).
- Then re-suture (secondary suture) as if it were a fresh, clean wound.
If infection or necrosis is present:
- Do NOT re-suture — allow the wound to heal by secondary intention (granulation tissue formation, wound contraction, epithelialization).
- Pack the wound open, perform daily cleansing and warm compresses, and use antibiotics if indicated.
Supportive measures:
- Apply Steri-Strips / wound closure tapes to support re-approximated edges and reduce tension.
- A proper layered deep closure is the key to maintaining tensile strength after surface suture removal.
Key Teaching Points
- Non-absorbable sutures must be left long enough for the tissue to develop adequate tensile strength — the required duration varies by site (5 days: face; 7–10 days: extremities/trunk; up to 14+ days: back/lower leg).
- A wound left to heal by secondary intention relies on contraction (myofibroblasts, peaks ~day 10) and epithelialization — resulting in a wider, more visible scar.
- Secondary suture / tertiary intention is the appropriate strategy for contaminated, old, or problematic wounds that require re-closure after an observation period.
Sources: Schwartz's Principles of Surgery 11e; Fitzpatrick's Dermatology 9e; Roberts & Hedges' Clinical Procedures in Emergency Medicine 6e.
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