When Surgical Wounds Reopen: Review Finds Evidence for Skin Surgery Is Strikingly Thin

Every surgeon who closes a wound knows the small, sinking moment when the skin edges separate. In dermatologic surgery, where millions of excisions, Mohs repairs, and flap closures are performed each year, postoperative wound dehiscence is a familiar and feared complication. Yet a new narrative review published in the Archives of Dermatological Research suggests that when the wound actually opens, the evidence telling clinicians what to do next is astonishingly thin.

The review, led by June Y. Moon, Yasir Al-Dojaily, Zahidul Islam, and Lucy Wang of New York Medical College’s Department of Dermatology, together with senior author Amor Khachemoune, systematically combed the published literature for reports on managing superficial cutaneous wound dehiscence. The search was deliberately broad, reaching beyond dermatology into other surgical specialties where wound separation has been studied in greater depth. What the authors found was sobering: after excluding a single-patient case report, the entire body of relevant comparative evidence amounted to just three studies covering 185 patients.

Those 185 patients were divided between two fundamentally different management philosophies. The first is secondary re-closure, in which a surgeon reintroduces sutures or other closure devices to bring the wound edges together again, sometimes after a period of wound preparation or delayed primary closure. The second is secondary intention healing, in which the wound is left open and allowed to fill in from the base through granulation tissue, contraction, and re-epithelialization. Each approach carries its own logic. Re-closure promises faster coverage and potentially better cosmesis but risks trapping bacteria and recreating the conditions that caused the separation. Secondary intention avoids foreign material in a potentially contaminated wound but demands weeks of dressing changes and leaves healing to the body’s slower processes.

The three studies that met the review’s criteria came from strikingly different clinical worlds. One was a randomized trial from obstetrics and gynecology, in which women with superficial dehiscence after gynecologic procedures were assigned to either secondary closure or healing by secondary intention. A second came from cardiothoracic surgery, examining superficial dehiscence after median sternotomy, the midline chest incision used to access the heart. The third was a retrospective case series in immunocompromised patients whose wounds were colonized by multidrug-resistant organisms, a population at extreme risk both from infection and from impaired healing.

Despite their differences, all three studies converged on a single descriptive finding: wounds that were re-closed healed faster than wounds left to heal by secondary intention. Two of the three studies also reported that re-closure required fewer clinic visits or fewer treatments, an outcome with real consequences for patients who face daily dressing changes over many weeks. In the sternotomy cohort, two closure failures were documented among the re-closed wounds, a reminder that suturing a previously opened wound back together does not always succeed. In the immunocompromised series, one late suture-associated abscess appeared, illustrating the infection risk that delayed closure is meant to mitigate but does not eliminate.

The authors are careful, and correctly so, to warn against over-reading these results. The studies differed substantially in design, wound characteristics, and how they reported outcomes, and none used the kind of rigorous, dermatology-specific framework that would allow confident generalization. The randomized trial did not provide detailed reporting of complications after re-closure, which makes a balanced risk assessment nearly impossible. Descriptive findings, the review emphasizes, do not establish superiority. A faster healing time in three heterogeneous, non-dermatologic cohorts is a signal worth investigating, not a treatment guideline.

For dermatologic surgeons, the gap is glaring. None of the three studies evaluated dehiscence after cutaneous surgery specifically, and none assessed cosmetic outcomes or patient satisfaction, two endpoints that matter enormously when the wound in question sits on a patient’s face, nose, or ear. Dermatologic surgery wounds differ in important ways from sternotomies or abdominal incisions: they are often smaller, frequently on sun-damaged skin with different biomechanics, frequently closed under significant tension on convex surfaces, and managed in an outpatient setting where healing is supervised by the operating surgeon rather than an inpatient team. Extrapolating from a 1992 obstetric trial or a cardiothoracic series to a nose defect after Mohs reconstruction is a leap that the evidence simply cannot yet support.

The biology of why wounds separate, and why they might behave differently when closed a second time, adds further nuance. Dehiscence usually follows a combination of factors: excessive tension across the closure, infection or hematoma beneath the surface, patient factors such as diabetes, smoking, immunosuppression, or advanced age, and mechanical forces from movement or trauma. Once the skin has opened, the wound bed is no longer a clean, surgically prepared plane. It is a contaminated, granulating surface colonized by bacteria, and the question of whether to close it becomes a question of whether the benefits of apposing the edges outweigh the risk of sealing microorganisms inside. The concept of delayed primary closure, well described in the plastic surgery literature, occupies the middle ground: the wound is managed briefly with dressings or negative pressure, then closed once it appears clean, theoretically capturing speed without sacrificing safety.

In practice, the review concludes, dermatologists currently manage dehiscence based on clinical experience, expert opinion, and extrapolation from other specialties. Many factors inform individual decisions: the size and depth of the wound, its location, the burden of contamination, the patient’s immune status and healing capacity, and the patient’s tolerance for repeated visits versus an open, healing wound. Some wounds on concave surfaces, such as the medial canthus or ear concha, are well suited to secondary intention and may heal with acceptable cosmetic results without re-closure. Others, under tension on convex surfaces, may benefit from being reapproximated once the infection risk is controlled. But the evidence base underlying any of these choices, when a wound actually opens, is essentially anecdote and judgment.

That is why the authors’ closing call for prospective dermatologic studies carries such weight. Wound dehiscence after skin surgery is common enough that well-designed trials, comparing re-closure against secondary intention with standardized measures of healing time, complication rates, cosmetic outcomes, and patient satisfaction, would be feasible and would transform a judgment-driven corner of practice into an evidence-based one. Until such trials exist, the review offers dermatologic surgeons something less satisfying but honest: a clear-eyed account of what is known, what is not, and where the field must go. When a wound separates, the surgeon’s hands may know what to do. The published literature, this review makes clear, does not yet.

Subject of Research: Evidence for managing postoperative cutaneous wound dehiscence in dermatologic surgery

Article Title: Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery

Article References: Management of postoperative cutaneous wound dehiscence: a narrative review and implications for dermatologic surgery. (n.d.). https://doi.org/10.1007/s00403-026-05005-8

Image Credits: AI Generated

DOI: 10.1007/s00403-026-05005-8

Keywords: wound dehiscence, dermatologic surgery, secondary re-closure, secondary intention healing, delayed primary closure, surgical complications, Mohs surgery, wound healing, systematic review, steronomy, infection risk, evidence gap