Wound Closure Methods: Butterfly Strips, Steri-Strips, Staples, and When to Use Each

The Decision Before the Technique

Closure technique matters. But the decision of whether to close matters more. A wound closed with perfect technique will become a serious infection if it was the wrong candidate for closure. Before you reach for any closure device, answer these questions:

1. Is this wound eligible for closure?

• Clean laceration, less than 6-8 hours old: eligible
• Contaminated or dirty wound: irrigate aggressively, then reassess. If still dirty, leave open.
• Animal or human bite: do not close except on the face
• Puncture wound: do not close, requires drainage
• Wound with signs of infection: do not close

2. Do I need sutures, or will strips work? Strips are appropriate for wounds that:

• Are less than 1 inch long
• Have clean, straight edges that approximate well without tension
• Are not over a joint or high-movement area
• Are not on a location that stays moist (palm, sole, axilla)

Sutures are required for:

• Wounds over 1 inch or with significant gaping
• Wounds under tension (joints, hands, feet)
• Deep wounds requiring layered closure
• Wounds needing precise cosmetic alignment (face)
• Full-thickness wounds through dermis

3. Is the wound fully irrigated? Do not close anything you have not irrigated thoroughly. Closure locks contamination inside. A closed contaminated wound will abscess.

Butterfly Strips

Butterfly strips are improvised closure devices cut from regular adhesive tape or made from wound closure strips that have a wider waist at the center. They apply tension across the wound edges to hold them together.

When to Use

Butterfly strips are the lowest-tech closure available and appropriate for:

• Small scalp lacerations
• Eyebrow lacerations (where hair makes strip adherence challenging)
• Any clean wound in a location where you cannot get regular closure strips to adhere

How to Make Them

Cut a strip of medical tape (paper tape, silk tape, or wound closure strips) into a bow-tie or butterfly shape: wide at the ends, narrow in the middle. The narrow waist concentrates the tension at the wound edge while the wider ends increase adhesion surface.

If you have standard wound closure strips, you can fold them in half lengthwise and cut the double-layered fold to create a butterfly shape when unfolded.

Application Technique

1. Dry the wound edges completely. Strip adhesion fails on moist skin. Pat dry with gauze, or allow the wound surface to air-dry for 1-2 minutes.

2. Apply tincture of benzoin compound to the skin on both sides of the wound (1 cm back from the wound edge). Allow it to become tacky (30-60 seconds). This dramatically increases strip adherence.

3. Attach one end of the strip to the skin on one side of the wound. Press firmly for 5 seconds.

4. Gently approximate the wound edges with your free hand, pushing the skin toward the wound center from both sides rather than pulling it across.

5. While holding the edges approximated, apply tension to the strip across the wound and secure the opposite end. The strip should be taut but not so tight it causes blanching.

6. Apply additional strips in parallel, spaced 3-5mm apart. Cover the full length of the wound.

7. Apply a cross-strip perpendicular to and over all the closure strips, 1 cm above and 1 cm below the wound line. This prevents the closure strips from peeling off at their ends.

Steri-Strips (Wound Closure Strips)

Steri-strips are thin, porous adhesive strips designed for wound closure. They are more adhesive and better-designed than improvised butterfly strips, and they come in multiple widths.

3M Steri-Strips are the standard. Closure strips from wound care kits or first aid supplies are equivalent. In a pinch, narrow medical tape works.

Sizing

• 1/4 inch wide × 3 inches long: small facial lacerations, fingertip wounds
• 1/2 inch wide × 4 inches long: standard lacerations on trunk and limbs
• 1/2 inch wide × 6 inches long: long lacerations requiring more cross-coverage

Application Technique

The technique is identical to butterfly strips but these are pre-formed for wound closure:

1. Control bleeding completely. Steri-strips will not adhere to actively bleeding tissue.
2. Irrigate and dry the wound.
3. Apply benzoin if available.
4. Start each strip at the center of the wound, not the ends. Securing the center first ensures the edges meet precisely at the critical midpoint. Then work outward toward each end.
5. For wounds longer than 1 inch, use 3-5 strips in parallel, each touching but not overlapping the previous.
6. Reinforce ends with cross-strips.

Common Failure Points

The most frequent problem with strip closure is premature strip removal — the strips peel off before healing is complete. This happens from:

• Moisture: Excessive sweating, wound drainage soaking through, patient showering too early
• Movement: Strips over joints or on mobile skin fail within hours
• Inadequate skin prep: Failure to dry the skin and apply benzoin
• Poor technique: Applying tension to the wrong side of the strip, not anchoring the cross-strips

Steri-strips should stay on for 5-7 days for scalp wounds, 7-10 days for wounds on the trunk, 10-14 days for wounds on limbs. Do not pull them off — allow them to detach naturally or soak them off with water.

Skin Staples

Stapling is the fastest wound closure technique and appropriate for straight lacerations on non-critical areas where cosmetic result is less important.

Appropriate locations:

• Scalp (the most common use)
• Trunk, back, and torso
• Extremities (thigh, calf, upper arm)

Inappropriate locations:

• Face (cosmetically unacceptable, near vital structures)
• Hands and feet (risk of tendon and vascular injury with placement)
• Over joints (staples will pull through with movement)
• Any location requiring future MRI imaging

Equipment

Disposable skin staplers come preloaded with 5-25 staples. The 35-staple disposable models are appropriate for medical kits. Standard staple size for skin closure is 35W × 6.5H mm (35mm wide, 6.5mm leg length).

Application Technique

1. Thoroughly irrigate the wound. Dry the wound edges.

2. Approximate the wound edges manually or have an assistant hold them together. Good edge approximation is critical — staples do not correct poor edge alignment.

3. Position the center of the stapler directly over the wound line, perpendicular to the wound.

4. Press the stapler firmly against the skin surface. The skin should slightly dome up into the stapler body.

5. Squeeze the trigger with one firm, decisive motion. Do not hesitate mid-squeeze.

6. Lift the stapler straight up after firing. Check the staple placement: the crossbar should span the wound with both legs penetrating the skin on opposite sides. The wound edges should be slightly everted (raised), not inverted (sunken). Everted edges heal with a better cosmetic result.

7. Space subsequent staples 5mm apart for scalp wounds, 1cm apart for trunk and extremity wounds.

8. After placing all staples, run a gloved finger along the wound to confirm edge approximation.

Staple Removal

Staples on the scalp are removed at 7-10 days. On the trunk at 10-14 days. On extremities at 14 days.

Use a dedicated staple remover (a bent-lever tool). Insert the lower jaw of the remover under the staple crossbar. Squeeze the handles — this bends the staple into an M-shape, withdrawing both legs simultaneously. Pull straight up. A staple remover costs $3 and is worth having in any medical kit.

Without a remover: use needle-nosed pliers or strong tweezers. Grasp the center crossbar and bend upward, then extract. This hurts more and has higher risk of tearing tissue.

Skin Glue (Tissue Adhesive)

Cyanoacrylate-based tissue adhesives (Dermabond, Histoacryl, or medical-grade super glue) work well for specific wound types. They are not a substitute for sutures in deep wounds but are highly effective for:

• Superficial lacerations less than 1/2 inch on low-tension areas
• Facial lacerations in cooperative patients
• Finger or hand lacerations in areas where movement would break strips
• Pediatric wounds where sutures require sedation

Application: Apply glue to the wound surface only — not in the wound. Approximate edges manually. Apply a thin coat across the wound in the direction of the wound line. Hold edges together for 60 seconds. Apply 2-3 coats total, allowing each to set for 30 seconds. Keep dry for 5-7 days.

Failures: Getting glue inside the wound (bonds edges apart), using on moist wounds (does not set), applying too thick a coat (takes too long to cure and loses adhesion).

When Not to Close: Wounds That Stay Open

This is the most important section. Closeing a wound that should stay open is a more serious error than not closing a wound that needed closure.

Leave open if:

• Animal or human bite anywhere except the face. Bites carry anaerobic bacteria that thrive in sealed wounds.
• Wound older than 6-8 hours in most body locations. Bacteria have colonized too heavily.
• Highly contaminated wounds: heavy soil, feces, sewage, organic debris
• Puncture wounds: the narrow opening needs to drain, not seal
• Any wound showing signs of infection: redness, pus, warmth, swelling developing before you treat it
• Crush injuries with devitalized tissue: dead tissue is a growth medium for infection

Management of open wounds:

Pack the wound loosely with moistened gauze (normal saline-moistened, or clean water). The dressing should be damp, not wet. Cover with dry outer dressing. Change every 12-24 hours. Irrigate at each change. After 4-5 days, if the wound is clean and granulating (filling in with new pink tissue), you can close it with strips. This is called delayed primary closure and it dramatically reduces infection rates in contaminated wounds.

Dressings After Closure

Regardless of closure method, cover the wound:

• Non-adherent dressing directly over the wound (Telfa, Adaptic, or equivalent). Standard gauze will adhere to the wound surface and tear it open when changed.
• Gauze pad over the non-adherent dressing for absorbency
• Tape or wrap to secure

Change the dressing daily for the first 3 days, or whenever it is wet. After 48 hours, clean wounds can tolerate brief water exposure (shower). Baths and swimming are prohibited until fully healed.

Watch for infection signs at each dressing change: increasing redness, warmth, swelling, pus, or worsening pain after the first 24 hours. Any of these findings warrant opening the wound and reassessing.