This article was reviewed by Tara Call Triplett, RN, WCC, CHFN

When managing complex wounds, nurses may encounter healing by tertiary intention, also known as delayed primary closure. Unlike primary intention (where wounds are closed immediately with sutures) or secondary intention (where wounds heal naturally from the bottom up), tertiary intention blends both strategies. It is used when immediate closure is not safe or appropriate, which is often due to infection risk, tissue loss, or contamination.

This article reviews tertiary intention healing, the normal stages of wound healing, suture considerations, and what wound care nurses should know when supporting patients through this specialized healing process.

What is tertiary intention healing?

Tertiary intention healing occurs when a wound is initially left open to allow for cleaning, drainage, assessment for infection in high-risk wounds, or infection control before it is later surgically closed. This approach allows wound care clinicians to minimize complications such as abscess formation or dehiscence.

Common scenarios include:

Traumatic or contaminated wounds
Wounds with significant tissue edema
Abdominal or orthopedic surgical sites at high risk for infection
Wounds requiring time for infection control before closure

By delaying closure, clinicians create a safer environment for final approximation and healing.

The stages of wound healing

Regardless of the intention, all wounds progress through the four overlapping stages of healing:

Hemostasis – Immediately after injury, vasoconstriction and clotting occur to stop bleeding.
Inflammation – White blood cells, especially neutrophils and macrophages, clear bacteria and debris. This phase may be prolonged in tertiary intention due to initial contamination.
Proliferation – Granulation tissue forms, new blood vessels develop, and epithelialization begins. In tertiary intention, the wound may be surgically closed during this phase once risk factors are reduced.
Maturation/Remodeling – Collagen reorganizes, tensile strength increases, and scar formation occurs.

Healing stages of stitches

When a wound is eventually sutured during tertiary intention healing, the tissue still follows predictable patterns:

First 48 hours: Sutures provide mechanical support while the wound edges bond with fibrin and early collagen deposition.
Days 3–5: Fibroblast activity and collagen production strengthen the wound. Sutures are still critical to hold edges together.
Days 7–14: Sufficient collagen is laid down, and sutures may be removed (depending on location). The wound gains tensile strength but is still weaker than normal tissue.
Weeks to months: Remodeling continues, scar tissue matures, and tensile strength increases toward 80% of the original skin.

Types of sutures

Suture choice is especially important in tertiary intention healing, where tissue integrity and infection risk are major concerns. Sutures can be classified by:

Absorbable vs. non-absorbable

Absorbable sutures, such as Vicryl and Monocryl, are designed to gradually break down in the body over time, eliminating the need for removal. These are commonly used in internal tissues or deep layers where suture removal would be difficult, such as in gastrointestinal surgery or internal muscle repair. For example, Vicryl is a braided absorbable suture often used for closing fascia, while Monocryl, a monofilament absorbable suture, is frequently chosen for subcuticular skin closures.

Non-absorbable sutures, like Nylon and Prolene, do not degrade and must be removed once the tissue has adequately healed. They are typically used in external skin closures or in vascular procedures where long-term tensile strength is needed. For example, Nylon is commonly used for scalp lacerations or orthopedic wounds, while Prolene is favored in vascular anastomoses due to its durability and minimal tissue reactivity.

Monofilament vs. Multifilament (braided)

Monofilament sutures consist of a single smooth strand, which passes through tissue with less friction and reduces the risk of bacterial harboring. They are ideal in contaminated wounds where infection prevention is paramount. For instance, Prolene and Monocryl are monofilament sutures that provide a cleaner passage through tissue but can be more challenging to knot securely.

Multifilament sutures are composed of multiple braided strands, making them easier to handle and knot. However, the braided surface can harbor bacteria and increase the risk of infection. Vicryl, a widely used multifilament absorbable suture, offers excellent handling and knot security, making it a preferred choice for internal soft tissue approximation in clean surgical fields.

Tensile strength needs

Stronger sutures are selected for areas of the body subject to high mechanical stress. For example, in abdominal closures, surgeons may use stronger non-absorbable sutures like Ethibond or absorbable sutures with extended tensile strength such as PDS (polydioxanone). These sutures help withstand tension in areas prone to dehiscence or where long-term support is necessary until tissue regains sufficient integrity.

What wound care nurses need to know about tertiary intention healing

For wound care nurses, tertiary intention healing presents unique considerations:

Monitoring infection: Nurses play a critical role in closely assessing wounds for signs of erythema, exudate, odor, or systemic changes both before closure and after. Ongoing vigilance ensures that infection is identified early and treated promptly, helping to prevent complications such as abscesses, wound breakdown, and sepsis.

Dressing management: While the wound remains open, nurses may apply moist dressings, utilize negative pressure wound therapy, or choose antimicrobial dressings to optimize the wound bed. These interventions help maintain a balanced environment that supports granulation tissue formation and reduces infection risk.

Collaboration with surgeons: The timing of delayed closure is a collaborative decision that involves continuous communication between the nursing team and the surgical team. Nurses provide essential updates on wound readiness, ensuring that closure occurs at the most appropriate moment to promote safe healing.

Patient education: Patients must understand why their wound closure has been delayed, how their dressings will be managed during the open phase, and what to expect once closure is performed. Clear, compassionate education empowers patients, reduces anxiety, and promotes adherence to care instructions.

Documentation: Detailed documentation of wound size, type and amount of drainage, presence of odor, and peri-wound condition is critical. These records guide closure decisions, support continuity of care, and provide benchmarks to evaluate the healing process over time.