The goals of wound closure include obliteration of dead space, even

distribution of tension along deep suture lines, maintenance of tensile

strength across the wound until tissue tensile strength is adequate, and
approximation and eversion of the epithelial portion of the closure. Methods
for mechanical wound closure include staples, tape, adhesive, and sutures.
Each method has specific indications, advantages and disadvantages, and
special considerations.
The subject of this article is the suture closure of wounds. Similar to other
methods of wound closure, suture closure permits primary wound healing.
Tissues are held in proximity until enough healing occurs to withstand
stress without mechanical support. An extensive review of wound healing
and the factors that influence this process are available elsewhere.
(See Incision Placement; Wound Healing and Repair; and Wound Closure
Technique).
Sutures
Suture material is a foreign body implanted into human tissues; it elicits a
foreign body tissue reaction. During wound closure, a sterile field and
meticulous aseptic technique are critical to minimize the risk of wound
infection. Other complications of wound healing, such as hypertrophic
scars, wide scars, and wound dehiscence, may result from patient factors
(eg, nutritional status), incorrect suture selection, or a technique that results
in excessive tension across the wound.
Skillful wound closure requires not only knowledge of proper surgical
techniques but also knowledge of the physical characteristics and
properties of the suture and needle.
Suture qualities
Ideal, essential, and other suture characteristics as well as suture size are
discussed in this section.
Ideal suture characteristics
The ideal suture has the following characteristics:
Sterile
All purpose (composed of material that can be used in any surgical
procedure)
Causes minimal tissue injury or tissue reaction (ie, nonelectrolytic,
noncapillary, nonallergenic, noncarcinogenic)
Easy to handle
Holds securely when knotted (ie, no fraying or cutting)
High tensile strength
Favorable absorption profile
Resistant to infection
Unfortunately, at present, no single material can provide all of these
characteristics. In different situations and with differences in tissue
composition throughout the body, the requirements for adequate wound
closure require different suture characteristics.
Essential suture characteristics
All sutures should be manufactured to assure several fundamental
characteristics, as follows:
Sterility
Uniform diameter and size
Pliability for ease of handling and knot security
Uniform tensile strength by suture type and size
Freedom from irritants or impurities that would elicit tissue reaction
Other suture characteristics
The following terms describe various characteristics related to suture
material:
Absorbable - Progressive loss of mass and/or volume of suture material;
does not correlate with initial tensile strength
Breaking strength - Limit of tensile strength at which suture failure occurs
Capillarity - Extent to which absorbed fluid is transferred along the suture
Elasticity - Measure of the ability of the material to regain its original form
and length after deformation
Fluid absorption - Ability to take up fluid after immersion
Knot-pull tensile strength - Breaking strength of knotted suture material
(10-40% weaker after deformation by knot placement)
Knot strength - Amount of force necessary to cause a knot to slip (related
to the coefficient of static friction and plasticity of a given material)
Memory - Inherent capability of suture to return to or maintain its original
gross shape (related to elasticity, plasticity, and diameter)
Nonabsorbable - Surgical suture material that is relatively unaffected by
the biologic activities of the body tissues and is therefore permanent
unless removed
Plasticity - Measure of the ability to deform without breaking and to
maintain a new form after relief of the deforming force
Pliability - Ease of handling of suture material; ability to adjust knot
tension and to secure knots (related to suture material, filament type, and
diameter)
Straight-pull tensile strength - Linear breaking strength of suture material
Suture pullout value - The application of force to a loop of suture located
where tissue failure occurs, which measures the strength of a particular
tissue; variable depending on anatomic site and histologic composition
(fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg)
Tensile strength - Measure of the ability of a material or tissue to resist
deformation and breakage
Wound breaking strength - Limit of tensile strength of a healing wound at
which separation of the wound edges occurs
Suture size
The United States Pharmacopeia (USP) classification system was
established in 1937 for standardization and comparison of suture materials,
corresponding to metric measures. The 3 classes of sutures are collagen,
synthetic absorbable, and nonabsorbable.
Suture size refers to the diameter of the suture strand and is denoted as
zeroes. The more zeroes characterizing a suture size, the smaller the
resultant strand diameter (eg, 4-0 or 0000 is larger than 5-0 or 00000). The
smaller the suture, the less the tensile strength of the strand.
Suture material and structure
Natural sutures, monofilament versus multifilament sutures, and
absorbable versus nonabsorbable sutures are reviewed in this section.
Natural sutures
Natural sutures can be made of collagen from mammal intestines or from
synthetic collagen (polymers). Tissue reaction and suture antigenicity lead
to inflammatory reactions, especially with natural materials.
[1, 2]

Monofilament vs multifilament sutures
Monofilament suture is made of a single strand; this structure is relatively
more resistant to harboring microorganisms. The monofilament suture also
exhibits less resistance to passage through tissue than the multifilament
suture. However, great care must be taken in handling and tying the
monofilament suture, because crushing or crimping of this suture can nick
or weaken the suture and lead to undesirable and premature suture failure.
Multifilament suture is composed of several filaments twisted or braided
together; these materials are less stiff but have a higher coefficient of
friction. Multifilament suture generally has greater tensile strength and
better pliability and flexibility than monofilament suture, and this type of
suture handles and ties well. However, because multifilament materials
have increased capillarity (ie, the extent to which absorbed fluid is
transferred along the suture), the increased absorption of fluid may act as a
tract for the introduction of pathogens, which increases the risk for wound
infection and dehiscence.
In addition, because the individual filaments of a multifilament suture are
braided together, an increased coefficient of friction is created when the
suture is passed through tissue. Multifilament sutures are often treated with
special coatings to allow tissue passage to occur more easily and to reduce
subsequent tissue damage.
Absorbable vs nonabsorbable sutures
Absorbable sutures provide temporary wound support, until the wound
heals well enough to withstand normal stress. Absorption occurs by
enzymatic degradation in natural materials and by hydrolysis in synthetic
materials. Hydrolysis causes less tissue reaction than enzymatic
degradation.
The first stage of absorption has a linear rate, lasting for several days to
weeks. The second stage is characterized by loss of suture mass and
overlaps the first stage. Loss of suture mass occurs as a result of
leukocytic cellular responses that remove cellular debris and suture
material from the line of tissue approximation. Chemical treatments, such
as chromic salts, lengthen the absorption time.
Importantly, note that loss of tensile strength and the rate of absorption are
separate phenomena. The surgeon must recognize that accelerated
absorption may occur in patients with fever, infection, or protein deficiency,
and this may lead to an excessively rapid decline in tensile strength.
Accelerated absorption may also occur in a body cavity that is moist or
filled with fluid or if sutures become wet or moist during handling before
implantation.
Nonabsorbable sutures elicit a tissue reaction that results in encapsulation
of the suture material by fibroblasts. The USP classification of
nonabsorbable sutures is as follows:
Class I - Silk or synthetic fibers of monofilament, twisted, or braided
construction
Class II - Cotton or linen fibers or coated natural or synthetic fibers in
which the coating contributes to suture thickness without adding strength
Class III - Metal wire of monofilament or multifilament construction
Suture characteristics
The absorbable and nonabsorbable surgical sutures are made from either
"natural" or synthetic polymers and are discussed separately.
Absorbable sutures
Absorbable natural sutures include the following:
Collagen
Plain surgical gut
Fast-absorbing surgical gut
Chromic surgical gut
The collagen sutures are derived from the submucosal layer of ovine small
intestine or the serosal layer of the bovine small intestine "gut." This
collagenous tissue is treated with an aldehyde solution, which cross-links
and strengthens the suture and makes it more resistant to enzymatic
degradation. Suture materials treated in this way are called plain gut.
The tensile strength of plain surgical gut is maintained for 7-10 days
postimplantation (variable with individual patient characteristics), and
absorption is complete within 70 days. This type of suture is used for: (1)
repairing rapidly healing tissues that require minimal support and (2)
ligating superficial blood vessels.
Fast-absorbing surgical gut is indicated for epidermal use (required only for
5-7 d) and is not recommended for internal use.
Chromic surgical gut is treated with chromium salt, which slows down the
absorption rate (90 d). Tensile strength is maintained for 10-14 days.
Tissue reaction is due to the noncollagenous material present in these
sutures. Also, patient factors affect rates of absorption and make tensile
strength somewhat unpredictable. Salthouse and colleagues demonstrated
that the mechanism by which chromic surgical gut reabsorbs is the result of
sequential attacks by lysosomal enzymes.
[3]

Natural fiber absorbable sutures have several distinct disadvantages. First,
these natural fiber absorbable sutures have a tendency to fray during knot
construction. Second, there is considerably more variability in their
retention of tensile strength than is found with the synthetic absorbable
sutures. A search for a synthetic substitute for collagen sutures began in
the 1960s. Soon, procedures were perfected for the synthesis of high
molecular weight polyglycolic acid, which led to the development of the
polyglycolic acid sutures.
[3]

Absorbable synthetic sutures are composed of chemical polymers that are
absorbed by hydrolysis and cause a lesser degree of tissue reaction
following placement. Many types of synthetic absorbable suture are
available depending on the anatomic site, surgeon's preference, and the
required suture characteristics, including the following, among others:
Polyglactin 910 (Vicryl)
Polycaprolate (Dexon II)
Poliglecaprone 25 (Monocryl)
Polysorb
Polydioxanone (PDS II)
Maxon
V-Loc
Polyglactin 910 (Vicryl) synthetic suture is a braided multifilament suture
coated with a copolymer of lactide and glycolide (polyglactin 370). The
water-repelling quality of lactide slows loss of tensile strength, and the
bulkiness of lactide leads to rapid absorption of suture mass once tensile
strength is lost. The suture is also coated with calcium stearate, which
permits easy tissue passage, precise knot placement, and smooth tie-
down. Tensile strength is approximately 65% at 14 days postimplantation.
Absorption is minimal for 40 days and complete in 56-70 days. These
sutures cause only minimal tissue reaction. Vicryl sutures are used in
general soft-tissue approximation and vessel ligation. Another similar
suture material is made from polyglycolic acid and coated with
Polycaprolate (Dexon II). This material has a similar tensile strength and
absorption profile.
Poliglecaprone 25 (Monocryl) synthetic suture is a monofilament suture that
is a copolymer of glycolide and e-caprolactone. The suture has superior
pliability, leading to ease in handling and tying. Tensile strength is high
initially, 50-60% at 7 days, and is lost at 21 days. Absorption is complete at
91-119 days. Poliglecaprone 25 sutures are used for subcuticular closure
and soft-tissue approximations and ligations.
Polysorb is a new, braided absorbable suture produced from the production
of a Lactomer copolymer via synthesis of copolymers of glycolide and
lactide. The glycolide and lactide behave differently when exposed to tissue
hydrolysis. Glycolide provides for high initial tensile strength, but hydrolyzes
rapidly in tissue.
[4]
Lactide has a slower and controlled rate of hydrolysis, or
tensile strength loss, and provides for prolonged tensile strength in tissue.
[4]

The Lactomer copolymer consists of glycolide and lactide in a 9:1 ratio. The
handling characteristics of the Polysorb sutures were found to be superior
to those of the Polyglactin 910 suture.
[4]
Using comparable knot construction
and suture sizes, the knot-breaking strength of Polysorb sutures was
significantly greater than that encountered by Polyglactin 910 sutures. In
addition, the mean maximum knot rundown force encountered with the
Polysorb sutures was significantly lower than that noted with the Polyglactin
910 sutures, facilitating knot construction.
The surfaces of the Polysorb sutures have been coated to decrease their
coefficient friction.
[5]
The Polysorb suture is coated with an absorbable
mixture of caprolactone/glycolide copolymer and calcium stearyl lactylate.
At 14 days postimplantation, nearly 80% of the USP tensile strength of
these braided sutures remains. Approximately 30% of their USP tensile
strength is retained at 21 days. Absorption is essentially complete between
days 56 and 70.
To study the determinants of suture extrusion following subcuticular closure
by synthetic braided absorbable sutures in dermal skin wounds, Drake et al
used miniature swine to develop a model that reproduced the human
clinical experience.
[6]
Standard, full-thickness skin incisions were made on
each leg and abdomen. The wounds were closed with either sized 4-0
Polysorb or Vicryl sutures. Each incision was closed with 5 interrupted,
subcuticular, vertical, loops secured with a surgeons knot. The loops were
secured with 3-throw knots in one pig, 4-throw knots in the second pig, and
5-throw knots in the third pig. Suture extrusion, wound dehiscence, stitch
abscess, and granuloma formation were all observed.
[6]

The cumulative incidence of suture extrusion over 5 weeks ranged from
10% to 33%. Vicryl sutures had a higher cumulative incidence of suture
extrusion than that of the Polysorb sutures (31% vs 19%). With Polysorb
sutures, the 5-throw surgeons knot had a higher cumulative incidence of
suture extrusion than the 3-throw or 4-throw surgeons knot square, 30%
versus 17% and 10%, respectively.
[6]

Polydioxanone (PDS II) is a polyester monofilament suture made of
polydioxanone. This suture provides extended wound support and elicits
only a slight tissue reaction. Tensile strength is 70% at 14 days and 25% at
42 days. Wound support remains for up to 6 weeks. Absorption is minimal
for the first 90 days and essentially complete within 6 months. This material
has a low affinity for microorganisms (like other monofilament sutures).
PDS II suture is used for soft-tissue approximation, especially in pediatric,
cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic)
situations. Another similar, new synthetic absorbable suture material is
made from polytrimethylene carbonate (Maxon). This material has a similar
tensile strength and absorption profile.
When Sanz et al randomized 210 rats into 1 of 5 study groups to compare
Maxon with 3 absorbable sutures (Vicryl, chromic catgut, and PDS II) with
respect to tissue inflammatory reaction, knot security, suture tensile
strength, and suture absorption, Maxon and PDS II elicited a lower degree
of chronic inflammation relative to Vicryl and chromic catgut.
[7]
In addition,
the tensile strengths of Maxon and Vicryl significantly exceeded those of
PDS II and chromic catgut during the critical period of wound healing.
Maxon and PDS II retained a larger percentage of tensile strength during
the long postoperative period, whereas Vicryl and chromic catgut were
mostly absorbed. The investigators concluded that Maxon was an excellent
addition to the armamentarium of the surgeon.
[7]

A barbed suture (V-Loc, Covidien Inc) was developed that is self-anchoring
with no knots required for wound closure. The elimination of knot tying may
reduce many of the challenges of knot construction. The barbed suture is
manufactured from a size 0 polydioxanone that reabsorbs within 26 weeks.
This suture consists of axially barbed segments on each side of a mid point
at which the barbs change direction. The tensile strength of the barbed
suture decreases over time. Each suture is attached to a premium cutting
and taper point needle with NuCoat coating technology.
[8]

The unique performance of the barbed suture was confirmed for
gastrointestinal wound closure in a randomized control study.
[9]
The V-Loc
wound closure device appeared to offer comparable gastrointestinal
closure as compared to 3-0 Maxon, while being significantly faster.
However, further studies with V-Loc are required to evaluate its use in
laparoscopic surgery.
[9]

Caprosyn suture is rapidly absorbing and the latest innovation in the
development of monofilament absorbable suture. Caprosyn monofilament
synthetic absorbable sutures are prepared from Polyglytone 621 synthetic
polyester, which is composed of glycolide, caprolactone, trimethylene
carbonate, and lactide. Implantation studies in animals indicate that
Caprosyn suture retains a minimum of 50-60% USP knot strength at 5 days
postimplantation, and a minimum of 20-30% of knot strength at 10 days
postimplantation. All of its tensile strength is essentially lost by 21 days
postimplantation.
When Pineros-Fernandez et al compared the biomechanical performance
of Caprosyn suture with that of chromic gut suture, both suture types
provided comparable resistance to wound disruption.
[10]
The biomechanical
performance studies included quantitative measurements of wound
security, strength loss, mass loss, potentiation of infection, tissue drag, knot
security, knot rundown, as well as suture stiffness. Before implantation,
suture loops of Caprosyn had significantly greater mean breaking strength
than suture loops of chromic gut
[10]
; 3 weeks after implantation of these
absorbable suture loops, the sutures had no appreciable strength. The rate
loss of suture mass of these 2 sutures was similar.
As expected, chromic gut sutures potentiated significantly more infection
than did the Caprosyn sutures.
[10]
However, the handling properties of the
Caprosyn sutures were far superior to those of the chromic gut sutures,
and the smooth surface of the Caprosyn sutures encountered lower drag
forces than did the chromic gut sutures. Furthermore, it was much easier to
reposition the Caprosyn knotted sutures than the knotted chromic gut
sutures.
[10]
In the case of chromic gut sutures, it was not possible to
reposition a 2-throw granny knot. These biomechanical performance
studies demonstrated the superior performance of the synthetic Caprosyn
sutures compared with chromic gut sutures and provide compelling
evidence of why Caprosyn sutures are an excellent alternative to chromic
gut sutures.
Nonabsorbable sutures
Natural nonabsorbable sutures include the following:
Surgical silk
Surgical cotton
Surgical steel
Surgical silk suture is made of raw silk spun by silkworms. The suture may
be coated with beeswax or silicone. Many surgeons consider silk suture the
standard of performance (superior handling characteristics). Although
classified as a nonabsorbable material, silk suture becomes absorbed by
proteolysis and is often undetectable in the wound site by 2 years. Tensile
strength decreases with moisture absorption and is lost by 1 year. The
problem with silk suture is the acute inflammatory reaction triggered by this
material. Host reaction leads to encapsulation by fibrous connective tissue.
Surgical cotton suture is made of twisted, long, staple cotton fibers. Tensile
strength is 50% within 6 months and 30-40% by 2 years. Surgical cotton is
nonabsorbable and becomes encapsulated within body tissues. Surgical
steel suture is made of stainless steel (iron-chromium-nickel-molybdenum
alloy) as a monofilament and twisted multifilament. This suture can be
made with flexibility, fine size, and the absence of toxic elements. Surgical
steel demonstrates high tensile strength with little loss over time and low
tissue reactivity. The material also holds knots well.
Surgical steel suture is used primarily in orthopedic, neurosurgical, and
thoracic applications. This type of suture may also be used in abdominal
wall closure, sternum closure, and retention. However, this material can be
difficult to handle because of kinking, fragmentation, and barbing, which
renders the wire useless and may present a risk to the surgeon's safety.
[11]

The cutting, tearing, or pulling of other patient tissues is also a risk. In
addition, surgical steel in the presence of other metals or alloys may cause
electrolytic reactions and, therefore, is not a safe choice in these
circumstances. The size of the steel wires is classified by the Brown and
Sharpe gauge, that is, 18 (largest diameter) to 40 (smallest diameter). The
standard USP classification is also used to denote wire diameter.
Nonabsorbable synthetic sutures include the following:
Nylon
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron
[coated])
Polybutester Suture (Novafil)
Coated Polybutester Suture (Vascufil)
Polypropylene (Prolene)
Surgipro II
Nylon suture is a polyamide polymer suture material available in
monofilament (Ethilon/Monosof) and braided (Nurolon/Surgilon) forms. The
elasticity of this material makes it useful in retention and skin closure. Nylon
is quite pliable, especially when moist. Of note, a premoistened form is
available for cosmetic plastic surgery. The braided forms are coated with
silicone. Nylon suture has good handling characteristics, although its
memory tends to return the material to its original straight form. Nylon has
81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years. The
material is stronger than silk suture and elicits minimal acute inflammatory
reaction. Nylon is hydrolyzed slowly, but remaining suture material is stable
at 2 years, due to gradual encapsulation by fibrous connective tissue.
Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron
[coated]) suture material is formed from polyester, a polymer of
polyethylene terephthalate. The multifilament braided suture also comes
coated with polybutilate (Ethibond) or silicone (Ti-cron). The coating
reduces friction for ease of tissue passage and improved suture pliability
and tie-down. The suture elicits minimal tissue reaction and lasts
indefinitely in the body. Polyester fiber sutures are stronger than natural
fibers and do not weaken with moistening. The material provides precise
consistent suture tension and retains tensile strength. This suture is
commonly used for vessel anastomosis and the placement of prosthetic
materials.
Polybutester suture (Novafil) is a block copolymer that contains butylene
terephthalate and polytetramethylene ether glycol. This monofilament
synthetic nonabsorbable suture has unique performance characteristics
that may be advantageous for wound closure,
[12]
and it exhibits distinct
differences in elongation compared with other sutures. With the
polybutester suture, low forces yield significantly greater elongation than is
seen in the other sutures. In addition, its elasticity is superior to the other
sutures, allowing the suture to return to its original length once the load is
removed.
Coated polybutester suture (Vascufil) is a unique absorbable polymer that
enhances the clinical performance of polybutester suture by its coating, a
polytribolate polymer composed of 3 compounds: glycolide, -caprolactone,
and poloxamer 188.
[13]
Coating the polybutester suture markedly reduces its
drag force in musculoaponeurotic, colonic, and vascular tissue.
Polypropylene (Prolene) is a monofilament suture that is an isostatic
crystalline stereoisomer of a linear propylene polymer, permitting little or no
saturation. The material does not adhere to tissues and is useful as a pull-
out suture (eg, subcuticular closure). Polypropylene also holds knots better
than other monofilament synthetic materials. This material is biologically
inert and elicits minimal tissue reaction. Prolene is not subject to
degradation or weakening and maintains tensile strength for up to 2 years.
This material is useful in contaminated and infected wounds, minimizing
later sinus formation and suture extrusion.
Surgipro II is a polypropylene suture that has been developed with
increased resistance to fraying during knot rundown, especially with smaller
diameter sutures. This suture is extremely inert in tissue and has been
found to retain tensile strength in tissues for as long as 2 years. Surgipro II
is widely used in plastic, cardiovascular, general, and orthopedic surgery. It
exhibits a lower drag coefficient in tissue than nylon sutures, making them
ideal for use in continuous suture closure.
[14]

Needles
Surgical needles are produced from stainless steel alloys, which have
excellent resistance to corrosion.
[14]
All true stainless steels contain a
minimum of 12% chromium, which allows a thin, protective surface layer of
chromium oxide to form when the steel is exposed oxygen. Since their
development during the early 1960s, high nickel maraging stainless steels
have found extensive use in structural materials in many applications that
require a combination of high strength and toughness.
The basic principle of maraging consists of strengthening tetrataenite
(FeNi) martensitic matrices by the precipitation of fine intermetallic phases,
such as nickel-titanium (Ni
3
Ti). These precipitates are so small that they
are only evident on transmission electron microscopy. They strengthen the
metal by preventing the planes of atoms in the stainless steel from sliding
over each other. A high nickel maraging stainless steel, like S45500, is
composed of 7.5-9.5% nickel, 0.8-1.4% titanium, and 11-12.5% chromium.
In contrast, S42000 stainless steel is composed of 12-14% chromium
without nickel or titanium. Scientists have successfully used the concept of
high nickel maraging stainless steels (S45500) to develop stainless steel
wires with superior strength and ductility for use as surgical needles.
Surgical needles made of a high nickel maraging stainless steel have a
greater resistance to bending and breakage than stainless steels without
nickel.
Wound closure and healing is affected by the initial tissue injury caused by
needle penetration and subsequent suture passage. Needle selection,
surface characteristics of the suture (eg, coefficient of friction), and suture-
coating materials selected for wound closure are important factors that
must be considered by the surgeon.
Needle qualities
Characteristics of the ideal surgical needle and needle performance are
reviewed in this section.
Ideal surgical needle characteristics
The ideal surgical needle has the following characteristics:
High-quality stainless steel
Smallest diameter possible
Stable in the grasp of the needle holder (see the following image)
Interaction between the needle holder and suture needle. A: A needle holder of
appropriate size for the needle; B: a needle holder that is too large for the needle
pressure applied by the needle holder leads to inadvertent straightening of the suture
needle; C: a needle holder that is too small for the needlethe needle rotates around
the long axis of the needle holder.
Capable of implanting suture material through tissue with minimal trauma
Sharp enough to penetrate tissue with minimal resistance
Sterile and corrosion-resistant to prevent introduction of microorganisms
or foreign materials into the wound
Needle performance characteristics and definitions
The following terms describe various characteristics related to needle
performance:
Strength - Resistance to deformation during repeated passes through
tissue (ie, increased needle strength results in decreased tissue trauma);
ultimate moment is the measure of maximum strength determined by
bending the needle to 90, and surgical-yield moment is the amount of
angular deformation that can occur before permanent needle deformation
occurs
Ductility - Resistance (of a needle) to breakage under a given amount of
deformation/bending
Sharpness - Measure of the ability of the needle to penetrate tissue;
factors affecting sharpness include the angle of the point and the taper
ratio (ie, ratio of taper length to needle diameter)
Clamping moment - Stability of a needle in a needle holder, determined
by measuring the interaction of the needle body with the jaws of the
needle holder
Anatomy of a needle
The anatomy of a needle includes the point, body, and swage (see the
following image).
Anatomy of a needle.
The point portion of the needle extends from the tip to the maximum cross-
section of the body. Point types include the following (see the image
below):
Cutting needles (conventional, reverse, or side [spatula])
Taper-point (round) needles
Beveled, conventional cutting edge needles
Blunt-point needles
See the image below.
Commonly used suture needles, with cross-sections of the
needles shown at the point, body, and swage. A: A taper needle; B: a conventional
cutting needle; C: a reverse cutting needle.
Cutting needles
The cutting needle has at least 2 opposing cutting edges (the point is
usually triangular). This type is designed for penetration through dense,
irregular, and relatively thick tissues. The point cuts a pathway through
tissue and is ideal for skin sutures. Sharpness is due to the cutting edges.
Conventional cutting needles have 3 cutting edges (triangular cross-section
that changes to a flattened body). The third cutting edge is on the inner,
concave curvature (surface-seeking).
In reverse-cutting needles, the third cutting edge is on the outer convex
curvature of the needle (depth-seeking). These needles are stronger than
conventional cutting needles and have a reduced risk of cutting out tissue.
The needles are designed for tissue that is tough to penetrate (eg, skin,
tendon sheaths, oral mucosa). Reverse-cutting needles are also beneficial
in cosmetic and ophthalmic surgery, causing minimal trauma.
Side-cutting (spatula) needles are flat on the top and bottom surfaces to
reduce tissue injury. These needles allow maximum ease of penetration
and control as they pass between and through tissue layers. Side-cutting
needles were designed initially for ophthalmic procedures.
Taper-point needles
Taper-point (round) needles penetrate and pass through tissues by
stretching without cutting. A sharp tip at the point flattens to an
oval/rectangular shape. The sharpness is determined by taper ratio (8-
12:1) and tip angle (20-35). The needle is sharper if it has a higher taper
ratio and lower tip angle. The taper-point needle is used for easily
penetrated tissues (eg, subcutaneous layers, dura, peritoneum, abdominal
viscera) and minimizes the potential tearing of fascia.
Beveled, conventional cutting edge needles
A beveled, conventional cutting edge needle was developed with superior
performance characteristics over those of other conventional cutting edge
needles. It is composed of a unique stainless steel, ASTM 45500, that has
been heat-treated after the curving process to enhance the resistance to
bending. The angle of presentation of its cutting edge has been decreased
to enhance needle sharpness. On the basis of the results of experimental
and clinical studies done by Kaulbach et al, this needle is recommended for
closure of lacerations.
[15]

Blunt-point needles
Blunt point needles dissect friable tissue rather than cut it. The points are
rounded and blunt, ideal for suturing the liver and kidneys. Additionally,
blunt needles are being developed for more conventional uses in an effort
to reduce needlestick injuries.
Needle body types include the following:
Straight body
Half-curved ski body
Curved body
Compound curved body
The body part of the needle incorporates most of the needle length and is
important for interaction with the needle holder and the ability to transmit
the penetrating force to the point. The needle factors that affect this
interaction include needle diameter and radius, body geometry, and
stainless steel alloy. These components determine the needle-bending
moment, ultimate moment, surgical-yield moment, and needle ductility.
The straight- body needle is used to suture easily accessible tissue that
can be manipulated directly by hand. This needle is also useful in
microsurgery for nerve and vessel repair. Examples of straight-body
needles include the Keith needle, which is a straight cutting needle used for
skin closure of abdominal wounds, and the Bunnell needle, which is used
for tendon/gastrointestinal tract repair.
The half-curved ski needle is rarely used in skin closure, because it is
difficult to handle. The straight portion of the body does not follow the
curved point, resulting in an enlarged curved point, which makes the needle
difficult to handle.
The curved needle has a predictable path through tissue and requires less
space for maneuvering than a straight needle does. The semicircular path
is the optimal course for sutures through tissue and provides an even
distribution of tension. Body curvature is commonly a one-quarterinch,
three-eighthsinch, half-inch, or five-eighthsinch circle. The three-eighths
inch circle is used most commonly for skin closure. The half-inch circle was
designed for confined spaces, and more manipulation by the surgeon is
required (ie, increased wrist motion is required).
The compound curved needle curvature was originally designed for anterior
segment ophthalmic surgery. The body has a tight 80 curvature at the tip,
which becomes a 45 curvature throughout the remainder of the body. A
microvascular compound curved needle may also facilitate vessel
approximation in microvascular surgery.
Swage
The suture attachment end creates a single, continuous unit of suture and
needle; this is known as the swage. The swage may be designed to permit
easy release of the needle and suture material (pop-off), and includes the
following types:
Channel
Drill
Nonswaged
In a channel swage, a needle is created with a channel into which the
suture is introduced, and the channel is crimped over the suture to secure it
into place. The diameter of the channel swage is greater than the diameter
of the needle body.
In a drill swage, material is removed from the needle end (sometimes with
a laser), and the needle is crimped over the suture. The diameter of the drill
swage is less than the diameter of the needle body.
Alternatively, in a nonswaged needle, the suture may be passed through an
eye, similar to that found in a sewing needle. In a closed-eye configuration,
the shape may be round, oblong, or square. In a French (split or spring)
eye, a slit is in the end of the needle with ridges that catch and hold the
suture in place.
Several disadvantages are associated with the use of a nonswaged needle.
Tissue passage of a double strand of suture leads to more tissue trauma.
In a swaged needle, the suture is less likely to become unthreaded
prematurely. Also, decreased handling helps maintain suture integrity.
Swaged sutures are not subject to suture fraying or damage due to sharp
corners in the eye of eyed needles.
Needle coating and needle measurements
The needle may be coated with silicone to permit easier tissue passage.
The coating helps reduce the force needed to make initial tissue
penetration and the frictional forces as the body of the needle passes
through the tissue.
The chord length, or bite width, is the linear distance from the point of the
curved needle to the swage (bite width). The needle length is the distance
measured along the needle from the point to the swage. Needle length, not
chord length, is the measurement supplied on suture packages. The radius
is the distance from the body of the needle to the center of the circle along
which the needle curves (bite depth), and the diameter is considered the
gauge or thickness of the needle wire. See the image below.
Anatomy of a needle.
Needleneedle holder interaction
The stability of the needle within the needle holder affects needle control
and performance. The jaws of the needle holder must be appropriate to the
needle size to hold it securely and prevent rocking, turning, and twisting
(see the following image). An ovoid cross-section of the needle body often
maximizes both the surface contact with the needle-holder jaws and the
bending moment of the needle.
Interaction between the needle holder and suture needle.
A: A needle holder of appropriate size for the needle; B: a needle holder that is too large
for the needlepressure applied by the needle holder leads to inadvertent straightening
of the suture needle; C: a needle holder that is too small for the needlethe needle
rotates around the long axis of the needle holder.
The needle-holder handle must be appropriate for the depth needed for
placement of the suture. The difference between the length of the handle
and the jaw creates a mechanical advantage for exerting force through the
needle point.
The needle-holder clamping moment is the force applied to a suture needle
by a needle holder. The jaws of the needle holder contact a curved needle
at 1 point on the outer curvature and 2 points along the inner curvature.
The force against the needle creates a moment arm, which acts to flatten
the curvature of the needle.
Technically speaking, the needle-holder clamping moment must be less
than the surgical yield of the needle, or the needle will bend and ultimately
may break. A bent needle takes a relatively traumatic path through soft
tissue and may cause increased soft-tissue injury. Repetitive injury by the
needle holder also may cause the needle to break. If the broken portion of
the needle is not identified and retrieved immediately, surgery may be
delayed in efforts to find it. The need for intraoperative radiology and other
potential difficulties may ensue.
Studies by Abidin et al demonstrated that the sharp edges of smooth
needle-holder jaws cut the smooth surface of monofilament sutures,
weakening their strength.
[16]
When the smooth tungsten carbide inserts of
needle holders clamped 6-0 monofilament nylon suture with the first
opposing teeth of the needle holder ratchet mechanism interlock, there was
a significant reduction in suture breaking strength.
[16]

This sutural damage can be prevented by mechanical grinding the outer
edges of the smooth tungsten carbide inserts, resulting in a rounded edge.
Clamping the suture with the smooth jaws of the needle holder was
atraumatic with no demonstrable damage to the suture's breaking
strength.
[16]

It is important to emphasize that the performance of needles and sutures
should be evaluated in a selection program by a healthcare resource
management group purchasing organization.
[14]
Unfortunately, only
Consorta, Inc. (Rolling Meadows, Ill) has had the leadership to do such a
surgical suture and needle product evaluation. In this expanded evaluation
program, when 42 Consorta shareholder hospitals enrolled 1913 surgeons
to participate in an observational study of the clinical performance of
surgical sutures and needles produced by Covidien, in the 30-day studies,
surgeons found that the needles and sutures were clinically acceptable in
98.1% of the evaluations.
[14]

Selection of sutures, surgical gloves, needles, and needle holders in clinical
practice are briefly discussed in this section.
Suture selection
Much of the process regarding suture selection depends on surgeon
training and preference. A wide variety of suture materials are available for
each surgical location and surgical requirement. Generally, the surgeon
selects the smallest suture that adequately holds the healing wound edges.
The tensile strength of the suture should never exceed the tensile strength
of the tissue. As the wound heals, the relative loss of suture strength over
time should be slower than the gain of tissue tensile strength.
Certain general principles can be applied to suture selection. Sutures are
no longer needed when a wound has reached maximum strength.
Therefore, consider nonabsorbable suture in skin, fascia, and tendons
(slowly healing tissues), whereas mucosal wounds (rapidly healing tissues)
may be closed with absorbable sutures.
Aesthetic concerns
Aesthetic concerns are at a premium in the anatomic regions of the head
and neck, such as the eyelid, periorbital area, nose, pinna, lip, and
vermillion. In these areas, tensile strength requirements tend to be less,
and smaller suture sizes are preferred. However, the mobility of the lip and
vermillion requires a relatively higher suture tensile strength. The activity
and mobility of the face, anterior and posterior neck, scalp, superior trunk,
and nasal and oral mucosa demand higher tensile strength requirements in
suture selection. Additionally, major musculocutaneous flaps tend to be
closed under significant tension, requiring maximal long-term tensile
strength.
Contaminated tissues
Because the presence of foreign bodies in contaminated tissues may
facilitate infection, special consideration of suture selection in these
locations, such as a contaminated posttraumatic wound, is imperative.
Multifilament sutures are more likely to harbor contaminants than
monofilament sutures; thus, monofilament sutures are generally preferable
in potentially contaminated tissues. Use the smallest inert monofilament
suture materials, such as nylon or polypropylene, in this setting.
Suture size
Optimal suture size is generally the smallest size necessary to achieve the
desired tension-free closure. If wound tension is high, smaller-diameter
sutures may actually injure tissues by cutting through them. Therefore,
closely match the tensile strength of the suture and tissue.
Surgical glove selection
Surgeons who use sutures and needles should wear sterile surgical gloves
without cornstarch, as cornstarch has been documented to promote wound
infection, to cause serious peritoneal adhesions and granulomatous
peritonitis, and to be a well-documented vector of the latex allergy
epidemic. In 2008, 13 health professionals filed a citizens petition to the
US Food and Drug Administration (FDA) to ban cornstarch powder on
medical gloves.
[17]

Because the FDA allows 1.5% of the surgical gloves to have holes, these
holes allow the transmission of blood with deadly borne viral infections to
be transmitted between the patient and the surgeon. After surgery has
begun, one of the major causes of glove holes is surgical needle
penetration through the glove. Consequently, the use of the double-glove
Biogel Puncture Indication System should be used to detect the location
and presence of holes in the gloves, allowing the surgeon to change the
gloves when a hole is detected, (as seen in the image below).
[18]

A poster for the Biogel Puncture Indication System.
Needle selection
No standardized sizing system or nomenclature is available for needles or
needle holders. The main consideration in needle selection is to minimize
trauma. A taper needle is sufficient for tissues that are easy to penetrate.
Cutting needles are typically reserved for tough tissues. As a general
guide, select tapered sutures for all closures except skin sutures. The
length, diameter, and curvature of the needle influence the surgeon's ability
to place a suture. The needle-body diameter ideally matches the suture
size.
Needle-holder selection
As discussed earlier, needle control and performance is affected by the
stability of the needle within the needle holder; thus, for a secure needle
hold and prevention of rocking, turning, and twisting, the jaws of the needle
holder must be appropriate to the needle size. Often, the surface contact
with the needle-holder jaws and the bending moment of the needle is
maximized with an ovoid cross-section of the needle body.
In addition, the handle of the needle handle must be appropriate for the
depth needed for the suture placement. A mechanical advantage for
exerting force through the needle point is created by the difference
between the length of the handle and the jaw.
The needle-holder clamping moment is a measure of the force applied to a
suture needle by the needle holder, and the needle-yield moment is the
amount of deformation that can occur before a needle is permanently
deformed. Thus, when the needle-holder clamping moment is greater than
the needle-yield moment, the needle is likely to be permanently deformed,
which may lead to complications.
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