BACKGROUND

As a method for closing cutaneous wounds, the technique of suturing is thousands ofyears old. Although
suture materials and aspects of the technique have changed, thegoals remain the same: closing dead
space, supporting and strengthening wounds untilhealing increases their tensile strength, approximating
skin edges for an aestheticallypleasing and functional result, and minimizing the risks of bleeding and
infection.Proper suturing technique is needed to ensure good results in dermatologic surgery.The
postoperative appearance of a beautifully designed closure or flap can becompromised if an incorrect
suture technique is chosen or if the execution is poor.Conversely, meticulous suturing technique cannot
fully compensate for impropersurgical technique. Poor incision placement with respect to relaxed skin
tension lines,excessive removal of tissue, or inadequate undermining may limit the surgeon's optionsin
wound closure and suture placement. Gentle handling of the tissue is also importantto optimize wound
healing.The choice of suture technique depends on the type and anatomic location of thewound, the
thickness of the skin, the degree of tension, and the desired cosmetic result.The proper placement of
sutures enhances the precise approximation of the wound edges, which helps minimize and redistribute
skin tension. Wound eversion is essentialto maximize the likelihood of good epidermal approximation.
Eversion is desirable tominimize the risk of scar depression secondary to tissue contraction during
healing.Usually, inversion is not desirable, and it probably does not decrease the risk ofhypertrophic
scarring in an individual with a propensity for hypertrophic scars. Theelimination of dead space, the
restoration of natural anatomic contours, and theminimization of suture marks are also important to
optimize the cosmetic and functionalresults.

SUTURE IN SURGERY
Sutures are the stitches that doctors, and especially surgeons, use to hold skin, internal
organs, blood vessels and all other tissues of the human body together, after they have
been severed by injury or surgery. They must be strong (so they do not break), non-toxic
and hypoallergenic (to avoid adverse reactions in the body), and flexible (so they can be
tied and knotted easily). In addition, they must lack the so called "wick effect", which
means that sutures must not allow fluids to penetrate the body through them from outside,
which could easily cause infections.

Absorbable and nonabsorbable sutures

Sutures are divided into two kinds - those which are absorbable and will break down
harmlessly in the body over time without intervention, and those which are nonabsorbable and must be manually removed if they are not left indefinitely. The type of
suture used varies on the operation, with a major criteria being the demands of the
location and environment:

Sutures to be placed internally would require re-opening if they were to be

removed. Sutures which lie on the exterior of the body can be removed
within minutes, and without re-opening the wound. As a result, absorbable
sutures are often used internally; non-absorbably externally.

Sutures to be placed in a stressful environment, for example the heart

(constant pressure and movement) or the bladder (adverse chemical
presence) may require specialized or stronger materials to perform their
role; usually such sutures are either specially treated, or made of special
materials, and are often non-absorbable to reduce the risk of degradation.

Absorbable sutures
Absorbable sutures are made of materials which are broken down in tissue after a given
period of time, which depending on the material can be from ten days to eight weeks.
They are used therefore in many of the internal tissues of the body. In most cases, three
weeks is sufficient for the wound to close firmly. The suture is not needed any more, and
the fact that it disappears is an advantage, as there is no foreign material left inside the
body and no need for the patient to have the sutures removed.
Absorbable sutures were originally made of the intestines of sheep, the so called catgut.
The manufacturing process was similar to that of natural musical strings for violins and
guitars, and also of natural strings for tennis racquets. The inventor, a 10th century
surgeon named al-Zahrawi reportedly discovered the dissolving nature of catgut when his
lute's strings were eaten by a monkey. Today, gut sutures are made of specially prepared

beef and sheep intestine, and may be untreated (plain gut), tanned with chromium salts to
increase their persistence in the body (chromic gut), or heat-treated to give more rapid
absorption (fast gut). However, the major part of the absorbable sutures used are now
made of synthetic polymer fibers, which may be braided or monofilament; these offer
numerous advantages over gut sutures, notably ease of handling, low cost, low tissue
reaction, consistent performance and guaranteed non-toxicity. (In Europe and Japan, gut
sutures have been banned due to concerns over bovine spongiform encephalopathy,
although the herds from which gut is harvested are certified BSE-free.) Each major suture
manufacturer has its own proprietary formulations for its brands of synthetic absorbable
sutures; various blends of polyglycolic acid, lactic acid or caprolactone are common.
In rare cases, absorbable sutures can cause inflammation and be rejected by the body
rather than absorbed.

Non-absorbable sutures
Nonabsorbable sutures are made of materials which are not metabolized by the body, and
are used therefore either on skin wound closure, where the sutures can be removed after a
few weeks, or in some inner tissues in which absorbable sutures are not adequate. This is
the case, for example, in the heart and in blood vessels, whose rhythmic movement
requires a suture which stays longer than three weeks, to give the wound enough time to
close. Other organs, like the bladder, contain fluids which make absorbable sutures
disappear in only a few days, too early for the wound to heal. Inflammation caused by the
foreign protein in some absorbable sutures can amplify scarring, so if other types of
suture are less antigenic (ie, do not provoke as much of an immune response) it would
represent a way to reduce scarring.
There are several materials used for nonabsorbable sutures. The most common is a
natural fiber, silk, which undergoes a special manufacturing process to make it adequate
for its use in surgery. Other nonabsorbable sutures are made of artificial fibers, like
polypropylene, polyester or nylon; these may or may not have coatings to enhance their
performance characteristics. Finally, stainless steel wires are commonly used in
orthopedic surgery and for sternal closure in cardiac surgery.

Surgical needles for use with sutures

Traumatic needles are needles with holes or eyes which are supplied to the hospital
separate from their suture thread. The suture must be threaded on site, as is done when
sewing at home. Atraumatic needles with sutures comprise an eyeless needle attached
to a specific length of suture thread. The suture manufacturer swages the suture thread to
the eyeless atraumatic needle at the factory. There are several advantages to having the
needle pre-mounted on the suture. The doctor or the nurse does not have to spend time
threading the suture on the needle. More important, the suture end of a swaged needle is
smaller than the needle body. In traumatic needles with eyes, the thread comes out of the
needle's hole on both sides. When passing through the tissues, this type of suture rips the

tissue to a certain extent, thus the name traumatic. Nearly all modern sutures feature
swaged atraumatic needles.
There are several shapes of surgical needles, including:

straight
half curved or ski
1/4 circle
3/8 circle
1/2 circle
5/8 circle
compound curve

Needles may also be classified by their point geometry; examples include:

taper (needle body is round and tapers smoothly to a point)

cutting (needle body is triangular and has a sharpened cutting edge on the inside)
reverse cutting (cutting edge on the outside)
trocar point or tapercut (needle body is round and tapered, but ends in a small
triangular cutting point)
blunt points for sewing friable tissues
side cutting or spatula points (flat on top and bottom with a cutting edge along the
front to one side) for eye surgery

Finally, atraumatic needles may be permanently swaged to the suture or may be designed
to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for
interrupted sutures, where each suture is only passed once and then tied.

Sizes of sutures
Suture sizes are defined by the United States Pharmacopeia (U.S.P.). Sutures were
originally manufactured ranging in size from #1 to #6, with #1 being the smallest. A #4
suture would be roughly the diameter of a tennis racquet string. The manufacturing
techniques, derived at the beginning from the production of musical strings, did not allow
thinner diameters. As the procedures improved, #0 was added to the suture diameters, and
later, thinner and thinner threads were manufactured, which were identified as #00 (#2-0
or #2/0) to #000000 (#6-0 or #6/0).
Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine
monofilament suture for ophthalmics). Atraumatic needles are manufactured in all shapes
for most sizes. The actual diameter of thread for a given U.S.P. size differs depending on
the suture material class.

A wound before and after being closed by simple interrupted sutures

U.S.P.
Designation

Collagen
metric
diameter
(mm)

Synthetic
absorbable
metric diameter
(mm)

11-0

Nonabsorbable
metric
diameter
(mm)

American wire
gauge

0.01

10-0

0.02

0.02

0.02

9-0

0.03

0.03

0.03

8-0

0.05

0.04

0.04

7-0

0.07

0.05

0.05

6-0

0.1

0.07

0.07

38-40

5-0

0.15

0.1

0.1

35-38

4-0

0.2

0.15

0.15

32-34

3-0

0.3

0.2

0.2

29-32

2-0

0.35

0.3

0.3

28

0.4

0.35

0.35

26-27

0.5

0.4

0.4

25-26

0.6

0.5

0.5

23-24

0.7

0.6

0.6

22

0.8

0.6

0.6

21-22

0.7

0.7

20-21

0.8

19-20

18

Suture techniques
Common suture stitching techniques include:

Simple Interrupted Stitch ( or running)

Mattress
Horizontal mattress
Vertical mattress
Figure 8
Continuous locking
Subcuticular

Removal of sutures
Whilst some sutures are intended to be permanent, and others in specialized cases may be
kept in place for an extended period of many weeks, as a rule sutures are a short term
device to allow healing of a trauma or wound. According to about.com's article on
nursing:
"Different parts of the body heal at different intervals. Common time to remove
stitches will vary: facial wounds 3-5 days; scalp wound 7-10 days; limbs 10-14
days; joints 14 days; trunk of the body 7-10 days.

"Not all stitches must be removed. If a small area remains unhealed, notify the
health care practitioner. Then if ordered, remove sutures from the healed area
only."

Suture materials
.

Description

Plain catgut

Chromic
catgut

Polyglycolic Polydioxanon
acid (P.G.A.)
e (PDS)

Absorbable
Absorbable
It is a
It is a synthetic
biological suture
biological
synthetic
absorbable
material. Plain is an suture
absorbable suture
absorbable suture material.
suture
material.
made by twisting
Chromic is an material.
Monofilament
together strands of absorbable
Braided
synthetic
purified collagen
suture made synthetic
absorbable
taken from bovine by twisting
absorbable suture,
intestines. The
together
multifilament prepared from
natural plain thread strands of
made of
the polyester,
is precision ground purified
polyglycolic poly (pin order to achieve a collagen taken acid and
dioxanone).
monofilament
from bovine coated with
character and
intestines. Due N-laurin and
treated with a
to undergoing L-lysine,
glycerol containing a ribbon stage which render
solution. Plain is
chromicisation the thread
absorbed by
(treatment
extremely
enzymatic
with chromic smooth, soft
degradation.
acid salts), the and knot safe.
chromic offers
roughly twice
the stitchholding time
of plain catgut.
The natural
chromic thread
is precision
ground in
order to
achieve a
monofilament
character and
treated with a

glycerol
containing
solution.
Chromic is
absorbed by
enzymatic
degradation.

Composition

Natural
purified
collagen

Polyester and
Polyglycolic
poly (pacid
dioxanone)

Tensile strength

Strength retention
for at least 7 days.

Structure

Monofilament

Monofilament Braided

Monofilament

Origin

Bovine serosa
surface finish.

Bovine serosa Synthetic

Synthetic
through the
critical wound

Treatment

Treatment
with a glycerol
Coated with
containing
magnesium Uncoated
solution and
stearate
chromic acid
salts

Type of
absorption

Proteolytic
enzymatic digestion
complete by 90
days.

Proleolytic
Absorption PDS
enzymatic
by hydrolysis
digestion
complete
complete in 70 between 60
days.
and 90 days.
Absorption by Always
enzymatic
predictable
digestion and and reliable
starts losing
tensile

strength on
implantation
from 1821
days of catgut
chromic

Moderate. Plain
catgut enjoys lower
Tissue reaction tissue reaction as
Moderate.
compared to
chromicised.

Thread color

Straw

Violet

Violet

Size available

USP 6-0 (1
USP 6-0 (1
USP 6-0 (1 metric)
metric) to
metric) to USP
to USP 3 (7 metric).
USP 2 (5
3 (7 metric).
metric)

USP 6-0 (1
metric) to USP
2 (5 metric)

Sterilization

E.O. Gas.

E.O. Gas

E.O. gas

Advantages

Very high knot-pull

tensile strength,
good knot security
due to special
excellent handling
features

Very high
High initial
knot-pull
tensile
tensile
strength,
strength, good guaranteed
knot security holding
due to special power
surface finish, through the
improved
critical
smoothness
wound
due to the dry healing
presentation of period.
the thread,
Smooth
excellent
passage
handling
through
features
tissue, easy
handling,
excellent
knotting

Brown

E.O. gas.

Tensile
strength
retention,
guaranteed
holding power

ability, secure
knot tying

Indications

PDS is
particularly
For all surgical
useful where
procedures
the
especially when
Subcutaneous combination of
tissues that
For all surgical
,
an absorbable
regenerate faster are procedures,
intracutaneou suture and
involved. General especially for
s closures,
extended
closure, ophthalmic, tissues that
abdominal
wound support
orthopedics,
regenerate
and thoracic is desirable,
obstetrics/gynecolog faster.
surgeries
pediatric
y and gastrocardiovascular
intestinal tract
surgery,
surgery.
ophthalmic
surgery

This type of
suture being
absorbable is
This suture
Not
not to be used
Not recommended
being
recommended
where
for incisions that
absorbable
for an incision
prolonged
require the
should not be
Contraindicatio
that requires
approximation
sustaining of the
used where
ns
sustaining of
of tissues
tissues for a
extended
the tissues for
under stress is
prolonged period of
approximatio
a prolonged
required and/
time.
n of tissue is
period of time.
or in
required.
conjunction
with prosthetic
devices

Precautions

Special precautions It is absorbed Special

should be taken in much faster precautions
patients with cancer, when used in should be
anemia and
the mouth and taken in
malnutrition
in the vagina, elderly
conditions. They
due to the
patients and
tend to absorb the presence of
patients with
sutures at a higher microorganism history of

The PDS
suture knots
must be
properly
placed to be
secure.
Conjunctival
and vaginal

mucosal
.
sutures
Cardiovascula
remaining in
rate. Cardiovascular r surgery, due
placed for
surgery, due to the to the
anemia and extended
continued heart
continued
malnutrition periods may
contractions. It is
heart
conditions. be associated
absorbed much
contractions. As with any with localized
faster when used in Special
suture
irritation.
the mouth and in the precautions
material,
Subcuticular
vagina, due to the should be
adequate knot sutures should
presence of
taken in
security
be placed as
microorganisms.
patients with requires the deeply as
Avoid using where cancer, anemia accepted
possible in
long term tissue
and
surgical
order to
approximation is
malnutrition technique of minimize the
needed. Absorption conditions.
flat and
erythema and
is faster in infected They tend to square ties. induration
tissues
absorb this
normally
suture at a
associated
higher rate.
with
absorption.

Other facts
Tissue adhesives
In recent years, topical cyanoacrylate adhesives ("liquid stitches") have been used in
combination with, or as an alternative to, sutures in wound closure. The adhesive remains
liquid until exposed to water or water-containing substances/tissue, after which it cures
(polymerizes) and forms a flexible film that bonds to the underlying surface. The tissue
adhesive has been shown to act as a barrier to microbial penetration as long as the
adhesive film remains intact. Limitations of tissue adhesives include contraindications to
use near the eyes and a mild learning curve on correct usage.

Antimicrobial sutures
Another recent development in wound closure involves the use of sutures coated with
antimicrobial substances to reduce the chances of wound infection. While long-term
studies are not yet available, preliminary results indicate that these sutures are effective at
keeping bacteria out of wounds.