Sutures Absorbable natural sutures Collagen

Chromic surgical gut Absorbable synthetic sutures Polyglactin 910 (Vicryl)

Plain surgical gut Fast-absorbing surgical gut

Polycaprolate (Dexon II) Poliglecaprone 25 (Monocryl) Polysorb Polydioxanone (PDS II) Maxon

V-Loc Absorbable monofilament sutures Caprosyn Absorbable multifilament sutures Nonabsorbable natural sutures Surgical silk Surgical steel Nonabsorbable synthetic sutures Nylon

Surgical cotton

Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]) Polybutester Suture (Novafil) Coated Polybutester Suture (Vascufil) Polypropylene (Prolene)

Surgipro II Needles Point types Cutting (conventional, reverse, or side [spatula])

Blunt pointAnatomy of a needle. 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. Body types Straight

Taper-point (round) Beveled, conventional cutting edge

Compound curved Swage types Channel Nonswaged 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.

Half-curved ski Curved

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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 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

Class II - Cotton or linen fibers or coated natural or synthetic fibers in which the coating contributes to suture thickness without adding strength

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)

Plain surgical gut Fast-absorbing surgical gut

V-Loc Polyglactin 910 (Vicryl) synthetic suture is a braided multifilament suture coated with a copolymer of lactide and glycolide (polyglactin 370). The waterrepelling 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.

Polycaprolate (Dexon II) Poliglecaprone 25 (Monocryl) Polysorb Polydioxanone (PDS II) Maxon

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 VLoc 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 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

Surgical cotton

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

Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]) Polybutester Suture (Novafil) Coated Polybutester Suture (Vascufil) Polypropylene (Prolene)

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 (Ni3 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 7.59.5% 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 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. 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])

Blunt-point needlesCommonly 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]

Taper-point (round) needles Beveled, conventional cutting edge needles

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

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-eighthsinch 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 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.

Half-curved ski body Curved body

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