SUTURE MATERIAL & SUTURING JOEL D’SILVA

DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

INTRODUCTION

• Surgical suture (commonly called

stitches) is a medical device used to hold

body tissues together after an injury or

surgery.

• A number of different shapes, sizes, and

thread materials as well as different types of

needles have been developed over its

millennia of history.

HISTORY

• Through many millennia, various suture materials were used, debated, and remained largely unchanged.

• Needles were made of bone or metals such as silver, copper, and aluminium bronze wire.

• Sutures were made of plant materials (flax, hemp and cotton) or animal material (hair, tendons, arteries, muscle strips and nerves, silk, catgut)

• African cultures used thorns, and Indians used ant sutures by coaxing insects to bite wound edges with their jaws and subsequently twisting off the insects' body to keep the wound closed by the clenched jaws.

• The earliest reports of surgical suture date back to 3000 BC in ancient Egypt, and the oldest known suture is in a mummy from 1100 BC

• A detailed description of a wound suture and the suture materials used in it is by the Indian sage and physician Sushruta, written in 500 BC.

• Joseph Lister introduced great change in suturing technique (as in all surgery) when he endorsed the routine sterilization of all suture threads. He first attempted sterilization with the 1860s "carbolic catgut," and chromic catgut followed two decades later. Sterile catgut was finally achieved in 1906 with iodine treatment

1- Provide an adequate tension of wound closure without dead space but loose enough to obviate tissue ischemia and necrosis.

2- Maintain hemostasis.

3- Permit primary intention healing

4- Reduce postoperative pain

5- Provide support for tissue margins until they have healed and the support no longer needed

6- Prevent bone exposure resulting in delayed healing and unnecessary resorption

7- Permit proper flap position

QUALITIES OF THE IDEAL SUTURE MATERIAL

1- Pliability, for ease of handling

2- Knot security

3- Sterilizable

4- Appropriate elasticity

5- Nonreactivity

6- Adequate tensile strength for wound healing

QUALITIES OF THE IDEAL SUTURE MATERIAL

7- Chemical biodegradability as opposed to foreign body breakdown

Postlethwait (1971), Varma et al. (1974), and

Ethicon (1985)

PRINCIPLES OF SUTURING

1- The completed knot must be tight, firm, and tied so that slippage will not occur

2- To ovoid wicking of bacteria, knot should not be placed in incision lines

3- Knots should be small and the ends cut short (2-3mm)

4- Avoid excessive tension to finer gauge materials as breakage may occur

PRINCIPLES OF SUTURING

5- Avoid using a jerking motion, which may break the suture

6- Avoid crushing or crimping of suture materials by not using hemostats or needle holders on them except on the free end for tying

7- Do not tie suture too tightly as tissue necrosis may occur. Knot tension should not produce tissue blanching

PRINCIPLES OF SUTURING

8- Maintain adequate traction on one end while tying to ovoid loosing the first loop

PRINCIPLES FOR SUTURE REMOVAL

1- The area should be swabbed with hydrogen peroxide for removal of encrusted necrotic debris, blood, and serum from about the sutures

2- A sharp suture scissors should be used to cut the loops of individual or continuous sutures about the teeth

PRINCIPLES FOR SUTURE REMOVAL

3- It is often helpful to use a No. 23 explorer to help lift the sutures if they are within the sulcus or in close opposition to the tissue

4- A cotton pliers is used to remove the suture. The location of the knots should be noted so that they can be removed first. This will prevent unnecessary entrapment under the flap

Suture should be removed in 7 to 10 days to prevent epithelialization or wicking about the suture

TECHNIQUE & PRINCIPLES OF SUTURING

• The technique of suturing begins by selecting the tissue forceps, needle and needle holder.

• Hold the needle holders in your dominant hand by placing the thumb and ring finger into the rings and the index finger on the hinge of the blades.

• This position permits good control of the instrument. Scissors should be held in a similar position.

• The needle should be grasped in the holders on its flattened area approximately one-third of its length away from the suture material.

• To facilitate eversion (turning outwards), support the wound edge with the tissue forceps and insert the needle 5 mm from the edge perpendicular to the skin surface. This creates good apposition without excessive tension.

• As the wound heals, it causes slight inversion with contraction; this will result in a flat scar. Where skin edges curl under during suturing they tend to invert further, leading to poor healing and a less satisfactory cosmetic result.

• Ensuring that the needle remains at right angles to the wound, follow the natural curve of the needle by rotating the wrist and move through each side of the wound separately. Do not be tempted to traverse both wound edges with one bite of the needle

• When the needle emerges from the wound, pull the suture through the tissues until a short tail remains at the initial skin entry site.

• Then enter the opposite side of the wound at the same depth as the first bite. Again, follow the natural curve of the needle by rotating your wrist so that the needle emerges at the same distance from the wound edge as the first bite and at right angles

• To tie the suture, keep the needle holders parallel to the skin and grasp the needle end of the suture. Then make two clockwise loops around the needle holder, followed by a single anti-clockwise throw.

• Note that each successive throw is looped around the forceps in the opposite direction to the last and that all the knots should be seated on the same side of the wound. The suture can then be cut free from the knot, leaving tail lengths of approximately 5 mm, before beginning the next insertion.

NOTE……

• tie sutures just tight enough for the edges to meet

• handle the skin edges with toothed forceps only

• if an irregular wound, start with a few initial strategic sutures to match up the obvious points

• if the edges meet under considerable tension, consider undermining the skin edges

• if one suture doesn’t look right it can affect the whole wound/ scar - consider taking it out and re-doing it

POINTS OF NEEDLES

•Cutting

• Cutting edge on inside of circle

• Skin

• Traumatic

POINTS OF NEEDLES

•Reverse Cutting

• Cutting edge on outside of circle

• Skin

• Less traumatic than cutting

SHAPES OF NEEDLES

• 3/8 circle

• 1/2 circle

• Straight

• Specialty

TYPES OF NEEDLES

• Eyed needles•More Traumatic•Only thread through once

•Suture on a reel

•Tends to unthread itself easily

TYPES OF NEEDLES

•Swaged-on needles

• Much less traumatic

• More expensive suture material

• Sterile

SURGICAL NEEDLES

•Most of surgical needles are fabricated from heat treated steel

•The surgical needle has a basic design composed of three parts

1- The eye which is swaged and permits the suture and needle to act as a single unit to decrease trauma

SURGICAL NEEDLES

2- The body which is the widest point of the

needle and is also referred to as the

grasping area. The body comes in number

of shapes (round, oval, rectangular,

trapezoid, or side flattened)

3- The point which runs from the tip to the

maximum cross-sectional area of the body.

The point also comes in a number of

different shapes (conventional cutting,

reverse cutting, side cutting, taper cut,taper,

blunt

PLACEMENT OF NEEDLE IN TISSUE

1- Force should always be applied in the direction that follows the curvature of the needle

2- Suturing should always be from movable to a non-movable tissue

3- Avoid excessive tissue bites with small needle as it will be difficult to retrieve them

PLACEMENT OF NEEDLE IN TISSUE

4- Use only sharp needles with minimal force. Replace dull needles

5- Never force the needle through the tissue

6- Grasp the needle in the body one-quarter to one-half of the length from the swaged area. Do not hold the swaged area; this may bend or break the needle. Do not grasp the point area as damage or notching may result

PLACEMENT OF NEEDLE IN TISSUE

7- Avoid retrieving the needle from the tissue by the tip. This will damage or dull the needle

8- Suture should be placed in keratinized tissue whenever possible

9- An adequate tissue bite is required to prevent the flap from tearing

INSTRUMENTS

adison forcep hemostat metzenbaum scissors suture scissors

INSTRUMENTS

Needle holders suture removal scissors

blade handle bandage scissors

SUTURE CLASSIFICATION

ACCORDING TO THEIR ORIGIN

•organic•synthetic•metallic

ACCORDING TO THEIR BEHAVIOR IN TISSUE:

•Absorbable (phagocytized or hydrolyzed)•Non-absorbable

ACCORDING TO THEIR STRUCTURE•monofilam

ent•multifilament

ACCORDING TO THE SIZE OF SUTURE

• It varies from 1-0 being the greatest in the diameter to 10-0 which are the least in diameter and difficult to see with the naked eye.

TYPES OF ABSORBABLE SUTURE MATERIAL

Surgical Gut

• Plain gut loses its strength in 7-10 days and is

completely digested by 60 days. It is seldom used now

due to poor strength and high tissue reactivity (due to

proteolytic enzyme degradation rather than hydrolysis).

• Chromic gut has been manufactured with chromium

salts to reduce enzyme digestion and therefore

maintains strength for 10-14 days making it useful for

mucosal closures.

• Fast-absorbing gut is produced by pre-heating and can be used for attaching skin grafts, or in areas of low tension where the wound is well supported by deep sutures, and suture removal would be difficult. It maintains strength for 3-5 days

Polyglactin 910 (Vicryl®,

Polysorb®)

• A synthetic braided co-polymer which

maintains 75% strength at 2 weeks, and 50%

at 3 weeks.

• Absorption is usually complete by 3 months.

• It handles well, has minimal tissue reactivity,

and does not tear tissue. It may occasionally

persist as a small nodule or extrude

(‘spitting’).

Poliglecaprone 25 (Monocryl®)

• Monofilament maintaining 50-60% strength at 7

days with complete absorption by 3 months.

• It offers better handling and knot security than

most other monofilament sutures, with even less

tissue reaction than Vicryl® and is therefore

useful where minimal tissue reaction is essential.

Polydioxanone (PDS II®)

• Monofilament polymer with prolonged tensile strength (70% at 2 weeks, 50% at 4 weeks) and may persist for more than 6 months.

• Good for high-tension areas or contaminated wounds, but being a monofilament it has poor handling and knot security. Its minimal tissue reaction makes it good for repair of cartilage where inflammation would lead to significant discomfort.

Polytrimethylene carbonate

(Maxon®)

• A monofilament that combines the prolonged

strength of PDS® and the good handling and

knotting of Vicryl®. 80% strength at 2 weeks,

60% at 4 weeks, and complete absorption by

6 months. Minimal tissue reaction.

Glycomer 631 (Biosyn®)

• A monofilament similar to Monocryl® in characteristics but with prolonged strength compared to Maxon®.

NON-ABSORBABLE SUTURES

Nylon (Ethilon®, Dermalon®, Surgilon®, Nurolon®, Nylene®)

• Inexpensive monofilament with good tensile strength, and minimal tissue reactivity.

• Disadvantages are its handling and knot security, but it remains one of the most popular non-absorbable sutures in dermatological surgery. Surgilon® and Nurolon® handle better but are more expensive.

Polybutester (Novafil®)

• A monofilament with good handling and excellent elasticity. It responds well to tissue oedema, and is also suited to subcuticular running sutures.

Polypropylene (Prolene®, Surgilene®, Surgipro®)

• A monofilament polymer with a very low coefficient of friction making it the suture of choice for running subcuticular stitches.

• It has good plasticity but limited elasticity, poor knot security, and it is relatively expensive.

Silk (Dysilk®, Mersilk)

• Braided natural protein with unsurpassed handling, knot security, and pliability (making it ideal for mucosal surfaces and intertriginous areas) but limited by its low tensile strength, and high coefficient of friction, capillarity, and tissue reactivity.

Polyester (Dacron®, Mersilene®, Ethibond®)

• Braided multifilament suture with high strength, good handling, and low tissue reactivity.

• Ethibond is coated and has a low coefficient of friction.

• Pliability makes these excellent for mucosal surfaces without the reactivity of silk.

ADHESIVES/GLUES

Simplifies Skin Closure

No Suture Related Problems

Noinflammation

Local Anaesthetic Not Needed

Used In Facial Lacerations & Children

Acts As Barrier Against Microbes

Dermabond(octyl-2-cyanoacrylate)

Approved By Us Fda

TISSUE ADHESIVES

• Sterilizable

• Easy in preparation

• Viscous liquid or liquid possible for spray

• Nontoxic

• Rapidly curable under wet physiological conditions (pH 7.3, 37°C, 1 atm)

• Reasonable cost

• Strongly bondable to tissues

• Biostable union until wound healing

• Tough and pliable

• Resorbable after wound healing

• Nontoxic

• Nonobstructive to wound healing or promoting wound healing

Before Curing After Curing

NATURAL TISSUE – FIBRIN GLUE

• First reported in 1940

• Mimics blood clot – major component fibrin network

• Excellent tissue adhesive but insufficient in amount for larger wounds

• Nontoxic if human protein sources are used to obtain fibrin

SYNTHETIC SYSTEMS: POLY-ALKYL-2-CYANOACRYLATES• Discovered in 1951

• “Crazy Glue”

• H2C=C―CO2―R

CN

• R = alkyl group

• CH3 (methyl)

• H3CCH2 (ethyl)

• Release small amount of formaldehyde when curing

• amount lessens with length of alkyl chain

CHARACTERISTICS OF CURRENTLY AVAILABLE ADHESIVE SYSTEMS

Fibrin Glue Cyanoacrylate

Handling Excellent Poor

Set time Medium Short

Tissue bonding Poor Good

Pliability Excellent Poor

Toxicity Low Medium

Resorbability Good Poor

Cell infiltration Excellent Poor

OTHER EXPERIMENTAL SYSTEMS

• Gelatin-based adhesives

• Mimic coagulation but without fibrin

• Polyurethane (-HNOCO-) based adhesives

• Capped with isocyanate to rapidly gel upon exposure to water

• More flexible than current cyanoacrylate adhesives

• Collagen-based adhesives

FIBRIN BASED TISSUE ADHESIVES

• Achieve Haemostasis

• Seals The Tissues

• Fixate Skin Grafts

• Arrest C.S.F Leak

• TISSEEL & HEMASEEL

*Image via Bing

TISSUE ADHESIVES

*Image via Bing

*Image via Bing

CYANO ACRYLATE GLUE AVAILABLE IN MARKET

*Image via Bing

APPLICATION OF TISSUE ADHESIVES

*Image via Bing

TISSUE ADHESIVES SUPPLIED WITH NONMETALLIC NEEDLES

SKIN STAPLES

• FAST METHOD

• STAINLESS STEEL STAPLES

• LESS REACTIVE

• FEW MICRO ORGANISMS ARE CARRIED INTO TISSUES

• EXPENSIVE

• APPLIED WITH GREAT CARE TO ENSURE EVERSION

SKIN STAPLER

*Image by 54155059@N03 via Flickr

STAPLES & CLIPS VS. SUTURES

• Speed

• Convenience

• Reduced infection rate

• Lower cost

• If done properly, no cosmetic difference

*Image by 61687822@N07 via Flickr

SKIN STAPLE REMOVER

THE SKIN STAPLING

REMOVER

*Image via Bing

REMOVAL OF SKIN STAPLES

ADHESIVE TAPES OR STRIPS

• FIRST USED IN FRANCE IN 1500 A.D

• CHEAPER

• STERISTRIPS USED TODAY ARE POROUS PAPER TAPES

• EG : CLOZEX

*Image via Bing

WOUND CLOSURE STRIPS

*Image via Bing

*Image via Bing

SCALP WOUND CLOSED WITH STERISTRIPS

*Image via Bing

PERIOSTEAL SUTURING

• Generally requires a high degree of dexterity in both flap management and suture placement. Small needles (P-3), fine sutures (4-0 to 6-0) and proper needle holder are a basic requirement

PERIOSTEAL SUTURING

• Technique

1- Penetration: The needle point is positioned perpendicular (90°) to the tissue surface and underlying bone. It is then inserted completely through the tissue until the bone is engaged.

PERIOSTEAL SUTURING

2- Rotation: The body of the needle is rotated about the needle point in the direction opposite to that in which the needle intended to travel. The needle point is held lightly against the bone so as not to damage or dull the needle point

PERIOSTEAL SUTURING

3- Glide: The needle point is now permitted to glide against the bone for only a short distance. Care must be taken not to lift or damage the periosteum

4- Rotation: As the needle glides against bone; it is rotated about the body, following its circumferenced outline. In this way, the needle will not be pushed through the tissue resulting in lifting or tearing of the periosteum

PERIOSTEAL SUTURING

5- Exit: The final stage of gliding and rotation is needle exit. The needle is made to exit the tissue through the gentle application of pressure from above, thus allowing the tip to pierce the tissue

SIMPLE INTERRUPTED SUTURES

• This suture is used for simple laceration closures or closure of office procedures like biopsies or lesion removals.

• It is also the basic suture used inside the wound to close deep sutures.

• It is useful in that a few sutures can be removed at a time instead of all at once to allow for slower sound healing

CONTINUOUS SUTURES

• The continuous suture as its name suggests, only has a knot at the beginning and the end.

• There are several methods of continuous suture – locking and non-locking.

• The knots must be very secure and minimal tesion on the wound or the wound will come apart if one loop or knot gives way.

• The advantage is that it is very quick and the wound tension is even across the wound.

HORIZONTAL MATTRESS SUTURE

• Used with wounds with poor circulation

• Helps eliminate tension on wound edges

• Requires fewer sutures to close a wound

• Can be placed quite quickly

• Can be done as a continuous suture

VERTICAL MATTRESS SUTURES

• Deep and shallow approximation of the tissue

• Can be used for wounds under tension.

• Can be useful with lax tissue e.g. elbow and knee.

• Should not be used on volar surface of hands or feet or on the face because of blind placement of the deep part of the suture.

SUB-CUTICULAR CLOSURE

• Used for cosmetic closures

• Use an absorbable suture if you plan to leave the sutures in and bury the knots

• Use either nylon or prolene (best) and keep the suture sliding while you are closing. The suture then can be easily removed with no exterior marks. The ends can be taped or a knot on the skin.

• At each entry point, enter across form the last exit with slight overlap.

ELIPTICAL INCISION

The ellipse should be three times as long as it is wide. This will make closure of the wound much easier. If the lesion you are removing is likely to be cancerous, make sure that you leave wide margins of clear skin around the lesion.

3 CORNERED SUTURE

• Used to close a skin flap which comes to a point.

• Helps close the wound, but maintain circulation to the tissue.

• Places minimal tension on the wound edges

INSTRUMENT TYING

WOUND EVERSION

WOUND EVERSION

BEST COSMETIC RESULTS

• Smallest size needle

• Monofilament

• Good wound eversion

SKIN SUTURE PLACEMENT

• Close wound in segments

• Sutures equidistant from skin edge on either side

• of wound

• Evert skin edges

• Wound margins loosely approximated

• Repeatedly bisect the wound

“WOUND EDGES SHOULD BEAPPROXIMATED, NOT STRANGULATED!”

• Too tight = tissue necrosis

• Too loose = edges not aligned

KNOTS

• A suture knot has three components

1- The loop created by the knot

2- The knot itself, which is composed of a number of tight “throws”, each throw represents a weave of the two stands

3- The ears, which are the cut ends of the suture

BASIC KNOT TYING

1 2 3 4

1 – square knot2 – granny knot3 - slip knot4 – surgeon’s knot

CONCLUSION

• Clinician should have a sound knowledge of the material property as well as the technical aspect of the ART OF SUTURING for better clinical decision making and appropriate management.

BIBLIOGRAPHY

• Text book of oral and maxillofacial surgery by S.M Balaji & Neelima Anil Malik.

• Postlethwait, R.W.: Wound healing and surgery. Somerville, New Jersey, Ethicon, Inc., 1971

• Varma, S., et al.: Comparison of seven suture materials in infected wound. An experimental study. J. Surg. Res., 17:165, 1974

• Chaiken, R.W.: Elements of surgical treatment in the delivery of periodontal therapy. Chicago, Quintessence, 1977

• Ethicon, Wound closure manual. Somerville, New Jersey, Ethicon, Inc, 1985, p. 9

• Internet sources.