-- Presented by

Dr. Anindya Chakrabarty

CONTENT

Introduction

History

Definition

Goals of suturing

Suture materials

- Introduction

- Requisites of ideal suture

- Classification

- Selection of suture material

- Absorption of suture material

- Biological response of body to suture.

Suture armamentarium- needles, needle holder, scissor

Principles of suturing

Suturing Techniques

Knots

Suture Removal

Other methods of wound closure

Suture means to ‘sew’ or ‘seam’. In surgery suture

is the act of sewing or bringing tissue together and

holding them in apposition until healing has taken

place.

A suture is a strand of material used to ligate blood

vessels and to approximate tissues together.

HISTORY

History of the Surgical Suture “I dress the wound, God heals it”.-- Ambroise Pare, surgeon16th century

The act of sewing is probably older then Homo sapiens, because Neanderthal man wore some sort of clothing.

Perhaps the world’s oldest suture was placed by an embalmer on the body of a twenty first dynasty mummy about 1100 B.C.

A south American method of wound closure used large black ants which bite the wound edges together and the ants body is then twisted off leaving the head in place.

East African tribes ligated blood vessels with tendons and closed wounds with acacia throns

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

Galen, the physician to Roman gladiators in the second century A.D. used silk for

haemostasis.

Andreas Vesalius first advocated the suture of all fresh wounds as well as severed tendon and nerves.

Joseph Lister (1827-1912) discovered that bacteria present in suture strands cause wound infection. He disinfected sutures with carbolic acid. He made sterile sutures possible to bury it in clean wounds without infection.

Rhazes of Arabia was credited in 900 A.D. with first employing ‘kit gut’ to suture

abdominal wounds. The Arabic word ‘kit’ means a dancing master’s fiddle, the musical strings of which ‘kit string’ were made up of sheep intestines. Over the years ‘kit’ was confused with kitten or cat, and the misuse of the term was propagated.

DEFINITION

suture material is an artificial fiber used to keep wound together until they hold sufficiently well by themselves by natural fiber (collagen) which is synthesized and woven into a stronger scar

Suture is a Stitch/Series of Stitches made to secure apposition of the edges of a Surgical/Traumatic wound (Wilkins)

Any Strand of Material utilized to ligate blood vessels or approximate Tissues (Silverstein L.H 1999)

GOALS OF SUTURING

Provide adequate tension

Maintain hemostasis

Provide support for tissue margins

Reduce post-op pain

Prevent bone exposure

Permit proper flap position

BASIC REQUISITE OF SUTURE MATERIALS

Tensile strength Tissue biocompatibility Low capillarity Good handling & knotting properties Sterilization without deterioration of properties Non allergic, non electrolytic and non carcinogènic Low cost

It should not fray, should slide through tissues readily & knot should not slip after tying.

It should be readily visualized

On break down ,it should not release toxic agents

It should disappear without excessive reaction once its task is completed

natural

synthetic

metallic

monofilament

multifilament

absorbable

Non-

absorbable

coated

Un-coated

Advantages

Smooth surface

Less tissue trauma

No bacterial harbours

No capillarity

Disadvantages

Handling and knotting

Stretch

Any nick or crimp in the material leads to breakage.

Absorbable

Surgical Gut- Plain, Chromic

Polydiaxanone

Polyglactin 910

Non Absorbable

Polypropylene

Polyester

Nylon/polyamide

Polyvinylidene fluoride / PVDF Sutures

Advantages Strength Soft and

pliable Good handling Good knotting

Disadvantages Bacterial

harbours Capillary action Tissue trauma

Non Absorbable

Silk

Cotton

Linen

Absorbable

Polyglactin 910

Polyglycolic Acid

ABSORBABLE – NATURAL

Plain catgut: light milk, Derived from submucusa of

sheep intestine or serosa of beef

intestine

Used for ligating superficial bld vessels &

subcut fatty tissues

Chromic catgut: yellow,Treated with chromium salt.

Adv may be used in the presence of infection

Gut / cat gut

Oldest known absorbable suture.

Galen referred to gut suture as early as 175 A.D.

Derived from sheep intestinal sub mucosa or bovine intestinal serosa.

Submucosa of sheep has a rich elastic tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as “tanned” in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.

ABSORBABLE -NATURAL

Catgut should not be boiled or autoclaved as heat destroys its tensile strength.

Catgut is sterilized during preparation and kept in a preservative solution (isopropyl alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reduced .

Absorption :40-60 days

When placed intra orally sutures are digested in 3-5days.

It is available pre-sterilized in aluminium-coated sterile foil overwrap pack with ethicon fluid as a preservative.

Colour: Plain catgut is yellow, while chromic catgut is tan

Absorbtion: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infection catgut is rapidly absorbed.

CHROMIC CATGUTCoated with thin layer of chromium salt solution to minimize tissue reaction, increase TS, slow the absorption rate, better knot security, and ease of handling.TS – 10-14 days

Absorbed in 90 days

Uses : Opthalmic surgery (6-0)

Oral surgery

Suture subcutaneous tissues

As it is an organic material and susceptibleto enzymatic degradation, packed inisopropyl alcohol as a preservative. Alsocondition or soften it.

Suture absorbs alcohol and swells. It iscombustible and is also irritating totissues. It is removed by a quick rinse insaline prior to use.

COLLAGEN SUTURE

Natural, absorbable, monofilament

Obtained by homogenous dispersion of pure

collagen fibrils from the flexor tendons of cattle.

Absorption – 56 days

TS - < 10% after 10 days.

Used in opthalmic surgery

Disadvantage of premature absorption.

ABSORBABLE - SYNTHETIC Polyglactin (vicryl):cream, copolymer of

lactide & glycolide

Minimal tissue rxn

Used in general soft tissue approx,intestinalanastomosis,vessels ligation in all surgical specialties

Minimal tissue reactivity and can be used in

infected tissues

Available in purple and undyed. Undyed used

on face.

Coated with polyglactin 370 and calcium

stearate which allows easy passage through

tissues as well as easier knot placement.

On skin wounds, associated with delayed

absorption as well as increased inflammation.

Dexon(Polyglyconic acid):purple/cream

Homo polymers of glycolide.

Avoid in adipose tissue

Losses tensile strength more rapidlythan vicryl.

Other e.g Polyglyconate(maxon) polydiaxone(PDS),Polyglecaprone(monocryl)

POLYDIOXANONE (PDS II)

Synthetic,absorbable,monofilament.

Polyester derivative poly P dioxanone.

TS -14-42 days

Absorption – Hydrolysis in 6 months.

Passes through tissues easily.

Significant memory – compromises theease of knot-tying and knot security.

Minimal tissue reaction

For wounds under tension andcontaminated wounds.

May extrude through the wound over time.So used only in tissues deeper thansubcuticular layer. Or if in face 6-0 used.

VICRYL –RAPIDE It is braided synthetic absorbable suture

material. Colour : White.

It has a similar initial high tensile strength as that of the normal vicryl suture.

It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days.

Its absorption is associated with minimal tissue reaction facilitating improved cosmetics and reduction of postoperative pain.

The absorption is essentially complete within 35-42 days.

Uses: Low tensile strength and Rapid absorption rate --Ideal for intra-oral use (dental surgeries).

VICRYL PLUS ANTIBACTERIAL SUTURE

Handles and performs same as normal vicryl.

In vitro studies shown that triclosan on VICRYL plus creates a zone of inhibition around the suture.

NON-ABSORBABLE-NATURAL

Surgical silk: Black, Derived from the cocoon of the silk

worm larvae, superior handling xtics,Triggerinflam rxns,Undergo proteolysis & undetected by 2yrs,Used in ligating maj bld

ves,tendon repair etc

Other e.g Virgin silk, cotton, linen

Surgical steel & wires High tensile strength

Hold knots very well

Used in orthopaedic,Neurosurg,& Thoracic surg

OMFS- for suspension of splints or arch bars and not as suture material

SURGICAL SILK-Braided or twisted

-Made from the filament spun by silkworm larva toform its cocoon. Each filament is processed toremove the natural waxes and sericin gum. Afterbraiding, the strands are dyed, stretched andimpregnated with a mixture of waxes andsilicone. Dry silk suture is stronger than wet silksuture.

NATURAL NON-ABSORBABLE

Advantage: Ease of handling – more for braided Good knot security made non capillary in order to withstand action of

body fluids & moisture.(wax or silicon coated) Cost effective

Contraindications:Should not be used in presence of infection

Uses:Plastic surgery, ophthalmic and general

surgeries, ligating body tissues.

Although characterized as non-absorbable,studies show that it loses most of theirTS after 1 yr. and cannot be detected intissues after 2 yrs.

SURGICAL COTTON

Natural, multifilament, non absorbable

From stable Egyptian cotton fibers

good knot security

Not good in presence of contaminated wounds or infection

Rarely used nowadays

Uses:

Most body tissues for ligating and suturing

SURGICAL STEEL

Natural, monofilament/multifilament, nonabsorbable

Alloy of iron, nickel and chromium Good TS even in infection Difficult to handle and tendency to cut through

tissues. Very hard to tie, and knot ends requirespecial handling.

Potential to corrode or break at pointsof twisting, bending or knotting.

Not to be used with a prosthesis ofanother alloy.

Used in abdominal wall and skin closure,sternal closure, retention, tendonrepair, orthopedic and neurosurgery.

OMFS- for suspension of splints orarch bars and not as suture material.

Major Disadvantages

1.Linear artifacts caused by substances with high atomic number on CT images

2.Possible movement of metal suture during MRI

3.Patch test for nickel sensitivity should be done.

NON-ABSORBABLE - SYNTHETIC

Nylon: Is a polyamide polymer,blue

81% tensile strength at 1yr & 66% at 11yrs

Elicits minimal tissue rxn

Has good memory

Pliable when moist

Premoistened form is used cosmetic plastic surgery

Its elasticity makes it useful for skin closure & Herniorhapy

Other e.g;Polypropylene(prolene),Polyester fiber(Mersilene/Dacron,Ethibond)

POLYPROPYLENE (PROLENE)-Polymer of propylene.-Inert and TS for 2 yrs-Holds knots better than other synthetic sutures.

Advantages-Minimal suture reaction and so used in infected

and contaminated wounds.-Do not adhere to tissues and is flexible. So used

for ‘pull-out’ type of sutures.Uses:

General, plastic, cardiovascular surgery, skinclosure, ophthalmology.

GORE-TEX

Nonabsorbable,synthetic,Monofilament

From,expanded polytetrafluoroethylene (ePTFE)

Extremely low tissue reaction, good knot tensile strenghtand ease ofhandling.

Uses

All type of soft tissue approximation and cardiovascular surgeries.

-New, monofilament, nonabsorbable, synthetic

-Made of polyglycol trephthate and polybutylene terephthalate and isconsidered as a modified polyester suture.

-No significant memory compared to polypropylene and nylon. Easier tomanipulate and greater knot security.

-Unique feature is their ability to elongate or stretch with increasingwound edema. When edema subsides, suture resumes original shape;so it is an ideal suture for lacerations secondary to blunt trauma.

POLYBUTESTER (NOVOFIL)

SUTURE SELECTION

The condition of the

wound,

The tissues to be repaired,

The tensile strength of the

suture material

Knot-holding

characteristics of the

suture material

The reaction of

surrounding tissues to the

suture materials.

SUTURE SIZES

Largest size 1 to extremely fine 11-0. Increasing number of zeroes correlates with decreasing suture diameter and strength.

Thicker sutures are used for approximation of deeper layers, wounds in tension prone areas and for ligation of blood vessels.

Thin sutures are used for closing delicate tissues like conjunctiva and skin incisions of the face. Size is chosen to correlate with the tensile strength of the tissue being sutured.

SUTURE SIZE

UNITED STATES PHARMACOPEIA

Sized according to diameter with “0” as reference size

Numbers alone indicate progressively larger sutures

(“1”,“2”, etc)

Numbers followed by a “0” indicate progressively

smaller sutures (“2-0”, “4-0”, etc)

Smaller<------------------------------------->Larger

.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

SIZE OF SUTURES

OLD GAUGE(USPD) DIAMETER IN MM

8/0 0.05

7/0 0.O7

6/0 0.1

5/0 0.15

4/0 0.2

3/0 0.3

2/0 0.35

0 0.4

1 0.5

2 0.6

3 0.7

4 0.8

PACKAGING………

METRIC GUAGE IMPERIAL GUAGE PRODUCT CODE

NEEDLE SIZE &

CURVATURE

NEEDLE TYPE

NEEDLE TIP

NEEDLE PROFILE

STERILIZED

ETHELENE OXIDE

DO NOT REUSE

SEE INSTRUCTIONS FOR USE

EXPIRY DATE BATCH NO

STERILIZATION OF SUTURES

May affect suture properties to some extent

Gamma Radiation

Ethylene oxide; poisonous gas is less

attractive

Autoclave

Sutures are usually stored in sterile pack by

the manufacturers , their integrity must be

checked before use

ARMAMENTARIUM FOR SUTURING

Suture needle

Needle holder

addson’s tissue forcep

SUTURE NEEDLE

Surgical needles are designed to lead suture material through tissue with minimal injury. Needles can be

- straight (GIT) or curved

- swaged or eyed

Made up of either SS or carbon steel.

Needle is selected according to:

-type of tissue to be sutured

-tissue’s accessibility

-diameter of suture material.

CLASSIFICATION OF SURGICAL NEEDLES

1.According to eye -eye less needles

-needles with eye

2.According to shape -straight needles

. -curved needles

3.According to cutting edge

a) round body

b) cutting -conventional

-reverse cutting

4.According to its tip -triangular tip

-round tip

-blunt tip

5.Others -spatula needles

-micro point needles

-cuticular needles

-plastic needles

Eyed require threading prior to use,results in pulling a double strandthrough tissue. Tying the suture tothe eye increases bulk of suturematerial drawn through tissues. Sothey are also called ‘traumaticneedles’.

Most suture materials and needlesare difficult to sterilize. Needlesare also difficult to clean afteruse and become blunt andworkhardened so that they snap.

Suture loop inserted through eye

Loop placed over tip

Loop drawn back

Suture tied on eyed needle

SWAGED NEEDLE

Swaged needles do not require threading and permit asingle strand of suture material to be drawn.

Suture attached to needle via a hole drilled throughthe end of the needle, and the end is swaged duringmanufacturing.

It is atraumatic and

act as a single unit.

Prepacked and presterilized

by gamma radiation.

NEEDLE ANATOMY

Term Definition

Chord

Length of needle

Radius

Diameter

The linear distance

between eye and tip.

The distance between

eye and tip following

the curvature

The distance of the

body of the needle from

the centre of the circle

Gauge or thickness of

the metal wire out of

which the needle is

made.

RADIUS OF CURVATURE OF THE

BODY(NEEDLE)

CLINICAL USE

Straight Needle

¼ circle

3/8 circle

½ circle

5/8 circle

Needle of choice for the skin

Limited use in oral surgery

May be used in surgery of the nose,

pharynx, tendons

Needle of choice for microsurgery

associated with very fine sutures;

ophthalmology

Oral surgery, flap surgery, wound closure

after placement of osseointegrated

implants and GTR procedures

May be used in all surgical wounds

Needle of choice in oral surgery

Wide range of uses in many surgical

wounds

Wounds of the urogenital tract

THE POINT

Point runs from tip to the max. cross sectional area of the body.

Can be -triangular tip/cutting

-round tip-blunt tip

Cutting needles are Ideal for suturing keratinizedtissues like skin, palatal mucosa, subcuticular layersand for securing drains.

Round/tapered needles used for closing mesenchymallayers such as muscle or fascia that are soft andeasily penetrable

The conventional cutting point has two opposing cutting edges and third edge on the inside curvature of the needle.

The reverse cutting point has two opposing cutting edges and third cutting edge on the outer curvature of the needle.

The tapered point is used primarily on soft, easily penetrated tissues . it leaves small hole and can be used in vascular surgery as well as fascial soft tissue surgery.

The blunt point has a rounded end which does ntcut through the tissue .it is used in friable tissue suturing or to the parotid duct or lacrimalcanaliculi.

Sharpened 12 times Designated as C or FS(CUTICULAR or FOR SKIN)

Sharpened an additional 24 times

Designated as P or PS or PC(PREMIUM or PLASTIC

SURGERY or PRECISION COSMETIC ).

Needles in the PC series are made up of stronger SS alloy and have flattened and conventional cutting edge.

Cuticular needles Plastic needles

NEEDLE HOLDER

The needle holder is used to

handle the suture needle and

thread while suturing the

surgical wound.

If used properly it enables the

surgeon to perform

procedures correctly and with

great precision.

Working tip/ jaws

Hinge device

Shank/body

Catch mechanism/ ratchet

Grip area

GRIPPING OF NEEDLE HOLDER

The scissor gripPalm Grip

PRINCIPLES OF SUTURING

1.Needle grasped at 1/4th to half the distance from eye.2.Needle should enter perpendicular to tissue surface3.Needle passed along its curve

4.The bite should be equal on both sides of the wound margin and the point of the entry of the needle should be closer to the wound edge than its point of exit on the deep surface

5.The bite should be about 2-3 mm from the wound margin of the flap because after wound closure the edge of the wound softens due to collagenolysisand the holding power is impaired.

6. Usually the needle to be passed from mobile side to the fixed side but not

always(exception in lingual mucoperiosteum flap) and from thinner to thicker

& from deeper to superficial flap.

7.The tissues should not be closed under tension , since they will either tear or

necrose around the the suture

8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to another should be about 3-4 mm apart to prevent strangulation of the tissue & to allow escape of the serum or inflammatory exudate & to get more strength of the wound.

11.Sutures placed at a greater depth than distance from the incision to evert wound margins

12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tying knot for provision of the slight edema post operatively, more tensioned sutures cause ischemia of the edges of the incision

causes tearing of the tissues

may leave suture mark

edges may get overlapped

16.Occasionally extra tissue may be present on one side of incision and cause ”DOG EAR” to be formed in the final phase of wound closure.

Simply extending the length of the incision to hide the exists will produce an unsatisfactory result.

Thus after undermining excess tissue incision is made at approx. 300 to parent incision directed towards undermined side. Extra tissue is pulled over incision and appropriate amount is excised. Incision is closed in normal manner.

SUTURING TECHNIQUES

INTERRUPTED SIMPLE SUTURE

Most commonly used. Inserted singly through side

of the wound and tied with a surgeon’s knot.

Advantages

Strong and can be used in areas of stress

Placed 4-8 mm apart to close large wounds, so that

tension is shared

Each is independent and loosening one will not

produce loosening of the other

Degree of eversion produced

In infection or hematoma, removal of few sutures

Free of interferences b/w each stitch and easy to clean

SIMPLE CONTINUOUS / RUNNING

A simple interrupted suture

placed and needle reinserted

in a continuous fashion such

that the suture passes

perpendicular to the incision

line below and obliquely

above. Ended by passing a

knot over the untightened

end of the suture.

Advantages

Rapid technique and distributes tensionuniformly

More water tight closure (Shoen, 1975)

Only 2 knots with associated tags

Disadvantages

If cut at one point, suture slackens along thewhole length of the wound which will thengape open.

CONTINUOUS LOCKING/BLANKET

Similar to continuous but locking provided by

withdrawing the suture through its own loop.

Indicated in long edentulous areas, tuberosities or

retromolar area.

Advantages

Will avoid multiple knots

Distributes tension uniformly

Water tight closure

Prevents excessive tightening.

Disadvantage :prevents

adjustment of tension over

suture line as tissue swelling

occurs.

VERTICAL MATTRESS

Specially designed for use in skin.

It passes at 2 levels, one deep to

provide support and adduction of

wound surfaces at a depth and

one superficial to draw the edges

together and evert them.

Used for closing deep wounds

This approximates subcutaneous

and skin edges

Needle passed from one edge to the other and again from

latter edge to the fist and knot tied.

When needle is brought back from second flap to the first,

depth of penetration is more superficial.

Advantages :

for better adaptation and maximum tissue approximation

To get eversion of wound margins slightly

Where healing is expected to be delayed for any reason, it is better to give

wound added support by vertical mattress. Used to control soft tissue

hemorrhage.

Runs parallel to the blood supply of the edge of the flap and therefore not

interfering with healing.

Uses: abdominal surgeries & closure of skin wounds.

HORIZONTAL MATTRESS

It everts mucosal or skin margins, bringing greater

areas of raw tissue into contact. So used for closing

bony deficiencies such as oro-antral fistula or cystic

cavities.

Disadvantage: constricts the blood supply to edges

of incision.

Needle passed from one

edge to the other and

again from the latter to the

first and a knot is tied.

Distance of needle

penetration and depth of

penetration is same for

each entry point, but

horizontal distance of the

points of penetration on

the same side of the flap

differs.

Advantages:

Will evert mucosal or skin margins, bringing greater

areas of raw tissue into contact.

-So used for closing bony deficiencies such as oro-

antral fistula or cystic cavities, extraction socket

wounds.

Prevents the flap from being inverted into the cavity.

To control post-operative hemorrhage from gingiva

around the tooth socket to tense the mucoperiosteum

over the underlying bone.

It does not cut through the tissue ,so used in

case of tissue under tension (inadequate

tissue)

Disadvantages:

More trouble to insert

Constricts the blood supply to the incision if

improperly used, cause wound necrosis and

dehiscence

FIGURE OF “8” SUTURE

Used for extraction socket closure and for adaption

of gingival papilla around the tooth Suturing begun

on buccal surface 3-4mm from the tip of the papilla

so as to prevent tearing of papilla.

Needle first inserted into theouter surface of the buccal flapand then the lingual flap. Needleagain inserted in same fashionat a horizontal distance andthen both ends tied.

SUBCUTICULAR SUTURE

Used to close deep wounds in layers. Knots will beinverted or buried, so that the knot does not lie betweenthe skin margin and cause inflammation or infection.

To bury the knot, first pass of the needle should be fromwithin the wound and through the lower portion of thedermal layer. Needle then passed through the dermallayer and emerge through subcutaneous tissue and knottied

CONTINUOUS SUBCUTICULAR SUTURE

Continuous short lateral

stitches are taken

beneath the epithelial

layer of the skin. The

ends of the suture come

out at each end of the

incision and are knotted.

Advantages

Excellent cosmetic result

Useful in wounds with strong skin tension,

especially for patients prone to keloid formation.

Anchor suture in wound and, from apex, take

bites below the dermal-epidermal layer

Start next stitch directly opposite the one that

precedes it.

PURSE STRING SUTURE

A circular pattern that draws together thetissue in the path of the suture when theends are brought together and tied.

KNOTS

Sutured knot has 3 components

1.Loop created by knot

2.Knot itself which is composed of a number of tight throws

3.Ears which are the cut ends of the suture

PRINCIPLE OF KNOT TYING

Use the simplest knot that will prevent slippage.

Tying the knot as small as possible and cutting the ends of the

suture as short as reasonable to minimize foreign body reaction.

Avoid friction or sawing

Avoid damage to suture material

Avoid excessive tension

Tying sutures too tightly strangulates the tissue

Placing the final throw as horizontally as possible to keep knot flat

Limiting extra throws to the knot, as they do not add strength to a

properly tied knot.

Square knot Formed by wrapping the

suture around the needle

holder once in opposite

directions between the ties.

Atleast 3 ties are

recommended.

Best for gut, silk, cotton

and SS

Surgeons knot Formed by 2 throws on the

first tie and one throw in the

opposite direction in the

second tie. Recommended

for tying polyester suture

materials such as Vicryl and

Mersiline

Granny’s knot A tie in one direction

followed by a tie in the

same direction and a third

tie in the opposite direction

to square the knot and hold

it permanently.

SUTURE REMOVAL Skin wounds regain TS slowly. It can

be removed in 3-10 days when the wound gained 5%-10% of final TS. Skin sutures on face removed between 3-5 days. Alternate sutures removed on 3rd day and remaining sutures after 2 days.

Intra oral Mucoperiosteal closure (without

tension) -- 5-7 days Where there is tension on the suture

eg : Oro-antral fistula- 7-10 days

Back and legs where cosmesis is less important – 10-14 days.

Continuous subcuticular can be left for 3-4 weeks without formation of suture tracks

A good guide is that as soon as they begin to get loose they should be taken out.

HOW TO REMOVE SUTURE

Suture area is first cleaned with normal saline.

The suture is grasped with non-tooth dissecting forceps and

lifted above the epithelial surface.

Scissors are then passed through one loop and then

transected close to the surface to avoid dragging

contaminated suture material through tissues.

The suture is then pulled out towards incision line to prevent

dehiscence. If suture entrapped in a scab, application of

hydrogen peroxide or saline solution is necessary.

If pieces of suture left, infection or granuloma formation can

ensue.

POSSIBLE COMPLICATION OF LEAVING SUTURE FOR MANY DAYS

1.Sutural abscess.

2.Suture scarring or stitch mark

3.Implanted dermoid cyst

SUTURE MARKS

Suture marks are caused by 3 factors

1.Skin sutures left in place longer than 7 days, resulting in epithelialisation of suture track

2.Tissue necrosis from sutures that were tied too tightly or became tight due to tissue edema

3.Use of reactive sutures in the skin.

Sutures passing through mucous membrane orskin provide a ‘wick’ or pathway through whichbacteria track down, and bacteria gain access tounderlying tissues.

The longer the suture remains, the deeper theepithelial invasion of the underlying tissue. Whensuture removed, epithelial tract remains.

These cells may eventually disappear or remain toform keratin and epithelial inclusion cysts. Theepithelial pathway result in typical ‘railroad scar’formation.

RAILROAD SCAR

NEW ADVANCEMENT IN SUTURING

Ligating clips

Skin staples

Surgical tape

Surgical adhesives

MECHANICAL WOUND CLOSURE DEVICES

Ligating clips :

can be resorbable or non resorbable.

Made up of SS,tantalum or titanium or

pidioxanone.

Designed for the ligation of tubular

structures.

Surgical staples:

Used for skin closure .

Made up of SS.

They are placed uniformly to span the

incision line.

They have minimal tissue reaction .

Can be used for routine skin closure

any where in the body.

Advantages

As the clips do not penetrate skin, yet give

apposition, the cosmetic result is excellent.

Speed and efficacy of stapling is more compared

to sutures.

Suturing causes more necrosis than stapling in

myocutaneous flaps.

Most significant advance is the introduction of

absorbable staples (Lactomer).

Contra indicated when it is not possible

to maintain atleast 5mm distance from

the stapled skin to the underlying bone

and blood vessels.

SURGICAL TAPE

Microporous tape is used alone or in conjugation withskin sutures to decrease tension at the wound margins.

The surgical tapes have a backing of viscous rayonfibers coated with an adhesive copolymer and they arepervious to sweat but not to blood or purulent material.

Comes in 1/8, 1/4, and 1/2 inch wide strips. Skinmargin is prepared with tincture of benzoin to providebetter adhesiveness for tape.

Used to decrease skin tension on cheek,forehead,chin.

ADVANTAGES

Minimizes wound dehiscence and allows earlier suture

removal

Provides continuous support for the wound and

minimizes scar expansion

Avoids the ordeal of suture replacement and removal

in children

Less inflammatory reaction, lower rate of wound

infection, greater TS and better cosmetic results.

No needle puncture marks and suture canals

Strangulation and necrosis of tissue are eliminated

Sterile paper tape is non expensive

Disadvantage

Do not evert edges of the wound, and readily loosenwhen wet by blood or serum.

Prior to placement, a thin coat of antibiotic ointment isplaced on wound margin to protect wound from skin oilsand bacteria.

While removing, to avoid epithelial margin separation,the ends should be lifted equally towards the woundmargin and then lifted evenly from the wound.

Cyanoacrylates

- n-butyl cyanoacrylate is the active ingredient.

Advantages :

Strong bonding to tissues in presence of moisture

Biodegradable, bacteriostatic & hemostatic.

Reduced post operative pain & facilitates healing.

Good shelf life.

Produces little or no heat during polymerisation.

Bonding is by secondary intermolecular forces aided by

mechanical interlocking of irregular forces.

Quick, atraumatic and cost effective with good cosmesis

No injection, suturing and post-op suture removal.

Disadvantages

1.When applied for skin closure, the polymer acts as

barrier, prevents wound apposition, delays healing, and

increases the infection rate.

2.Should not be allowed to come in contact with tissue

under skin as it causes necrosis.

DERMABOND®

A sterile, liquid topical skin adhesive

Reacts with moisture on skin surface to form a strong, flexible bond

Only for easily approximated skin edges of wounds

punctures from minimally invasive surgery

simple, thoroughly cleansed, lacerations

DERMABOND®

Standard surgical wound prep and dry

Crack ampule or applicator tip up; invert

Hold skin edges approximated horizontally

Gently and evenly apply at least two thin

layers on the surface of the edges with a

brushing motion with at least 30 s between

each layer, hold for 60 s after last layer until

not tacky

Apply dressing

Degraded either by enzymatic process as in gut

sutures, or by hydrolysis, as in many of the synthetic

materials like glycolic acid, ployglactin910 or

polydioxanone.

Non absorbable sutures are walled off or

encapsulated.

In infected tissues or in a patient who is febrile or

protein deficient, suture breakdown may be

accelerated.

If the loss of TS outpaces the healing phase, failure

of the wound results.

Absorbable sutures must be placed well into the

dermis.

ABSORPTION OF SUTURE MATERIALS

BIOLOGIC RESPONSE OF BODY

TO

SUTURE MATERIALS

The initial body response to sutures is almost identical in the first 4-7 days, regardless of the suture material.

The early response is a generalized acute aseptic inflammation, involving primarily polymorphonuclearleukocytes.

After few days mononuclear cells, fibroblasts & histiocytes become evident.

Capillary formation occurs at the end of this initial phase.

BIOLOGIC RESPONSE OF BODY TO SUTURE MATERIALS

Natural Absorbable – Proteolytic

degradation. Intense tissue response

Synthetic Absorbable – Hydrolysis. Less Intense

Non Absorbable – Encapsulation. AcellularResponse

CONCLUSION

Human body is very delicate & important.

When surgeries are needed to improve our

health is very important to select a suitable

suture. Today we know allots of biomaterials

to select, but is important to always think of

biocompatibility.

REFERENCES

Suturing techniques in oral surgery –Sandro Siervo

Laskin vol-1

Oral & Maxillofacial Surgery Vol 1- W. Harry Archer

Textbook of oral & maxillofacial surgery- Neelima Anil Malik

Minor Oral Surgery- Goeffrey L.Howe

Text book of surgery: Sabiston

Periodontology-Caranza.

THANK YOUTHANK YOU