Commonly used sutures in plastic surgery, its pros and cons and clinical

applications

Absorbable

Surgical Gut

 The origin of the name catgut, is uncertain. Gut sutures in general

consist of processed strands of highly purified collagen from the
small intestines of sheep or cattle.
 Collagen is a fibrous protein. Every third residue is glycine. Proline
and hydroxyproline follow each other relatively frequently, and the
gly-pro-hyp sequence makes up about 10% of the molecule. A
catgut suture is composed of triple helical structure.
 This triple helical structure generates a symmetrical pattern of
three left-handed helical chains that are, in turn, slightly displaced
to the right, superimposing an additional “supercoil”structure.

 Catgut may be treated with chromium salts, which react with the
collagen in a process similar to the tanning of leather.
  This produces a tougher, harder substance known as chromic
catgut that is stronger and more resistant to tissue degradation
than plain catgut.
 Both plain and chromic gut are difficult to manipulate and tie and
the knot-holding properties are poor in the presence of body
fluids.
 Knots tend to become hard and can traumatize adjacent tissue.
The rate of absorption is unpredictable because body enzymes and
macrophages can break them down.
 Plain gut does not remain intact for more than 5 to 7 days, but
chromic gut can last approximately twice as long. Of the commonly
used sutures, surgical gut causes the highest degree of tissue
reaction, which often impedes healing.

hjhClinical Application
For this reason it is not wise to use this suture in patients predisposed to
delay wound healing. Approximately 60% of the tensile strength of
surgical gut is lost in a week and no tensile remains in two weeks.

Clinical Application
For this reason it is not advisible to use this suture in patients
predisposed to delay wound healing. Approximately 60% of the tensile
strength of surgical gut is lost in a week and no tensile remains in two
weeks.

Seldom used, can be used :

In general soft tissue approximation

- circumcision 5’0 chromic catgut, to avoid distressful suture removal
procedure

Absorbable
Polyglycolic acid

 Polyglycolic acid was discovered in the 1960s and implemented in

the 1970s.
 In 1971 this suture was introduced as a synthetic homopolymer
processed from glycolic acid to give polyglycolic acid:

 The polymer is extruded into thin filaments, heat stretched, and

braided into sutures. This suture is biologically and physically
superior to gut, and was a major advance in absorbable suture
 materials. Absorption occurs by slow hydrolysis in the presence of
tissue fluids and the low pH of infection minimally increases the
rate of suture absorption.
 By 15 days the suture has lost more than 80% of its original
strength. By 28 days, this material retains only 5% of its original
tensile strength, and it is completely dissolved by 90 to 120 days.
Polyglycolic acid causes much less tissue reaction and inflammation
than natural collagen; however, bacteria can pass through its
multifilament structure into a wound easier than through
monofilament sutures.
 In 1977 Dexon S became available. Its finer filaments and tighter,
smoother braid provided optimal handling characteristics, similar
to silk. A third generation of polyglycolic acid sutures is Dexon Plus,
which contains a surface coating of Polaxamer 188. The coating is
used to lubricate the surface of the suture to improve its handling
characteristics.
 The non-toxic Polaxamer 188 is very soluble in aqueous solutions
and is therefore rapidly absorbed in tissue resulting in an uncoated
suture that has increased knot security.

Clinical Application
Polyglycolic acid possesses good tensile strength and excellent knot
security. After 3 weeks of implantation, 20% of the initial tensile strength
remains with polyglycolic acid suture, in contrast to 0% of surgical gut
suture.

Suitable for approximation of clean wound of dermis, muscles ( soft

tissue approximation)
Not for use in vascular tissue and neuro tissue

Absorbable
Polyglactin 910

 In 1974 polyglactin 910 suture was introduced as a synthetic

copolymer of glycolic and lactic acid, which are present in a ratio of
90 to 10, giving polyglactin 910:
  The suture is braided to enhance its surgical handling quality. The
loss in strength of polyglactin 910 is very similar to that of
polyglycolic acid, the material retains only 8% of its original tensile
strength by 28 days. However, complete absorption time of
polyglactin 910 suture is 40-70 days, less than that of polyglycolic
acid (90 to 120 days) because the bulky lactide group holds the
polymer chains apart, which creates a rapid water hydrolysis.
 Coated polyglactin 910 is treated with polyglactin 370 and calcium
stearate for lubrication to improve its passage through tissue, knot
placement, and tie down.
 The residual tensile strength of a polyglactin 910 suture is greater
than that of polyglycolic acid suture. Polyglactin 910 sutures are
absorbed more rapidly than polyglycolic acid suture.

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Clinical Application

Suitable for short term wound support and closure of dead space in
subcutaneous soft tissue layers, and ligation.

Not for use in vascular tissue and neurological tissue

Commonly use in dermal layer closure

Palatoplasty/lip repair : mucosa and subcutis layer vicryl 5-0

Absorbable
Polydioxanone (PDS)
 A relatively new absorbable suture is PDS. It is a homopolymer
made from paradioxanone to give polydioxanone, a polyester.
 Unlike polyglactin 910 or polyglycolic acid, PDS is manufactured as
a monofilamentous suture. PDS takes more time to be completely
absorbed than either polyglactin 910 or polyglycolic, it takes
approximately 180 days.
 It also retains significant tensile strength after 28 days, 58% of the
original value.
 Tissue reaction to the suture is minimal. Since it is a monofilament
its affinity for microorganisms is less than is the case for Vicryl or
Dexon.
 However, PDS is stiffer than the braided synthetics and more
difficult to handle.
Pds has long term strength. Its frequently use in general soft tissue
approximation, designed to be an absorbable alternative to
non-absorbable monofilament sutures.
Suitable used in : tendon, ligament repair
-positioning of alar base of the nose pds 5-0 in rhinoplasty/lips repair

Absorbable

Polyglyconate

 Polyglyconate is the newest synthetic absorbable suture on the

market. It is a copolymer consisting of glycolic acid and
trimethylene carbonate combined in a 2 to 1 ratio to give
polyglyconate:

 It is a monofilament that was designed to combine the excellent

tensile-strength retention properties of PDS with improved
handling characteristics.
 Polyglyconate has an average strength retention of 59% after 28
days, complete absorption occurs between 180 and 210 days, with
minimal tissue reaction. Moreover, polyglyconate is much more
supple and easier to handle than PDS, with 60% less rigidity.
Clinical Application
It retains 75% of original strength at two weeks of post-implantation.
Absorption is essentially complete by 180 days.

Prolonged absorption with very high tensile strength : suitable use in

tendon repair

Can also be used in closure of muscles strings in palatoplasty

Available in barbed form. Used in abdominoplasty as running suture 2-0

V-Loc 90 for the Scarpa’s fascia and a running subcuticular closure of
3-0 V-Loc 90 for the dermis layer, irreversible.

NON-ABSORBABLE
Silk

 Surgical silk is derived from silkworm species Bombyx mori of the

family Bombycidae, the larva of which spins silk to weave its
cocoon.
 The raw silk is degummed, scoured and bleached, braided,
stretched, and dyed. The silk strands are treated with silicone or
waxes to improve handling characteristics and to reduce capillary
action. Silk is naturally occurring organic substance and induces a
significant host inflammatory response.
  A special quality of silk is its ease of handling. Unfortunately, its
tensile strength is very low and it exhibits high capillarity, which
increases the risk of infection.
 Although silk is classed by the USP as a nonabsorbable suture the
material loses most of its tensile strength in 90 to 120 days, and is
usually completely absorbed after 2 years.
 Thus it is rather a slowly absorbed suture. Silk is not as strong as
the synthetic sutures, but it is exceptionally workable, soft, has
little memory, and is easy to knot. However it cause high tissue
inflammatory responds. The braided nature of silk gives it a
tendency to draw fluid into the tissue, which causes delay in
wound healing.
 Furthermore silk should not be used in areas of infection or
contamination. Nevertheless silk has been a favorite suture
material for years, primarily because of its exceptional handling
properties and ease of knot tying.

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Clinical Application
It loses approximately 50% of its strength in one year. Due to its property
of reactivity, it is rarely used for cutaneous closures; however, it is
commonly used on mucosal and intertriginous areas as it is soft and
pliable.

Suture to anchor drain at the skin

NON-ABSORBABLE
Nylon

 Nylon suture materials are available in mono or multifilament

forms. It is composed of long-chain aliphatic polymers of nylon 6.
 Due to its property of elasticity, it is useful for surface (epidermal,
superficial) closure. Monofilament nylon suture has a great
memory and its tendency for knot slippage is high.
 It is classed by the USP as a nonabsorbable suture, yet it loses
strength and is absorbed by hydrolysis at a rate of 15% to 20% per
year. It is therefore really rather a slowly absorbed suture.
 The polyamide material is either extruded into monofilamentous
strands (Ethilon and Dermalon) or it is twisted into a yarn, braided
into multifilaments, and treated with silicone (Nurolon and
Surgilon).
 Little tissue reaction or fragmentation occurs from this material,
and it does not support bacterial growth.
 The monofilament strand is smooth with no capillary action. When
monofilament nylon is moistened, it is more pliable and handles
like the multifilaments, but it has a rather high memory and
therefore a decreased knot security.
 The multifilament nylon feels and handles similar to silk
 Multifilament braided nylon sutures exhibit decreased memory
and they are associated with higher infection rate.
 In vivo, nylon loses 15−20% of tensile strength every year by
hydrolysis.
Clinical Use:
Nylon monofilament: Approximation of epidermis and dermis
Nylon multifilament : cardiovascular, ophthalmic, and neurological
procedures

Plastic cases:monofilament nylon

-closure of muscles strings in palatoplasty
-vascular anastomosis : 8-0/9-0

NON-ABSORBABLE

Polypropylene (Prolene)

 Polypropylene (Prolene) was devloped in 1970 as a first synthetic

nonabsorbable suture. It is a monofilament suture. Surgilene and
Prolene are relatively new synthetic monofilament sutures made
from the linear hydrocarbon polymer polypropylene:
  Prolene is made of isotactic crystalline stereoisomer of
polypropylene with few unsaturated bonds. Polypropylene has a
tensile strength more than nylon.
 It is available as dyed or undyed form.
 This suture maintains its above-average strength indefinitely, it
remains encapsulated in body tissues.
 Polypropylene has extremely low tissue reactivity. Because of its
lack of adherence to tissue, it is and excellent “pull-out” suture.
This suture is smooth and resists flexural fatigue. The material is
elastic, allowing elongation under tension and recovering its
original form as the tension decreases.

Clinical Application
It has good plasticity and it expands with tissue swelling to accommodate
the wound. High memory, poor knot security and lack of elasticity are the
few disadvantages with Prolene.
It can easily pass through tissues and induces minimal host response. It
does not adhere to the tissues and can be used as an intradermal suture.

-vascular anastomosis, 8-0/9-0

NON-ABSORBABLE
 Polyester

 Polyester sutures are nonabsorbable synthetic braided

multifilament sutures composed of polyethylene terephthalate.
 Polyester fibers are polymers formed, like nylon, by condensation
polymerization:


 The polyester sutures handle well because they are

multifilamentous and braided. These sutures have extremely high
tensile strength, second only to that of metal suture.
 Polyester sutures are either uncoated or coated. One disadvantage
of the uncoated polyester sutures (Mersilene and Dacron) is that
they have a relatively rough surface that produces drag when
brought through tissues and when knots are set. Therefore
lubricant coatings have been developed for polyester sutures to
produce a smooth surface that is less grabby, for example
polybutilate (Ethibond).
Clinical Application
They are used for prosthetic implantations, face lifts, tendon repair and
cardiovascular surgeries due to its unique properties, such as minimal
tissue reactivity, high tensile strength, good handling and everlasting.

NON SUTURE ALTERNATIVES

Tissue Adhesives
Surgical Strips
Staples

Tissue Adhesives

Tissue adhesives belong to the family of cyanoacrylates, and their

adhesive properties are a result of polymerization that occurs on contact
with moisture on the skin. There are various formulations of
cyanoacrylates, and their strength and physical properties are dependent
on their alkyl side chains.
Commercially available tissue adhesives include octylcyanoacrylate , butyl
cyanoacrylate and N-butyl-2-cyanoacrylate.
Tissue adhesive is typically used in place of epidermal sutures, once
buried intradermal sutures are in place. It is applied to a clean, dry
surgical site by brushing or dropping the liquid directly onto the wound. It
is extremely important that wound edges be in direct apposition before
application of the adhesive, so that the liquid does not seep between the
edges of the defect and inhibit good wound healing.

Tissue adhesive also has innate hemostatic properties and low allergic
potential, does not require a secondary bandage or water avoidance after
surgery, and alleviates the need for suture removal.

The disadvantages of tissue adhesives are that they must be used on

perfectly approximated wounds and postoperative bleeding may cause
epithelial wound edge separation.

Surgical Strips

Surgstrips are sterile wound closure strips made from non-woven fabric
and coated with medical grade polyacrylate adhesive. The wound closure
strips are hypoallergenic for completely atraumatic wound closure.
Despite the strong proven adhesive properties. Surgistrip wound closure
strips can be removed without pain or residue.

Surgical strips are placed across the wound and are most commonly used
to support the standard sutured wounds or to repaired lacerations.

They can also be used in place of sutures for epidermal closure in

low-tension wounds, after the placement of buried sutures.

To increase the length of time of the strips to stay in a place, a liquid

adhesive, such as Mastisol can be placed on the dry skin surrounding the
surgical line before the placement of the strips. Using this method, the
strips can last 1 to 2 weeks.
Staples

Surgical skin staples are composed of stainless steel and are an efficient
means of skin closure.

They are most commonly used to close long or high-tension wounds on

the scalp. They provide the highest tensile strength of any skin closure
materials; have low reactivity, and a lower risk of infection than most
sutures.

Staples provide good wound eversion and, in comparison to nylon

sutures in epidermal closure, staples have been shown to have equivalent
cosmetic outcomes. The placement of staples is faster than observed in
sutures and, factoring in time, is more cost efficient.

CHOOSING THE RIGHT SUTURE/WOUND CLOSURE MATERIAL

 The surgeon should use the smallest caliber suture possible to

maintain the strength of the wound.
 Sutures of 5-0 and 6-0 are most commonly used in facial defects
and in areas of low tension.
 In areas of higher tension, a higher-caliber suture that has high and
prolonged tensile strength must be used. For example, on areas
like the trunk, slow-absorbing and strong 2-0 to 4-0 polydioxanone
sutures are useful for deep sutures, whereas polypropylene and
nylon are useful as surface stitches.
 On areas like the face, fast absorbing and weaker sutures, such as
fast-absorbing gut and irradiated polyglactin 910 (Vicryl Rapide,
Ethicon), are useful for small facial closures under minimal tension.
They are also useful sutures for simple epidermal closure and
full-thickness skin graft fixation and provide a good cosmetic
outcome and alleviate the need for suture removal.
  A dyed suture material provides easy visualization when the
sutures are placed and removed. If suture removal is not planned,
undyed material can be used to avoid unsightly show through the
skin.

MICROSURGERY SUTURES AND NEEDLES

A. Microsurgical vessel anastomoses and nerve repairs require

specialized instruments and sutures that are small enough to be used on
structures as small as 1 mm in diameter.

B. The majority of microsurgical sutures are non-absorbable, nonbraided

nylon. At the small sizes used, handling and memory are not significant
issues.

C. Most free flap arterial/venous anastomoses (vessel diameter usually

2–4 mm) and peripheral nerve repairs can be performed with 9–0 nylon
sutures. Smaller digital arteries and veins, as in digital replantation, are
more appropriately anastomosed with 10–0 sutures.

D. Suture diameters for microsurgery sutures are 25 μm for 10–0 sutures

and 35 μm for 9–0 sutures.

E. Most microsurgery needles are 75, 100, or 130 μm in size. Careful

matching of needle size and suture diameter must be performed in order
to prevent a needle that is too big for a given suture, which may result in
leaking at an anastomosis.

F. A tapered 3/8-circle needle is the most frequently used needle in

microsurgical applications.
REFERENCES

1. Fuller, J.K (2013). Surgical Technology, Principles and Practice. 6th

ed. Canada: Elsevier. p454-459
2. Frey, K. B (2008). Surgical Technology for the Surgical Technologist.
3rd ed. Canada: Delmar. p292 -294
3. Ethicon wound closure manual

4. Handbook of plastic surgery Steven Greer