Types of sutures

1. Non-absorbable sutures:

Generally used to close skin, and must be removed after wound healing  is complete. These
sutures are fine/thin, hassle-free, unlikely to leave marks, unlikely to get infected, and may be
removed by the patient (on the 7th or 8th day.). The non-absorbable sutures are "non- reactive"
to the body's immune response, so they need to be removed  when placed through the skin.

Types of non-absorbable sutures

1. Synthetic (nylon and polypropylene, which are inert),

2. Silk (animal protein) and cotton.
3. Non-dissolving stitches are usually coloured blue or black to make them more
visible against the blood  red of a wound. They have a smooth surface that
usually allows them to be removed easily

The Non-absorbable Sutures

1. Silk

This is prepared from the thread spun by the silkworm larva in making its cocoon. It may be twisted or
braided, and it comes in sizes comparable with surgical gut.

- High tensile strength

- Relatively inexpensive
- Less tissue reaction

2. Cotton

This is made from cotton fibers. The strands are twisted and used for both internal and external suture.
It should always be used wet for maximal strength.

3. Nylon

- Monofilament
- Multifilament
- Braided
- The chief disadvantage is that a triple knot must be tied

4. Wire

This material has maximal flexibility and tensile strength, yet causes little or no local reaction in the
tissue in which it is placed.
5. Dacron

This is a synthetic polyester fiber that has greater tensile strength, minimal tissue reaction, maximal
visibility, non-absorbent and non-fraying qualities.

6. Linen

This is made of twisted line thread; it has sufficient tensile strength but is rarely used as suture material.

7. Silver Wire Clips

Many styles of clips are available for the purpose of holding the edges of the tissue in approximation.
They tend to produce some scarring when used in the skin, but may be used when the wound is
infected.

8. Silkworm Gut

This is made from the fluid secreted by the silkworm when they are ready to form their cocoons. The
disadvantage is that they must be soaked in normal saline for about 10 minutes before use to make
them pliable.

9. Mesh

This type of suture is made of stainless steel, usually used for hernia repairs and large defects. It is rarely
used.

10. Tantalum

This is a bluish bray metal that is non-irritating to the body tissues. It is used because of its high tensile
strength and its inert reaction to tissues.

2.  Absorbable (self-dissolving) sutures

These are degraded by the body's enzymatic pathways through a  reaction against
"foreign" material. Phagocytes carried by the blood- stream attack and destroy the stitch
material. They are not intended  to be used on the surface of the skin. Absorbable sutures
can also be  used to close skin but only in a subcuticular or completely buried  pattern.
Absorbable sutures should not be exteriorized. They work  better when used on internal
surgery (buried inside) where the body  can break them down easier, and if scar tissue
should develop, it is  not visible.  
 Types of self-dissolving sutures:

* Catgut (old technology): Natural fibre made from the submucosa of  the bovine
intestine. Excites considerable inflammatory reaction and  tends to potenciate infections.
It loses strength rapidly and it's of  little use in modern surgery. Plain catgut dissolves
more quickly  than the type treated with chromium salts. 

* Vicryl / Dexon (Polyglactin): Dissolves slower than catgut, but causes less of a
reaction on implantation. Used below the surface of  the skin. Also used in areas where
suture removal might jeopardize  the repair such as with small children who might not
easily cooperate  with suture removal. 

* Vicryl Rapide: Similar substance to Vicryl, but absorbed in a shorter period (5

days). Recent development, worth asking your  surgeon about.

* Monocryl: The least reactive substance of this group, and should  leave least
scarring. Unfortunately this is not a very soft material  and may be slightly irritating
while the stitches are in place.

Sutures also come either as monofilament or braided:

* Monofilament sutures cause less reaction than do braided sutures  but require
more ties to assure an adequate maintenance of the knot  compared to braided suture.
Monofilament sutures are usually non- absorbable.

* Braided suture usually incites a greater inflammatory response but  requires

fewer ties to maintain the knot integrity. These include  silk, cotton and Mersilene.

The strength of the sutures varies according to their size, which can  be
determined by a uniformly applied number. For example, a 6-0  suture is more delicate
and has less strength than a 4-0 suture.  

The surgeon uses as many stitches as necessary to approximate the  wound edges.
Every stitch becomes a foreign body and becomes the  source of an additional wound, so
one must use what is required and  no more

Absorbable Sutures

1. Surgical Gut

Surgical guts are also known as a catgut and is made from the submucous layer of a sheep's intestine.
Once cleaned, dried and twisted into threads of various sizes they are prepared for use by special
processes, that include innumerable inspections of gauze and tensile strength and scrupulous
sterilization. The length of time for complete absorption of surgical gut in a wound varies according to
the action of certain hardening agents.
2. Fascia Lata

This muscle connective tissue of beef has been used in reconstructive orthopedic surgery and for the
repair of hernias. It is not a true absorbable suture, but becomes part of the tissue after the wound has
healed.

Suture Characteristics

1. Tensile Strength
1. Related to suture size (see below)
2. Related to weight required to break a suture
2. Knot strength
1. Force required for a knot to slip
3. Configuration
1. Monofilament (less risk of infection)
2. Braided multifilament (easier to handle and tie)
4. Elasticity
1. Degree suture stretches and return to original length
5. Memory or suture stiffness
1. High memory: Suture stiff, difficult handling, unties
6. Tissue reactivity (inflammatory response to suture)
1. Reaction peaks in first 2 to 7 days

A. Needles

1. Curvature
1. Straight needle
2. Curved 2/8 of circle
3. Curved 3/8 of circle (preferred needle in most cases)
4. Curved 4/8 of circle
5. Curved 5/8 of circle
2. Needle Tip
1. Tapered (used in vascular sutures)
2. Conventional cutting needle
3. Reverse cutting needle (preferred in most cases)

B. Suture types recommended for skin closure

1. Deep (dermal or buried) Absorbable Sutures

1. Polyglecaprone 25 (Monocryl)
2. Polydioxanone (PDS)
3. Polyglactin-910 (Vicryl)
4. Polyglycolic acid (Dexon)
2. Superficial, monofilament Nonabsorbable Sutures
1. Nylon (Ethilon)
 2. Polypropylene (Prolene)

C. Suture Size (See suture types above)

1. General
1. Superficial facial lesions: 6-0 nylon
2. Other superficial skin lesions
1. Low skin tension areas: 5-0 nylon
2. Higher skin tension areas: 4-0 nylon
2. Annotation for suture size indications below
1. Skin: Superficial monofilament Nonabsorbable Suture
2. Deep: Dermal Absorbable Sutures
3. Size O: Largest suture
4. Size 2-O
5. Size 3-O
1. Skin: Foot
2. Deep: Chest, Abdomen, Back
6. Size 4-O
1. Skin: Scalp, Chest, Abdomen, Foot, Extremity
2. Deep: Scalp, Extremity, Foot
7. Size 5-O
1. Skin: Scalp, Brow, Oral, Chest, Abdomen, Hand, Penis
2. Deep: Brow, Nose, Lip, Face, Hand
8. Size 6-O
1. Skin: Ear, Lid, Brow, Nose, Lip, Face, Penis
9. Size 7-O: Smallest Suture
1. Skin: Eyelid, Lip, Face

D. Suture indications by location (see suture types above)

1. Mucosal Lacerations (mouth, Tongue or genitalia)

1. Absorbable Suture: 3-0 or 4-0
2. Scalp, Torso (chest, back, abdomen), Extremities
1. Superficial Nonabsorbable Suture: 4-O or 5-O
2. Deep Absorbable Suture: 3-O or 4-O
3. Face, Eyebrow, Nose, Lip
1. Superficial Nonabsorbable Suture: 6-O
2. Deep Absorbable Suture: 5-O
4. Ear, Eyelid
1. Superficial Nonabsorbable Suture: 6-O
5. Hand
1. Superficial Nonabsorbable Suture: 5-O
2. Deep Absorbable Suture: 5-O
6. Foot or sole
 1. Superficial Nonabsorbable Suture: 3-O or 4-O
2. Deep Absorbable Suture: 4-O
7. Penis
1. Superficial Nonabsorbable Suture: 5-O or 6-O

E. Suture removal timing

1. Scalp: 6-8 days

2. Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
1. Follow with papertape or steristrips
3. Ear: 10-14 days
4. Chest and abdomen: 8-10 days
5. Back: 12-14 days
6. Extremities: 12-14 days
7. Hand: 10-14 days
8. Foot and sole: 12-14 days
9. Penis: 8-10 days
10. Condition delaying Wound Healing: 14 to 21 days
1. Chronic Corticosteroid use
2. Diabetes Mellitus