Histologic comparisonof polylactic and

polyglycolic acid sutures

Duane E. Cutright, Lieutenant Colonel, DC, USA,’
Joe D. Beusley, III, Maj,or, DC, UHA,** and
Bienvenido Perez, Lieutenant Colonel, DC, USA*“*
UNITED STATES ARMY INSTITUTE OF DENTAL RESEARCH,
WALTER REED ARMY MEDICAL CENTER, WASHINGTON, D. C.

Comparative studies were carried out to determine soft-tissue reactions and

speeds of biodegradation of polylactic acid (PLA) and polyglycolic acid (PGA)
sutures in rats. These sutures were placed in the posterior aspects of the thigh
muscles, and the animals were killed intermittently through a go-day post-
operative period. The results of the experiment indicate that both PGA and
PLA may be acceptable for use as a suture material.

D uring the last decade there has been an increasing interest in biodegrad-
able sutures. This has been stimulated by the problems involved in obtaining
surgical gut and by the desire to have a suture which could be selected to degrade
at different time periods after insertion. Recently Hermann, Kelly, and Higgins,l
Postlethwaite,2 Wallace and Maxwell,3 and Dardik and associates4 have re-
ported on a new biodegradable suture made from polyglycolic acid (PGA).
The results of their experiments have indicated that PGA may very well prove
to be an excellent suture material.
We have recently used a closely related material, polylactic acid (PLA), as
an experimental biodegradable suture. The following report gives the results
of a preliminary experiment comparing the histologic reaction of PLA to that of
PGA.

In conducting the research described in this report, the investigators adhered to the
“Guide for Laboratory Animal Facilities and Care,” as promulgated by the Committee on
the Guide for Laboratory Animal Facilities and Care of the Institute of Laboratory Animal
Resources, National Academy of Sciences, National Research Council.
*Chief, Division of Oral Pathology, United States Army Institute of Dental Research.
**Division of Oral Pathology, United States Army Institute of Dental Research.
***Assistant Chief, Division of Oral Pathology, United States Army Institute of
Dental Research.

165
166 Cutright, Beasley, am? Perez Oral Surg.
<July, 1971

Table I

$pproximnte nrea
.4pproximate area (average of in,-
Postoperative Average inflam- (average) of dividual) szcturc
sacr@ce and matory response suture (mm.%) strands (X
number of animals Materials (0 to 9) (X section) section) (,p”)
5 days PLA 1.5 0.15 615
3 animals PGA 3.0 0.17 530
11 days PLA 1.0 0.14 4183
4 animals PGA 1.8 0.13 707
20 days PL.\ 1 .O 0.33 N/AL
4 animals PGA 1.3 0.18 530
28 days PLA 0.5 0.12 3846
4 animals PG.4 1.0 0.15 660
40 days PLh 0.3 0.10 3316
4 animals PGA 0.5 0.14 660
50 days PLA 0.0 0.20 N/h
4 animals PGA 1.0 0.13 615
60 days PL‘\ 0.0 0.22 N/A
4 animals PGh 0.8 0.08 572
71 days PL>Z 0.3 0.15 N/A
4 animals PGA 0.0 0.06 453
80 days PLA 0.0 0.11 N/A
3 animals PGS 0.3 0.04 284
90 days PLA 0.3 0.07 N/A
3 animals PGA 0.0 0.01 200

METHODS AND MATERIALS

Thirty-eight adult albino rats, weighing 250 to 300 grams each, were anes-
thetized with intrapcritoncal injections of Pentosol. The right posterior legs
were shaved and presurgically cleansed. Incisions were made on the lateral
aspects of the thighs, and the skin and incision lines were displaced so as to
expose the posterior portions of the thigh muscles. Approximately 7 mm. lengths
of polylactic acid (PLA) and the polyglycolic acid (PGA) sutures were
placed in these muscles and were marked in place by strands of 3-O braided silk
suture. The skin and incisions were returned to their original positions and were
closed with interrupted 3-O silk sutures.
The basic polylactic acid (PLA) suture consisted of major strands which,
in turn contained fifteen to nineteen minor strands, each measuring an average
of 0.20 mm. in diameter. The three major strands were twisted to form the basic
suture, which measured an average of 0.35 mm. in diameter.
The basic polyglycolic acid (PGA) suture likewise consisted of major
strands with an average diameter of 0.12 mm. each. Each major strand con-
tained approximately eight minor strands measuring an average of 26 microns
each in diameter. The eight minor strands were braided to form the major strand,
and major strands were braided to form the basic PGA suture, which measured
an average of 0.33 mm. in diameter.
 Histologic comparison of PLA and PGA sutures 167

Fig. 1. Eleven-day comparison. The inflammatory reaction is mild, with scattered giant cells.
Notice the apparent confluence of the PLA on the right. (Magnification, approximately x45.)

The animals were killed at 5, 11, 20, 28, 40, 50, 60, 71, 80, and 90 days post-
operative, as indicated in Table I. The specimens were examined visually, re-
moved, and fixed in 10 per cent buffered formalin. Following adequate fixation,
the specimens were grossly cut and oriented as to suture positions. Serial step
sections were cut at 5 microns and stained with hematoxylin and eosin.
The histologic grading as shown in Table I was done as follows: The
inflammation was graded 0 (no inflammation), 1 (mild), 2 (moderate) or
3 (severe). The approximate average area of suture cross sections was
selected only from slides showing cross sections of the suture material
used. The a,reas measured encompassed the total area occupied by the suture
strands plus the connective tissue infiltration between individual strands. The
approximate average areas represent not only average dimensions of the sutures
from blocks taken from each animal but also averages from at least three slides
from each block used. The average cross-sectional area of individual suture
strands was taken only from slides showing cross sections of the suture used.
The average area of the individual strands was computed by (1) measuring and
averaging the approximate diameters of all the strands as seen on three high-
power fields, when possible, taking this average and (2) compiling the average
of at least three slides from each block, and (3) determining the average value
from all blocks of the various animals that were used. Many of the individual
PLA strands were not measured because of their confluence. These are listed as
N/A in Table I.
The PLA suture material was developed at the United States Army Medical
Biological Research Laboratory.
168 Cutright, Beasley, rind Perez Oral Surg.
July, 1971

Pig. 8. Twenty-eight-day comparison. The PLA (on the left) silk marking suture (cwltcsr 1
and PGA (right) all show comparable reactions and sizes. PLA is being dispersed in the
tissues. (Magnification, approximately x20.)

FINDINGS

The comparative rates of biodegradation between the polylactic acid (PLA)

and polyglycolic acid (PGA) sutures in soft tissues are given in Table I. In
addition, comparative inflammatory responses were roughly quantitated. Only
sections showing appropriate cross sections of the suture material were used for
measurement purposes. In addition to the information presented in Table I,
certain histologic features are summarized below.

Five days

Histologic examination of tissues of these animals revealed a chronic inflam-

matory cell infiltration about the sutures (including the silk marking suture),
but the reaction was more profound in the PGA areas, even to the extent of
microabscess formation. The PGA suture strands remained tightly bound to-
gether, although the suture area increased in size. The PLA strands, however,
demonstrated an early “unraveling.” Foreign-body giant cells were evident in
all suture areas.
Eleven days

Once again inflammatory cell infiltrations were evident in all of the suture
areas (Fig. 1)) but the severity of the response had subsided, except in the silk
suture areas. Confluence of individual strands was apparent in the PLA suture.
These strands demonstrated a more loosely bound appearance and were seen
Volume 32 Histologic comparison of PLA and PGA sutures 169
Number 1

Pig. 3. Forty-day comparison. Inflammation is minimal, but giant cells and phagocytic
cells can be seen lying against the sutures, PLA (left) and PGA (right). (Magnification,
approximately x45.)

to be infiltrated by young connective tissue elements, such as plump fibroblasts,

endothelial cells, and mononucIear phagocytes.
The PGA remained tightly bound in all areas.

Twenty days
The inflammatory reactions were again not of serious proportions, although
the PGA material seemed to elicit a slightly greater response. Confluence of
PLA individual strands had progressed to such a degree that an average mea-
surement of intact strands was of no practical value. The total cross section area
of the PLA sutures increased markedly, not only because of the continuing
confluence of minor strands but also because of the continuing “unraveling”
and dispersion of strands in the tissues. One animal demonstrated an area of
dystrophie calcification associated with the PLA. The PGA sutures remained
tightly bound together.

Twenty-eight days
The inflammatory reactions continued to subside gradually. The confluence
of the PLA strands was evident, with only a few irregular small strands left
intact. The PGA suture remained tightly bound, but the total cross-section area
decreased somewhat in size. Foreign-body giant cells were evident in all suture-
bearing areas, although the reaction did not extend into the adjacent tissues
(Fig. 2).
170 Cutright, Beasley, cwd Perez Oral SIX-g.
July, 1971

Forty days

No appreciable inflammatory reactions were evident, although the foreign-

body giant cells persisted in the immediate areas. Once again, dystrophic calcifi-
cation was demonstrated in one PLA area, but this was not consistent with the
other specimens. Quite interestingly, although there was no apparent dccreasc in
size of the individual PGA strands, the total PGA suture area again showed a
slight decrease in size (Fig. 3).

Fifty days

The PLA suture proved to be extremely variable, not only in st,rancl size but
also in suture area size. The PGA strands, on the other hand, remained tightly
bundled and demonstrated progressive, consistent biodegradation. Inflammator)
reactions with all material proved to bc of little consequence. When the PLA did
not unravel, its size and architect,ure were very similar to those of PGIA (Fig.
4).

Sixty days

At this time histologic findings proved to be consistent with previous find-

ings; that is, a continued regular reduction in the suture area with PGA and
continued irregularity in strand size and suture area size with PLA. Again, the
tightly bound PGA strands did not appreciably decrease in their individual size.

Seventy-one days

At this time a gradual reduction in size of the suture areas was seen with
the PGA and, for the first time, an average decrease in the individual strands
of PGA was noted, although they remained tightly bound. The total suture area
likewise decreased with the PLA. A mild foreign-body giant-cell reaction per-
sisted in all suture areas.

Eighty days

A continued reduction in strand and suture area sizes was the only significant
finding with the PGA material at this time. The PLA likewise demonstrated
a reduction in suture area size, occasionally being almost completely degraded.

Ninety days

Throughout the entire experimental period the PGA suture remained rela-
tively intact, although progressive biodegradation was evident, and 90 days post-
operatively the findings were still consistent. The average diameter of the PGA
suture area was only 0.12 mm., and the intact, tightly bound, individual strands
remained prominent. Connective tissue infiltration between the PGA strands
remained minimal throughout the entire period. The PLA suture areas were
also reduced in size, and the irregularity of the confluent strands persisted. As
can be seen in Fig. 5, some PLA sutures were almost completely degraded and
in many cases they were smaller over-all than the PGA sutures. Foreign-body
giant cells were likewise evident in all suture areas.
Volume 32 Histologic comparison of PLA and PGA sutures 171
Number 1

Pig. 4. Fifty-day comparison. The PGA (right) is seen within adipose tissue, and the
PLA (left) is seen in a fascial plane. However, the reactions are typical. Notice that where
PLA did not unravel it compares favorably with PGA in size and shape. (Magnification,
approximately x28.)

DISCUSSION
This study shows the soft-tissue reactions and rates of biodegradation of two
suture materials (polylactic acid and polyglycolic acid) when the materials are
placed in soft tissues of the white rat and the rats killed at variable times up to
90 days postoperatively. The following information may be presented with regard
to each of the materials.

Polylactic acid (PLA)

1. An initial mild to moderate inflammatory reaction accompanies the
placing of a PLA suture in soft tissues, but this reaction becomes considerably
lessened after 11 days and practically disappears after 35 days.
2. Some “unraveling” was noted as early as 5 days, and this seemed to
become more profound in later specimens. The method of suture preparation
(that is, twisting as opposed to braiding was done in the PGA suture) may
well account for this finding.
3. A foreign-body reaction is evident throughout the experimental period,
but it is essentially localized.
4. Confluence or “blending” of minor strands was seen to occur after 11
days, and this also became more profound in later sacrifice periods.
5. The PLA suture area (strands plus connective infiltration) was seen
to occupy a cross-sectional area of 0.15 mm.2 after 5 days, increased to a maxi-
mum cross-sectional area of 0.33 mm.2 after 20 days, and finally decreased
irregularly to a cross-sectional area of 0.07 mm.2 after 90 days.
172 Cutright, Beasley, ad, Perez

Fig. 5. Ninety-day comparison. The PIA in this animal is continuing to dcgradc, BR

shown by the variation in strand size (left ). The PGA (right) shows a milder Imt 1argc1
response. (Magnification, approximately x38.)

Polyglycolic acid (PGA)

1. The initial inflammatory reaction to the PGA suture was of severe
proportions, and several microabscesses were noted. It is interesting to note
that 3-O braided silk marking suture showed an identical response. This initial
reaction became less severe in the following sacrifice periods and was of a mild
nature 28 days postoperatively.
2. As with the PLA, foreign-body reactions persisted throughout the ex-
perimental period, but such reactions were essentially localized.
3. At no time during the study did the PGA become unraveled or dispersed.
The suture essentially remained bound together throughout the experiment,
with a slight connective tissue wall surrounding it and with minimal connective
tissue infiltration between minor strands.
4. The minor or individual strands of the PGA suture did not display
confluence or blending; in fact, they showed a progressive, orderly average
decrease in size after 40 days.
5. The total PGA suture area showed very little early increase in cross-
sectional size as compared to the PLA suture. The total PGA suture area dis-
played orderly biodegradation from a maximum cross-sectional area of 0.18
mm.2 after 20 days to a final area of 0.01 mm.2 90 days postoperatively.

SUMMARY
Thirty-eight adult albino rats were used in comparative studies to de-
termine soft-tissue reactions and speeds of biodegradation of polylactic acid
Volume 32 Histologic comparison of PLA and PGA sutures 173
Number 1

(PLA) and polyglycolic acid (PGA) sutures. These sutures were placed in
the posterior aspects of the thigh muscles, and the animals were killed intermit-
tently through a go-day postoperative period. The following comparative obser-
vations were noted:
1. The initial inflammatory reaction with the PGA suture was of great-
er severity (comparable with the reaction to 3-O braided silk suture) when
compared with the PLA suture, but both materials demonstrated a pro-
gressively milder response at later sacrifice periods.
2. The PGA strands composing the suture remained more oriented
throughout the study in comparison to PLA, whose strands became con-
fluent and somewhat dispersed after 11 postoperative days.
3. Foreign-body giant cells were evident throughout the study in all
suture-bearing areas, but this reaction remained essentially localized.
4. Progressive biodegradation of both PLA and PGA sutures was ob-
served in this study, but degradation of the PGA sutures proceeded in a
more orderly manner.
5. At 90 days some of the PLA sutures were nearly degraded and
were smaller than the PGA sutures.
The results of the experiment indicate that both PGA and PLA may be
acceptable for use as a suture material. Further, it is possible that part of the
PLA reaction could be due to the handling of the suture, as it was hand
fabricated from the individual strands.
A more intensive experiment is in progress.
REFERENCES
1. Herrmann, John B., Kelly, Richard, J., and Higgins, George A.: Polyglycolic Acid Sutures,
Arch. Surg. 100: 486490, 1970.
2. Postlethwdt, R. W.: Polyglyeolic Acid Surgical Suture, Arch. Surg. 101: 489-494, 1970.
3. Wallace, William R., Maxwell, Gary R., and Cavalaris, C. J.: Comparison of Polyglycolic
Acid Suture to Black Silk, Chromic, and Plain Catgut in Human Oral Tissues, J. Oral
Surg. 28: 739-746, 1970.
4. Dardik, Herbert, Dardik, Irving, Katz, Abraham R., Imith, Robert B., Schwibner,
Barry H.! and Laufman, Harold: A New Absorbable Synthetic Suture in Growing and
Adult Pnmary Vascular Anastomoses: Morphologic Study, Surgery 68: 1112-1121, 1970.

Reprint requests to :
Lieutenant Colonel Duane E. Cutright
Division of Oral Pathology
U. S. Army Institute of Dental Research
Walter Reed Army Medical Center
Washington, D. C. 20012