Suture Materials and

Suturing Techniques
 Objectives and Outlines
➢ Ideal requirement of suture materials
➢ Type of Suture materials
➢ Absorbable versus non-absorbable
➢ Natural versus synthetic
➢ Principles of Wound Closure
➢ Surgical Instruments used in suturing
➢ Obtaining Haemostasis
 Essential suture characteristics
➢ All sutures should be manufactured to assure
several fundamental characteristics, as follows:
➢ Sterility
➢ Uniform diameter and size
➢ Pliability for ease of handling and knot security
➢ Uniform tensile strength by suture type and size
➢ Freedom from irritants or impurities that would
elicit tissue reaction
 The Ideal Suture Material
➢ Causes minimal tissue injury or tissue reaction (
nonelectrolytic, noncapillary, nonallergenic,
noncarcinogenic)
➢ Easy to handle
➢ Holds securely when knotted (no fraying ‫ نسل ثوب‬or
cutting)
➢ High tensile strength
➢ Favorable absorption profile
➢ Resistant to infection
➢ Can be used in any tissue
➢ Good knot security
➢ Minimal tissue reaction
➢ Absorbable - Progressive loss of mass and/or
volume of suture material; does not correlate
with initial tensile strength
➢ Breaking strength - Limit of tensile strength at
which suture failure occurs
➢ Capillarity - Extent to which absorbed fluid is
transferred along the suture
➢ Elasticity - Measure of the ability of the material
to regain its original form and length after
deformation
➢ Unfriendly to bacteria
➢ Fluid absorption - Ability to take up fluid after
immersion
➢ Knot-pull tensile strength - Breaking strength of
knotted suture material (10-40% weaker after
deformation by knot placement)
➢ Knot strength - Amount of force necessary to cause a
knot to slip (related to the coefficient of static friction and
plasticity of a given material)
➢ Memory - Inherent capability of suture to return to or
maintain its original gross shape (related to elasticity,
plasticity, and diameter)
➢ Nonabsorbable - Surgical suture material that is
relatively unaffected by the biological activities of the
body tissues and is therefore permanent unless removed
➢ Plasticity - Measure of the ability to deform without
breaking and to maintain a new form after relief of the
deforming force
➢ Pliability ‫ليونة‬- Ease of handling of suture material;
ability to adjust knot tension and to secure knots (related
to suture material, filament type, and diameter)
➢ Tensile strength - Measure tissue's ability to resist
deformation and breakage
➢ Wound breaking strength - Limit of tensile
strength of a healing wound at which
separation of the wound edges occurs
➢ Cheap
Suture Materials
Classification of Sutures
Synthetic Natural, Biological

Monofilament Multifilament

Absorbable Non - Absorbable

 Suture Material and Structure
➢ Natural versus synthetic
➢ Natural sutures may cause tissue reaction and suture antigenicity
lead to inflammatory reactions
⚫ synthetic materials
• less reaction
• less inflammatory reaction
➢ absorbable versus nonabsorbable
⚫ nonabsorbable sutures offer longer mechanical
support
⚫ Absorbable sutures provide temporary wound support,
until the wound heals well enough to withstand normal
stress
➢ Monofilament versus multifilament
⚫ Monofilament suture is made of a single strand
Infection is avoided
⚫ This structure is relatively more resistant to harboring
microorganisms. The monofilament sutures exhibit
less resistance to passage through tissue than
multifilament suture.
⚫ Multifilament suture is composed of several filaments
twisted or braided together
⚫ Multifilament suture generally has greater tensile
strength and better pliability and flexibility than
monofilament suture. This type of suture handles and
ties well. Because multifilament materials have
increased capillarity, the increased absorption of fluid
may act as a tract for the introduction of pathogens
➢ Monofilament
⚫ Polypropylene

⚫ Polydioxanone

⚫ Nylon

➢ Multifilament
⚫ Silk (braided)

⚫ Vicryl
⚫ Absorption occurs by enzymatic degradation in
natural materials and by hydrolysis in synthetic
materials.
⚫ Hydrolysis causes less tissue reaction than
enzymatic degradation
⚫ gut last 4-5 days in terms of tensile strength
⚫ chromic form, gut can last up to 3 weeks
⚫ Vicryl and Dexon maintain tensile strength for 7-14
days
⚫ complete absorption takes several months
 Types of Suture Materials
➢ Absorbable
⚫ catgut, polydioxanone, polyglycolic acid
⚫ Used for deep tissues, membranes, &
subcuticular skin closure
➢ Non-Absorbable
⚫ polyester, nylon, stainless steel
⚫ Used for skin (removed) & some deep
structures (tendons, vessels, nerve repairs –
not removed)
 Silk Catgut

➢ Natural
⚫ Silk, linen, catgut

➢ Synthetic polymer Polypropylene Polyester

⚫ Polypropylene,
 Synthetic
➢ Synthetic materials are man – made, produced by industrial processes.
➢ Advantages
• Synthetic non-absorbable materials do not elicit tissue reaction as they are
not absorbed.
• Synthetic absorbable are polymers which resemble sugars in their
chemical structure, therefore they are eliminated easily.
• Absorption is by hydrolysis, which causes very little tissue reaction.
This is in contrast to the biological group where absorption or suture
breakdown is caused by enzymatic action.
• Finally, synthetic materials tend to be stronger than their biological
equivalents for similar gauge sizes.
➢ Disadvantages
• The drawbacks of synthetic material tend to be related to their structure
rather than their chemical composition.
• They can be more difficult to handle in the monofilament structure and at
times, encapsulation can result in the suture being extruded or expelled by
the body.
 Natural or Biological
➢ materials are those derived from naturally occurring
sources such as animal / plant tissues
➢ Advantages
➢ Biological sutures are usually quite economical and
tend to have good handling and knotting
characteristics.
➢ Disadvantages
➢ Because biological materials are identified by the body
as foreign proteins, proteolytic enzymes are produced
which attack the collagen.
➢ The process of attack on the collagen causes localised
cell necrosis in the region of the implanted material.
This is a tissue reaction, which can produce pain and
discomfort in skin tissue.
 Non - Absorbable
Advantages Disadvantages
• Permanent wound Support
• Foreign body left
• They can be used to suture • Suture removal can
tissues which need long term be costly and
support, they provide permanent inconvenient
wound support. • Sinus & Extrusion if
left in place
• For example, prosthetic heart
valve implants must obviously be
held in place by a suture that will
never lose its strength
 Non-absorbable Suture
➢ Primarily Skin
⚫ Needs to be removed later
➢ Stainless steel = exception
⚫ Can be used internally
• Ligature
⚫ Can be left in place for long periods
 Monofilament
Advantages Disadvantages
➢ Smooth surface single strand which can be wiry
➢ Less tissue trauma with a strong material
memory leading to handling
➢ No bacterial harbours difficulties and a tendency for
➢ No capillarity knots to unravel
➢ Fluids are unable to ➢ Handling & knotting
travel along the length ➢ Ends/knot burial
of a monofilament as is ➢ Stretch Monofilaments tend
possible in to be more stiff than
multifilaments because multifilament materials
of the spaces between
multiple strands.
 Multifilament
Advantages Disadvantages
➢ inherently strong ➢ Bacterial harbours
because of their braided
➢ Capillary action
construction
➢ Tissue trauma
➢ soft and pliable which
provides excellent
handling and knotting
properties
➢ Good handling
➢ Good knotting
 Monofilament Vs. Multifilament

➢ memory easy to handle

➢ less tissue drag more tissue drag
➢ doesn’t wick wicks/ bacteria
➢ poor knot security good knot security
➢ - tissue reaction +tissue reaction
 Natural Vs. Synthetic
➢ Natural:
⚫ Gut
⚫ Chromic Gut
⚫ Silk
⚫ Collagen
➢ All are absorbable
➢ These natural materials are broken down by the
body after using
➢ Advantages
➢ Main advantage is that no foreign body is left
permanently in the patient which could
precipitate long term problems.
➢ Disadvantages
➢ A suture must provide support to a tissue for as
long as it’s necessary. If the suture absorbs too
quickly, it could lead to wound failure.
 Catgut / Chromic Gut
➢ Tensile strength for 4-5 days only
high tissue reactivity ,poor tensile
strength for a given suture diameter
monofilament uses: tubal ligation,
ligation of blood vessels

➢ Made of submucosa of small

intestines

➢ Breaks down by phagocytosis:

inflammatory reaction common
 Gut/ Chromic Gut

➢ Chromic: tanned, lasts

longer, less reactive
➢ Easy handling
➢ Plain: 5 -7days
➢ Chromic: 10-15 days
➢ Bacteria love this stuff!
 Collagen and Silk

➢ Natural sutures
➢ VERY reactive, absorbable
➢ Ophthalmic surgery only
 Vicryl (Polyglactin 910)
➢ Braided, synthetic, absorbable
➢ Stronger than gut: retains strength 3
weeks
➢ Broken down by enzymes, not
phagocytosis
➢ Break-down products inhibit bacterial
growth
⚫ Can use in contaminated wounds, unlike
other multifilaments
 Dexon and PGA
➢ Polymer of glycolic acids
➢ Braided, synthetic, absorbable
➢ Broken down by enzymes
➢ Both PGA and dexon have increased
tissue drag, good knot security
➢ Both are stronger than gut
 NYLON
➢ Synthetic
➢ Surgilon, Ethilon, Dermalon
➢ Monofilament
➢ Memory
➢ Inert, Very little tissue reaction
➢ Pronounced memory Poor knot security
➢ - lots of knots
➢ Uses- skin closure, drains fixation
 Polypropylene
➢ Prolene, Surgilene
➢ Monofilament, Synthetic
➢ Won’t lose tensile strength over time
➢ Good knot security, requires extra knots
➢ Inert, very little tissue reaction
➢ High plasticity - expands to prevent
strangulation, but loosens when edema
subsides (use with steri-strips)
➢ Will stretch when pulled
 Stainless Steel
➢ Monofilament
➢ Strongest !
➢ Great knot security
➢ Difficult handling
➢ Can cut through tissues
➢ Very little tissue reaction, won’t harbor
bacteria
 Absorbable Suture
Chromic gut
➢ Tensile strength for 2 to 3 weeks
➢ High tissue reactivity
➢ Poor tensile strength for a given tissue
diameter
➢ Monofilament
 Absorbable Suture

➢ Dexon, Vicryl, Polysorb

➢ Synthetic polymers with modest tissue reactivity
➢ Tensile strength for 2 to 3 weeks
➢ 10% strength at 28 days
➢ Low elasticity - may cut soft tissue
➢ Braided - handle well but wick fluid
➢ Good for subcuticular closure and fascia
 Absorbable Suture PDS,
Maxon
➢ Monofilament
➢ Delayed absorption
➢ 59% strength at 28 days
➢ Minimal tissue reaction
➢ Less suture abscesses and cut through
than vicryl
➢ Complete absorption by 180 days
 Absorbable Suture
Monocryl
➢ Virtuallyinert in tissue
➢ Tensile strength for 2 to 3 weeks
➢ Less suture absesses
➢ Great for mucosa and skin closures
 Packaging…
Imperial Gauge Product (re-order) Code
Metric Gauge

Needle size
& curvature

Needle type

Needle point

Needle profile

Do Not Re-use Batch Number

Sterilized Expiry date
Ethylene Oxide See Instructions
for use
Gauge of the suture materials

2 Thick
1
0
00
000
0000
00000
Fine
Selection of Sutures Material

➢ Eyelid 6/0
➢ Face 5/0, 6/0
➢ Oral cavity 4/0 , 3/0
➢ Scalp 3/0, 4/0
➢ Lip 4/0, 5/0
 The Anatomy of a Surgical Needle

➢ Needle Point : Penetration of a needle is dependant on

the point. .
➢ Chord Length : The straight line distance from the point
of a curved needle to the swage. .
➢ Swage : This is the area in which the suture is attached
to the needle. The swage area is of specific importance
to the relationship of needle and suture thicknesses. It is
also the weakest point of the needle.
Anatomy of a Surgical
Needle
➢ Needle Diameter : The gauge or thickness of the
needle wire. Needle Diameter various from 30
microns to over 1mm
➢ Needle Radius : If the curvature of the needle
were to continue to make a full circle, the radius
of the curvature is the distance from the centre
of the circle to the body of the needle. Think of
the needle as part of a circle.
➢ Needle Body : Is the portion between point
and swage and is used as the grasping
area.
➢ Needle Arming : The needle should be
grasped in the middle to 1/3 of the distance
from the swage area to the point.
➢ After the needle has penetrated the tissue,
the needle holder can be used to pull the
needle and suture through..
 Types of Needles
➢ Eyed needles
⚫ More Traumatic

⚫ Only thread through

once
➢ Eyeless, Swaged-on
needles
⚫ Much less traumatic

⚫ More expensive suture

material
⚫ Sterile
Types of Needles
 Point of the Needles
➢ Round designed to
separate tissue fibres rather
than cut them
⚫ traumatic
⚫ Internal organs
➢ Cutting, Atraumatic
➢ Cutting edge on inside of circle
➢ Reverse Cutting
➢ Cutting edge on outside of
circle
➢ Less traumatic than
cutting
Cutting Needles
➢ Cutting needles are required whenever dense or
tough tissue is encountered.
➢ CONVENTIONAL CUTTING: needles have the third

cutting edge on the inside curvature of the

needle.
➢ REVERSE CUTTING needles have a cutting edge on

the outer convex curvature of the needle.

➢ Reverse cutting needles are stronger than
conventional cutting needles because of their
different triangular shape.
 Cutting vs Reverse Cutting

➢ Cutting

➢ Reverse
cutting
 Shapes of Needles
➢ 3/8 circle
➢ 1/2 circle
➢ Straight
➢ Specialty
Using needle holder, grasp needle
 Use of Needle Holders

Loading
Needle

Needle
passing
through
skin
How to use suture instrument?
 Needle Holder
➢ Remember!!! Thumb & ring finger into needle holder’s
rings (NOT your middle finger!)
 Toothed forceps

➢ Grasp forceps between thumb & middle finger,

while index finger is used for stabilization.
➢ If possible, use forceps to grasp dermis, rather
than epidermis or skin surface itself. This helps
prevent marking & injuring of skin at wound
edge.
Smooth or teethed forceps?
➢ Smooth
⚫ Hold knots, tying suture or vessels
➢ Tooth (teethed)
⚫ Hold tissue
 Principles of Wound Closure:
1.Equal Bites on each side of the wound
2.Distance between sutures = distance
suture is from wound edge
3.Apposition,Eversion (skin), not inversion of
wound edges vertical mattress sutures
are used in skin surgery to produce
eversion of the wound edges, which
produces a better, cosmetically acceptable
scar.
Principles of Wound Closure:
4.Follow curve of Needle, levering causes
damage
5.Approximation not Strangulation: avoid
excessive stitches placed too close
together, be careful of post-op swelling
with running and running locking sutures.
Principles of Wound Closure:
6.Principle of Halving: 1st suture placed
centrally.Next suture placed halfway
between end of wound and 1st
suture.And so on.
Avoids mismatch of wound edges with
“Dog Ear”
 Method of Skin Suture
➢ Simple interrupted
⚫ Good for irregular wounds
➢ Vertical mattress
⚫ Good for thick and thin skin
➢ Horizontal mattress
⚫ Looks bad early
➢ Continuous with lock
⚫ Cosmetic demand
➢ Simple running
⚫ Quick, for linear wounds
⚫ Subcuticular
⚫ The knot should be tied
adequately and cause no
blanching
 Suturing Technique
➢ Atraumatic technique
⚫ Avoid crushing with forceps

⚫ Avoid sutures and needles unnecessarily

large
⚫ Avoid bites of tissue unnecessarily large

⚫ Avoid strangulation with knots too tight

⚫ Avoid drying of tissues

 Simple Interrupted
Definition: Equal full
thickness bites thru
skin and subcutaneous
layers
 Vertical Mattress:
Definition: Far-Far
Reverse, Near-Near
Purpose: Everts skin edges
with precise
approximation and little
tension
Uses: Any setting where
you want good approx.
with no tissue ischemia
Simple Interrupted vs. Vertical Mattress

➢ This suture is best used

in creases & areas of
natural inversion
 Horizontal Mattress:

Definition: Simple
interrupted ,but
additional parallel
bites are taken in
reverse
Purpose: Everts skin
edges in wounds
under tension
 Important points to think about
➢ Tightly tied sutures can cause ischemia & wound edge
necrosis. Gentle but firm knots & minimal wound
tension will minimize these factors.
➢ Remember, keep skin edges everted, NOT inverted!
 How many knots?
➢ With a braided material, such as silk, a
3rd throw (replicating the first) would be
placed to secure the knot.
➢ If a slippery monofilament material,
such as nylon were being used, one
would place 5 or 6 throws of alternating
construction in order to minimize knot
slippage.
 KNOT TYING
Is it really all that important?

➢A patient’s life may depend on the security

of one ligature. Slippage of a tie may
result in a life-threatening hemorrhage.
 Cutting Sutures
➢ With skin sutures, leave 3-4mm tail.
⚫ Tail = amount of suture left above knot
⚫ Tail is left because it helps prevent loosening
or undoing of sutures.
➢ Buried sutures are left within the body.
➢ Cut the suture on the knot, leaving no tail
behind.
Placement of Dermal Sutures

Note that the knot is buried in the depth of the wound

and the suture is in the dermis not fat
Timing of Sutures Removal

➢ Eyelid 3-5 (days)

➢ Face 3-5
➢ Oral cavity 7-8…or dissolve
➢ Scalp 7-12
➢ Lip 3-5
 Skin Staples

➢ Very common in human medicine

➢ Expensive
➢ Very easy
➢ Very secure
➢ Very little tissue reaction
➢ Removal =
⚫ Special tool required