Supplement

Aesthetic Surgery Journal

The Surgical Suture 2019, Vol 39(S2) S67–S72

Published by Oxford University
Press on behalf of The American
Society for Aesthetic Plastic
Surgery 2019. This work is written
by (a) US Government employ-
ee(s) and is in the public domain
Miriam Byrne, MD, FRCS (Plast); and Al Aly, MD, FACS

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in the US.
DOI: 10.1093/asj/sjz036
www.aestheticsurgeryjournal.com

Abstract
Surgeons must select the optimal suture materials for tissue approximation to maximize wound healing and scar aesthetics. Thus, knowledge regarding
their characteristics is crucial to minimize ischaemia, excess wound tension, and tissue injury. This article describes the selection of various suture
materials available today and their intended design. Modern suture material should have predictable tensile strength, good handling, secure knot-tying
properties, and could be enhanced with an antibacterial agent to resist infection. Tensile strength is limited by suture size. The smallest suture size that will
accomplish the purpose should be chosen to minimize tissue trauma and foreign material within tissues. Monofilament suture has lower resistance when
passed through tissues, whereas multifilament sutures possesses higher tensile strength and flexibility but greater tissue friction and pose risks of suture
sinus and infection. Natural absorbable sutures derived from mammalian collagen undergo enzymatic degradation whereas synthetic polymers undergo
hydrolysis. Collagen or polymer structures in the suture can be modified to control absorption time. In contrast, nonabsorbable sutures typically cause
an inflammatory reaction that eventually encapsulates by fibrous tissue formation. Excess reaction leads to chronic inflammation, suboptimal scarring,
or suture extrusion. More recently, barbed sutures have transformed the way surgeons approximate wounds by eliminating knots, distributing wound
tension, and increasing efficiency of closure. Similarly, modern skin adhesives function both as wound closure devices as well as an occlusive dressing.
They eliminate the need for skin sutures, thus improving scar aesthetics while sealing the wound from the external environment.

Editorial Decision date: January 31, 2019.

The word suture is derived from the Latin sutura, “a sewn
seam.” Materials including linen, cotton, horsehair, ani-
mal tendons and intestines, and wire from precious metals
have been used to approximate wounds and act as liga-
tures. Many adaptations over time have led to the highly
sophisticated products we use in our practice today.
Surgeons approximate tissue daily, but often their choice
of suture and needle are based on what they learned in
training or through negative events during their careers.
The surgeon must be well informed regarding the charac-
teristics of their suture choice and select a suitable mate-
rial that will minimize dead space and risk of microbial
invasion while maximizing precise wound approximation
and, ultimately, optimizing scar aesthetics. What suture
or suture combinations to utilize in any particular surgi-
cal case varies greatly among surgeons. Thus, knowledge
regarding the multiple available options gives direction
and enables surgeons to develop their own predilections.
The purpose of this article is to familiarize the reader
with the general characteristics of sutures, along with the
accompanying article on the characteristics of needles, so
that operative choices are better understood in the greater
scheme of the science of tissue coaptation.
Suture Characteristics
The favorable characteristics of a suture are well
documented and include possessing the greatest predictable
tensile strength consistent with size limitations, good
handling properties, and secure knot tying.1 With time,
From the Department of Plastic, Reconstructive, and Aesthetic
Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab
Emirates. Dr Aly is Body Contouring Section Co-editor for Aesthetic
Surgery Journal.
Corresponding Author:
Dr Miriam Byrne, Cleveland Clinic Abu Dhabi, Department of
Plastic, Reconstructive and Aesthetic Surgery, A Maryah Island,
PO Box 112412, United Arab Emirates.
E-mail: drmiriambyrne@yahoo.com
S68 Aesthetic Surgery Journal 39(S2)

a surgeon develops suture preferences, specific to their Table 1. Varying Sizes of Synthetic Sutures According to Their US Phar-
practice, based around their knowledge of tissue healing macopeia Denotation, Metric Gauge, and Diameter (in millimeters)
and the physical and biological characteristics of suture USP size Reference Metric gauge Diameter (mm)
materials and factors such as infection, biofilm formation,
3 Three (3) 6 0.600-0.699
and multi-resistant pathogens.2 Modern suture materials
are impregnated with a variety of agents that improve their 2 Two (2) 5 0.500-0.599
handling, antibacterial properties, and visibility.3,4
1 One (1) 4 0.400-0.499

0 Zero (0) 3.5 0.350-0.399

Size and Tensile Strength

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2-0 Two zero (00) 3 0.300-0.339
Suture sizes are commonly denoted using the USP (United 3-0 Three zero (000) 2 0.200-0.249
States Pharmacopeia) system. This numbering system can
4-0 Four zero (0000) 1.5 0.150-0.199
be a little confusing, but it centers around the “0” suture.
Suture sizes increase from USP size 0 (“zero”) to size 1, 5-0 Five zero (00000) 1 0.100-0.149
commonly called “number 1,” to USP size 2 (“number
6-0 Six zero (000000) 0.7 0.070-0.099
2”), and upwards. Alternatively, suture sizes decrease
in size, again from 0, to USP size 2-0, commonly called 7-0 Seven zero (0000000) 0.5 0.050-0.069
“two 0,” 3-0 (“three 0”), and downwards. Table 1 provides 8-0 Eight zero (00000000) 0.4 0.040-0.049
size comparison based on USP denotation, metric gauge,
and diameter. An example of an extremely fine suture for 9-0 Nine zero (000000000) 0.3 0.030-0.039

ophthalmic and microsurgery such as USP size 9-0 has a

metric gauge size of 0.3 and diameter of between 0.030 to
0.039 mm.
The purpose of sutures in general is to approximate tis-
sues, without excess tension, while minimizing ischaemia
and tissue injury. As wound healing progresses, the wound
strength increases over weeks or months until it approxi-
mates the original tensile strength of the tissue. Whether
wound closure is single or multilayered, the smallest size
or diameter of suture that will accomplish the purpose
at hand should be chosen, thus minimizing both tissue
trauma with each passage of the needle and the amount
of foreign material left behind. Smaller-diameter sutures
are, however, associated with less tensile strength, and a
balance must be struck between size of suture and main-
tainance of tissue reapproximation.1
Multi- and Monofilament Sutures
Whether a suture has a single or multiple strand composition
is an important consideration, especially when weighing
its potential for harboring bacteria against the need for
greater tensile strength. Monofilament sutures pose lower
resistance on tissue passage, are less likely to accommodate
organisms, and tend to snug down more readily. On the
other hand, they must be handled carefully, because when
crushed by certain instruments, they can weaken or break.
They are favored in vascular and microvascular surgery
where ease of tying down sutures is crucial.
When several strands are braided together forming the
multifilament suture, greater tensile strength, flexibility,
and pliability is offered. In recent years, coating the suture
has assisted its passage through tissue and decreased
potential for infection, making multifilament suture the
choice for many intestinal surgeries. Multifilament sutures,
when used on the subcutaneous or intradermal level,
tend to be extruded in the form of a suture sinus or small
localized abscess, compared with a monofilament, which
behaves in a cleaner, less reactive manner.
Suture Degradation: Absorbable and
Nonabsorbable Options
The manner by which a suture degrades influences the
material choice for internal use in deeper layers and for
skin approximation. Absorbable sutures are typically made
from either mammalian collagen, which is ultimately
digested by body enzymes, or synthetic polymers that
undergo hydrolysis. Hydrolysis is a process where water
penetrates the suture strands, causing breakdown of the
filament’s polymer structure. Maintaining the balance
between rapid absorption and the prolongation of tensile
strength has been aided by treatments and chemical
structuring, which lengthen absorption time.
Typically, when a wound is closed with absorbable
suture, the decrease in tensile strength over the first weeks
is in a gradual, linear fashion. During this period, a leu-
kocyte cellular response is mounted to remove cell debris
and physical suture material, and this process overlaps
with the second stage where the majority of suture mass
is lost. Either of these phases can be affected by infection
and protein deficiency, where tensile strength is lost too
quickly, and wound dehiscence is manifested clinically.
Hydrolysis produces a lesser degree of tissue reaction com-
pared with the enzymatic degradation process.
Byrne and AlyS69
In contrast, the in vivo tissue response around non-
degradable material involves fibroblasts that encapsulate
the suture by fibrous capsule formation. Adjacent macro-
phages and foreign body giant cells respond in a process
known as frustrated phagocytosis, where they attempt to
enzymatically degrade the nondegradable suture.
For example, nonabsorbable Nylon sutures are com-
monly used to approximate skin edges on the face where
aesthetic outcome is crucial. These are removed early to
avoid tissue inflammation and unwanted tissue response
around the suture material, which would leave undesir-
able track marks. In contrast, nonabsorbable Prolene
sutures can be used for optimal mesh fixation in her-
nia repair. They are left permanently in situ, where they
remain encapsulated by fibrous tissue together with the
mesh. When enhanced mechanical strength is required
such as in the closure of sternotomy, steel wires are used
to achieve bony union.
Specific Suture Materials: Natural
Absorbable Sutures
Absorbable sutures may be classified as natural (surgical
gut) or synthetic (Polyglactin in its many forms [eg, Coated
Vicryl Polyglactin 910, Monocryl Poliglecaprone 25, and
PDS II Polydioxanone]).
The naturally occurring types of surgical gut are formed
from processed strands of highly purified collagen, which
dictates not only the tensile strength but also its degradabil-
ity. A higher percentage of pure collagen along the strand
equates to less foreign material in the wound. An exam-
ple of the composition of one such gut suture is 97% to
98% pure strands of collagen (serosa of beef intestine, or
submucosa of sheep intestine) spun into monofilaments of
varying sizes but uniform diameter to within an accuracy of
0.0002 inch. This eliminates variations known as high and
low spots, which contribute to frays and breakages in the
suture knot that is malpositioned or unsecurely tied down.
Plain surgical gut is a rapidly absorbed suture, gen-
erally used for closing the epidermis, ligating superficial
blood vessels, and suturing subcutaneous tissue. The ten-
sile strength is maintained for 7 to 10 days and absorption
is complete by 70 days. When heat treated, the filaments
are absorbed at a more rapid pace and they lose tensile
strength compared with their nontreated counterparts.
Clinically, it can be placed in the mucosa of the lip and eye
and as an external suture for rhinoplasty closure where
minimal tensile strength is required.
The corollary is chromic gut, which resists the body’s
enzymatic digestion. The collagen filaments are bathed in
buffered chrome tanning solution salt before formation
into its strands. This process turns the suture yellowish
tan to brown. Tensile strength remains for 10 to 14 days,
with residual measurable strength present for 3 weeks
and absorption time prolonged to over 90 days. The main
advantage over plain gut is less tissue reaction.
Specific Suture Materials: Synthetic
Absorbable Sutures
One of the most frequently used sutures amongst plastic
surgeons is an absorbable suture that holds its tensile
strength for a predictable period of time and shows lower
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tissue reaction than surgical gut. The original introduction
to the market of one such suture in 1974 was Vicryl, a
braided, naturally absorbing pliable suture, which was later
modified in 1979 to improve smoother tissue passage and
handling and ensure more secure knot tying (Coated Vicryl).
The raw material of this braided suture is a copolymer
of lactide and glycolide coated with polyglactin 370 and
calcium sterate. It is absorbed by hydrolysis, with 75% still
present at 2 weeks, 25% at 1 month, and is completely
absorbed by 56 to 70 days and thus useful for soft tissue
approximation. In 2003, a broad-spectrum antibacterial
agent, triclosan, was added.3,4 Subsequently, an undyed
braided suture of similar composition to the original but
treated with gamma rays to have a lower molecular weight
was designed (Vicryl Rapide) for faster absorption; 50% of
tensile strength is lost at 5 days with complete absorption
by 6 weeks. It is ideally used for short-term wound support
of superficial soft tissue mucosa and skin.
Since its introduction in 1982, PDS II (Polydioxanone)
has gained popularity among plastic surgeons. It features
a polyester polymer monofilament construct, with 25% of
the tensile strength still remaining at 6 weeks and max-
imum support for the first 2 weeks (70%). The actual
absorption is insignificant until 3 months and is essen-
tially complete by 6 months. Because of its minimal tissue
reaction, it is also favored in pediatric, cardiovascular, and
ophthalmic surgeries.
A synthetic suture specifically for skin closure, Monocryl
(Poliglecaprone 25), was introduced in 1993 and is formed
of a copolymer of glycolide and epsilon-caprolactone. This
monofilament retains 60% to 70% of its tensile strength
at 1 week, with complete loss at 3 weeks and complete
absorption between 91 and 119 days. Dyed and antibac-
terial versions have a similar profile.3 This has been the
suture of choice for many subcuticular skin closures,
including abdominoplasty, flap inset, and breast wound
closure.
Specific Suture Materials: Natural
Nonabsorbable Sutures
Nonabsorbable sutures are useful for their superior
handling characteristics. Raw silk is produced through
S70
a process whereby a continuous filament is spun by the
silkworm. The silk filaments were processed to become a
tightly braided, dyed suture coated with waxes or silicone.
Although silk suture is classified as a nonabsorbable
suture in the USP, in the materials literature it is
considered a degradable material by material scientists.
Silk biodegradation is mediated by foreign body tissue
response. Slow but progressive enzymatic degradation of
the fibers will result in gradual loss of tensile strength.
Surgical stainless steel is used in its 316L low-carbon
alloy formula and may be braided into multifilaments.
It is most typically encountered by the plastic surgeon
reconstructing a sternal wound or in hand fracture fix-
ation. It affords indefinite tensile strength and flexibil-
ity and lacks toxic elements, but sensitivity to chromium
and nickel may occur in susceptible patients. Wires can
be associated with difficult handling, fragmentation, or
kinking, which can result in fatigue. There is a risk of
tearing tissue and puncturing skin, thus posing risk of
virus transmission and the possibility of unfavorable
electrolytic reactions.
Specific Suture Materials: Synthetic
Nonabsorbable Sutures
Nylons were introduced to the market by the DuPont
Company in the late 1930s with Nylon 66, the first true
synthetic fiber. Sutures are produced from the long-chain
aliphatic polymers Nylon 6 and Nylon 6.6. used for sizes
7-0 and smaller. They lend themselves to a broad range
of applications in surgery including skin approximation,
vessel ligation, and microsurgery. With the introduction
of fine needles and sutures (8-0 to 11-0), the scope
for microscopic surgery has greatly expanded in all
specialties. For plastic surgeons, it is frequently utilized for
anastomosis, neurorhaphy, and oculoplastic surgeries. For
aesthetic plastic surgery, a premoistened or “pliabilized”
monofilament suture in sizes 3-0 to 6-0 was devised to
enhance tissue handling and knot tying to make it more
similar to a braided suture.
Nylon monofilament suture (eg, Ethilon) possesses the
characteristics of high tensile strength and extremely low
reactivity. Both monofilament and its multifilament coun-
terpart (eg, Nurolon) degrade approximately 15% to 20%
per year by the process of hydrolysis and are eventually
encapsulated if left in place (in vivo study).
In the 1920s, Mersons Manufacturing Company pro-
duced the first synthetic braided suture preattached to the
butt of the needle, which was shown to remain indefinitely
in the body. Mersilene (polyethylene terephthalate) is
uncoated and thus has a higher coefficient of friction with
passage through tissue, but provides consistent suture ten-
sion, and minimal breakage.
Aesthetic Surgery Journal 39(S2)
Many orthopedic surgeons prefer to use coated poly-
ethylene terephthalate suture (Ethibond Excel), a nonab-
sorbable braided suture for ligament or tendon repair. It
is coated with polybutylate, thus enabling easy passage
of the fibers through tissue and smooth knot tying. Being
inert, it elicits minimal reaction and its tensile strength is
not known to significantly change with time. In the realm
of body contouring surgery, when employed to either pli-
cate the abdominal wall or close abdominoplasty incisions,
Ethibond can cause sinuses/granulation tissue due to per-
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manent presence of a foreign body in the wound. This can
lead to problems arising years after surgery.
Prolene, a widely utilized nonabsorbable synthetic
monofilament, is an isostatic crystalline stereoisomer of
polypropylene. It tends not to lose tensile strength through
degradation and can be used on skin to diminish reactiv-
ity or, in a contaminated field, to minimize delayed sinus
formation and extrusion. Prolene is commonly utilized
as a pull-through suture in facial lacerations and trauma,
where aesthetics are paramount and track marks must be
avoided.
A less familiar monofilament suture, which is rela-
tively resistant to infection and contamination, is Pronova
Poly (hexafluoropropylene-VDF). It is a polymer blend
of poly (vinylidene fluoride) and poly (vinylidene fluo-
ride-co-hexafluoropropylene) and is employed in ligation
and wound closure, where it resists adherence to adjacent
tissues in cardiovascular, ophthalmic, and neurosurgical
procedures.
Barbed Sutures
Barbed sutures, first designed by John Alcamo in
1956, were granted a US patent in 1964. The first FDA-
approved barbed suture was not available until 2002.
This was a unidirectional 2/0 polypropylene suture
on a straight needle for midface lift (Contour Thread,
Surgical Specialties). Subsequently, barbed absorbable
polydioxanone suture was produced for wound closure
(Quill Medical).5 The V-Loc unidirectional barbed suture
with a fixed loop was introduced in 2009 (Covidien
Healthcare) and Stratafix was introduced in 2012. These
barbs serve to grip the sutured tissue in a continuous
manner and retain tensile strength. The main benefits
of barbed sutures include elimination of surgical knots,
knot-related complications, and increased efficiency
of wound closure.6 The size and spacing of the barbs,
which are integrally formed into the core, are designed
to provide maximum holding in soft tissue such as
fascia and provide tactile feedback to regulate tension.
They have become particularly popular for abdominal
wall repair following free flap harvest.7 In some barbed
sutures, the barbs are created by cuts through the suture
Byrne and AlyS71
thread rather than adding the barb to the suture core,
which reduces the original tensile strength of the suture
by reducing its functional diameter. Therefore, a larger
suture size should be considered routinely.
The clinical advantages of barbed sutures include
reduced suturing time and reduced overall operating time.8
These sutures demonstrated a lower rate of wound healing
complications in body contouring operations.9,10 Barbed
sutures have proven successful in both conventional and
robotic urological procedures11 and laparoscopic gynecolog-
ical procedures.12 Bidirectional barbed sutures performed
better than unidirectional barbed sutures, and postopera-
tive complications appear to be higher in cosmetic surgery.
In a large clinical series, the 2-layered technique to repair
deep dermal and superficial skin layers separately with
barbed sutures was associated with significantly higher
rates of wound separation. The same study found that the
Quill barbed suture was associated with more incisional
site erythema compared with the V-Loc barbed suture.13
Therefore, further evaluation is required before their lib-
eral use in reconstructive and aesthetic surgery.
Topical Skin Adhesives
Skin adhesives are popular for closure of low-tension
wounds and pediatric traumatic lacerations and serve
as a suitable wound dressing in many elective breast
and abdominal wall procedures. Butylcyanoacrylate (eg,
LiquiBand, Histoacryl), which has proved favorable in
well-designed clinical trials,14 is rapid-acting, cost effective,
and easy to apply.
Octyl cyanoacrylate (eg, Dermabond) forms a transpar-
ent and flexible bond, enabling placement over nonuni-
form wounds by creating a protective seal and providing
the benefits of an occlusive dressing. Its flexibility also
overcomes topical shear forces exerted on the adhesive,
thereby reducing early wound sloughing and possible
dehiscence. Compared with Butylcyanoacrylate, it had
twice the breaking strength and was more favorable for
longer incisions. One of the main benefits, from an aes-
thetic perspective, is the fact that there are no evident track
marks, particularly where facial aesthetics and pediatrics
are concerned. From a patient’s perspective, being able
to take a shower in the immediate postoperative period
without concern for compromising the incision is of great
benefit.1
CONCLUSIONS
Many adaptations and technological advancements in
material science have resulted in the production of sutures
that have impressive mechanical and physical properties.
Not only do they perform their primary function of wound
closure, but they afford other benefits such as antimicrobial
properties and, more recently, elimination of the surgical
knot with barbed suture and replacement of skin sutures
with adhesives.
It is imperative that a surgeon develops their own per-
sonal choice of suture so familiarity translates to consis-
tent reproducible results. Future generations of sutures
will no doubt be innovative and exciting, but the attentive
surgeon must always remain mindful of the controllable
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factors, namely perfection of technique, gentle handling,
and appropriate suture selection.
Disclosures
Dr. Aly was a consultant for Ethicon for approximately 15
years and has not consulted with them for several years.
He was part of a group of key opinion leaders who offered
insights about massive weight loss body contouring. He also
contributed to product development. Dr. Byrne declared no
potential conflicts of interest with respect to the research,
authorship, and publication of this article.
Funding
This supplement is sponsored by Ethicon US, LLC
(Somerville, NJ, USA).
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