sutures Overview

The goals of wound closure include obliteration of dead space, even distribution of tension along deep suture lines, maintenance of tensile strength across the wound until tissue tensile strength is adequate, and approximation and eversion of the epithelial portion of the closure. Methods for mechanical wound closure include staples, tape, adhesive, and sutures. Each method has specific indications, advantages and disadvantages, and special considerations. The subject of this article is the suture closure of wounds. Similar to other methods of wound closure, suture closure permits primary wound healing. Tissues are held in proximity until enough healing occurs to withstand stress without mechanical support. An extensive review of wound healing and the factors that influence this process are available elsewhere (eg, see the eMedicine articles Incision Placement; Wound Healing, Nerve; and Wound Healing, Skin). An image depicting the anatomy of a needle can be seen below.

Anatomy of a needle.

Suture material is a foreign body implanted into human tissues; it elicits a foreign body tissue reaction. During wound closure, a sterile field and meticulous aseptic technique are critical to minimize the risk of wound infection. Other complications of wound healing, such as hypertrophic scars, wide scars, and wound dehiscence, may result from patient factors (eg, nutritional status), incorrect suture selection, or a technique that results in excessive tension across the wound. Skillful wound closure requires not only knowledge of proper surgical techniques but also knowledge of the physical characteristics and properties of the suture and needle. The goal of this article is to review the types of sutures and needles for wound closure and to discuss principles that influence suture and needle selection. For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Suture Care.

Suture Qualities
Ideal suture characteristics
The ideal suture has the following characteristics: Sterile All-purpose (composed of material that can be used in any surgical procedure) Causes minimal tissue injury or tissue reaction (ie, nonelectrolytic, noncapillary, nonallergenic, noncarcinogenic) Easy to handle Holds securely when knotted (ie, no fraying or cutting) High tensile strength

Favorable absorption profile Resistant to infection Unfortunately, at present, no single material can provide all of these characteristics. In different situations and with differences in tissue composition throughout the body, the requirements for adequate wound closure require different suture characteristics.

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

Other suture characteristics

The following terms describe various characteristics related to suture material: 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 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 - Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to suture material, filament type, and diameter) Straight-pull tensile strength - Linear breaking strength of suture material Suture pullout value - The application of force to a loop of suture located where tissue failure occurs, which measures the strength of a particular tissue; variable depending on anatomic site and histologic composition (fat, 0.2 kg; muscle, 1.27 kg; skin, 1.82 kg; fascia, 3.77 kg) Tensile strength - Measure of a material or 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

Suture size
The United States Pharmacopeia classification system was established in 1937 for standardization and comparison of suture materials, corresponding to metric measures. The 3 classes of sutures are collagen, synthetic absorbable, and nonabsorbable. Size refers to the diameter of the suture strand and is denoted as zeroes. The more zeroes characterizing a suture size, the smaller the resultant strand diameter (eg, 40 or 0000 is larger than 5-0 or 00000). The smaller the suture, the less tensile strength of the strand.

Suture Material and Structure

Natural sutures
Natural sutures can be made of collagen from mammal intestines or from synthetic collagen (polymers). Tissue reaction and suture antigenicity lead to inflammatory reactions, especially with natural materials.[1,
2]

Monofilament versus multifilament sutures

Monofilament suture is made of a single strand. This structure is relatively more resistant to harboring microorganisms. The monofilament sutures exhibit less resistance to passage through tissue than multifilament suture. Great care must be taken in handling and tying monofilament suture because crushing or crimping of this suture can nick or weaken the suture and lead to undesirable and premature suture failure. Multifilament suture is composed of several filaments twisted or braided together. These materials are less stiff but have a higher coefficient of friction. 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.

Absorbable versus nonabsorbable sutures

Absorbable sutures provide temporary wound support, until the wound heals well enough to withstand normal stress. Absorption occurs by enzymatic degradation in natural materials and by hydrolysis in synthetic materials. Hydrolysis causes less tissue reaction than enzymatic degradation. The first stage of absorption has a linear rate, lasting for several days to weeks. The second stage is characterized by loss of suture mass and overlaps the first stage. Loss of suture mass occurs as a result of leukocytic cellular responses that remove cellular debris and suture material from the line of tissue approximation. Chemical treatments, such as chromic salts, lengthen the absorption time. Importantly, note that loss of tensile strength and the rate of absorption are separate phenomena. The surgeon must recognize that accelerated absorption may occur in patients with fever, infection, or protein deficiency and may lead to an excessively rapid decline in tensile strength. Accelerated absorption may also occur in a body cavity that is moist or filled with fluid or if sutures become wet or moist during handling prior to implantation. Nonabsorbable sutures elicit a tissue reaction that results in encapsulation of the suture material by fibroblasts. The United States Pharmacopeia classification is as follows: Class I - Silk or synthetic fibers of monofilament, twisted, or braided construction Class II - Cotton or linen fibers or coated natural or synthetic fibers in which the coating contributes to suture thickness without adding strength Class III - Metal wire of monofilament or multifilament construction

uture Characteristics
Absorbable Sutures
The absorbable surgical sutures are made from either "natural" or synthetic polymers.

Natural
Collagen: The collagen sutures are derived from the submucosal layer of ovine small intestine or the serosal layer bovine small intestine "gut." This collagenous tissue is treated with an aldehyde solution, which cross-links and strengthens the suture and makes it more resistant to enzymatic degradation. Suture materials treated in this way are called plain gut.

Surgical gut, plain: Tensile strength is maintained for 7-10 days postimplantation (variable with individual patient characteristics), and absorption is complete within 70 days. This type of suture is used for (1) repairing rapidly healing tissues that require minimal support and (2) ligating superficial blood vessels. Surgical gut, fast-absorbing: This type of suture is indicated for epidermal use (required only for 5-7 d) and is not recommended for internal use. Surgical gut, chromic (treated with chromium salt): Tensile strength is maintained for 10-14 days. The absorption rate is slowed by chromium salt (90 d). Tissue reaction is due to the noncollagenous material present in these sutures. Also, patient factors affect rates of absorption and make tensile strength somewhat unpredictable. Salthouse and colleagues demonstrated that the mechanism by which gut reabsorbs is the result of sequential attacks by lysosomal enzymes.[3] Natural fiber absorbable sutures have several distinct disadvantages. First, these natural fiber absorbable sutures have a tendency to fray during knot construction. Second, there is considerably more variability in their retention of tensile strength than is found with the synthetic absorbable sutures. A search for a synthetic substitute for collagen sutures began in the 1960s. Soon, procedures were perfected for the synthesis of high molecular weight polyglycolic acid, which led to the development of the polyglycolic acid sutures.[3]

Synthetic
Chemical polymers are absorbed by hydrolysis and cause a lesser degree of tissue reaction following placement. Polyglactin 910 (Vicryl): This synthetic suture is a braided multifilament suture coated with a copolymer of lactide and glycolide (polyglactin 370). The water-repelling quality of lactide slows loss of tensile strength, and the bulkiness of lactide leads to rapid absorption of suture mass once tensile strength is lost. The suture is also coated with calcium stearate, which permits easy tissue passage, precise knot placement, and smooth tie-down. Tensile strength is approximately 65% at 14 days postimplantation. Absorption is minimal for 40 days and complete in 56-70 days. These sutures cause only minimal tissue reaction. Vicryl sutures are used in general soft tissue approximation and vessel ligation. Another similar suture material is made from polyglycolic acid and coated with Polycaprolate (Dexon II). This material has a similar tensile strength and absorption profile. Poliglecaprone 25 (Monocryl): This synthetic suture is a monofilament suture that is a copolymer of glycolide and e-caprolactone. The suture has superior pliability, leading to ease in handling and tying. Tensile strength is high initially, 50-60% at 7 days, and is lost at 21 days. Absorption is complete at 91119 days. Poliglecaprone 25 sutures are used for subcuticular closure and soft tissue approximations and ligations. Polysorb Copolymers of glycolide and lactide were synthesized to produce a Lactomer copolymer that is used to produce a new braided absorbable suture, Polysorb. The glycolide and lactide behaved differently when exposed to tissue hydrolysis. Glycolide provides for high initial tensile strength, but hydrolyzes rapidly in tissue.[4]Lactide has a slower and controlled rate of hydrolysis, or tensile strength loss, and provides for prolonged tensile strength in tissue.[4] The Lactomer copolymer consists of glycolide and lactide in a 9:1 ratio. The handling characteristics of the Polysorb sutures were found to be superior to those of the Polyglactin 910 suture.[4]Using comparable knot construction and suture sizes, the knot breaking strength Polysorb sutures was significantly greater than that encountered by Polyglactin 910 sutures. In addition, the mean maximum knot rundown force encountered with the Polysorb sutures was significantly lower than that noted with the Polyglactin 910 sutures, facilitating knot construction. The surfaces of the Polysorb sutures have been coated to decrease their coefficient friction.[5] The Polysorb suture is coated with an absorbable mixture of caprolactone/glycolide copolymer and calcium stearyl lactylate. At 14 days postimplantation, nearly 80% of the United States Pharmacopeia (USP) tensile strength of these braided sutures remains. Approximately 30% of their USP tensile strength is retained at 21 days. Absorption is essentially complete between days 56 and 70. Drake et al studied the determinants of suture extrusion following subcuticular closure by synthetic braided absorbable sutures in dermal skin wounds.[6] Miniature swine were used to develop a model for studying suture extrusion. Standard, full-thickness skin incisions were made on each leg and abdomen. The wounds were closed with either sized 4-0 Polysorbor Vicryl sutures. Each incision was

closed with 5 interrupted, subcuticular, vertical, loops secured with a surgeons knot. The loops were secured with 3-throw knots in one pig, 4-throw knots in the second pig, and 5-throw knots in the third pig. The swine model reproduced the human clinical experience and suture extrusion, wound dehiscence, stitch abscess, and granuloma formation were all observed. The cumulative incidence of suture extrusion over 5 weeks ranged from 10-33%. Vicryl sutures had a higher cumulative incidence of suture extrusion than that of the Polysorb sutures (31%vs 19%). With Polysorbsutures,the5throwsurgeonsknothada higher cumulative incidence of suture extrusion than the 3-throw or 4-throw surgeons knot square, 30% versus 17% and 10%, respectively. This swine model offers an opportunity to study the parameters that influence suture extrusion. Polydioxanone (PDS II): This is a polyester monofilament suture made of polydioxanone. This suture provides extended wound support and elicits only a slight tissue reaction. Tensile strength is 70% at 14 days and 25% at 42 days. Wound support remains for up to 6 weeks. Absorption is minimal for the first 90 days and essentially complete within 6 months. This material has a low affinity for microorganisms (like other monofilament). PDS II suture is used for soft tissue approximation, especially in pediatric, cardiovascular, gynecologic, ophthalmic, plastic, and digestive (colonic) situations. Another similar suture material is made from polytrimethylene carbonate (Maxon). This material has a similar tensile strength and absorption profile. A barbed suture (V-Loc, Covidien Inc) was developed that is self-anchoring with no knots required for wound closure. The elimination of knot tying may reduce many of the challenges of knot construction. The barbed suture is manufactured from a size O polydioxanone that reabsorbs within 26 weeks. This suture consists of axially barbed segments on each side of a mid point at which the barbs change direction. The tensile strength of the barbed suture decreases over time. Each suture is attached to a Premium Cutting and Taper Point needle with NuCoating technology.[7] The unique performance of the barbed suture was confirmed for gastrointestinal wound closure in a randomized control study. The V-Loc wound closure device appeared to offer comparable gastrointestinal closure as compared to 3-O Maxon, while being significantly faster. However, further studies with V-Loc are required to evaluate its use in laparoscopic surgery. [8] Sanz et al randomized 210 rats into one of five study groups to compare three absorbable sutures with a new synthetic absorbable suture, Maxon. They evaluated Maxon, Vicryl, chromic catgut and PDS II with respect to tissue inflammatory reaction, knot security, suture tensile strength, and suture absorption. The results indicated that Maxon and PDS II elicited a lower degree of chronic inflammation when compared with Vicryl and chromic catgut. The tensile strengths of Maxon and Vicryl significantly exceeded those of PDS II and chromic catgut during the critical period of wound healing. Maxon and PDS II retained a larger percentage of tensile strength during the long postoperative period, whereas Vicryl and chromic catgut were mostly absorbed. The authors concluded that Maxon was an excellent addition to the armamentarium of the surgeon.[9] Caprosyn The latest innovation in the development of monofilament absorbable sutures has been the rapidly absorbing Caprosyn suture. Caprosynmonofilament synthetic absorbable sutures are prepared from Polyglytone 621 synthetic polyester, which is composed of glycolide, caprolactone, trimethylene carbonate, and lactide. Implantation studies in animals indicate that Caprosyn suture retains a minimum of 50-60% USP knot strength at 5 days postimplantation, and a minimum of 20-30% of knot strength at 10 days postimplantation. All of its tensile strength is essentially lost by 21 days postimplantation. Pineros-Fernandez et al recently have compared the biomechanical performance of Caprosyn suture with that of chromic gut suture.[10] The biomechanical performance studies included quantitative measurements of wound security, strength loss, mass loss, potentiation of infection, tissue drag, knot security, knot rundown, as well as suture stiffness. Both Caprosyn and chromic gut sutures provided comparable resistance to wound disruption. Prior to implantation, suture loops of Caprosyn had significantly greater mean breaking strength than suture loops of chromic gut. Three weeks after implantation of these absorbable suture loops, the sutures had no appreciable strength. The rate loss of suture mass of these 2 sutures was similar. As expected, chromic gut sutures potentiated significantly more infection than did the Caprosyn sutures. The handling properties of the Caprosyn sutures were far superior to those of the chromic gut sutures. The smooth surface of the Caprosyn sutures encountered lower drag forces than did the chromic gut sutures. Furthermore, it was much easier to reposition the Caprosyn knotted sutures than

the knotted chromic gut sutures. In the case of chromic gut sutures, it was not possible to reposition a two-throw granny knot. These biomechanical performance studies demonstrated the superior performance of the synthetic Caprosyn sutures compared with chromic gut sutures and provide compelling evidence of why Caprosyn sutures are an excellent alternative to chromic gut sutures. The examples listed above represent only some of the available synthetic absorbable sutures. Depending on the anatomic site, surgeon's preference, and the required suture characteristics, other types of synthetic absorbable suture are available.

Nonabsorbable Sutures
Natural Surgical silk: This suture is made of raw silk spun by silkworms. The suture may be coated with beeswax or silicone. Many surgeons consider silk suture the standard of performance (superior handling characteristics). Although classified as a nonabsorbable material, silk suture becomes absorbed by proteolysis and is often undetectable in the wound site by 2 years. Tensile strength decreases with moisture absorption and is lost by 1 year. The problem with silk suture is the acute inflammatory reaction triggered by this material. Host reaction leads to encapsulation by fibrous connective tissue. Surgical cotton: This is made of twisted, long, staple cotton fibers. Tensile strength is 50% in 6 months and 30-40% by 2 years. Surgical cotton is nonabsorbable and becomes encapsulated within body tissues. Surgical steel: This is made of stainless steel (iron-chromium-nickel-molybdenum alloy) as a monofilament and twisted multifilament. It can be made with flexibility, fine size, and the absence of toxic elements. Surgical steel demonstrates high tensile strength with little loss over time and low tissue reactivity. The material also holds knots well. Surgical steel suture is used primarily in orthopedic, neurosurgical, and thoracic applications. This type of suture also may be used in abdominal wall closure, sternum closure, and retention. This material can be difficult to handle because of kinking, fragmentation, and barbing, which renders the wire useless and may present a risk to the surgeon's safety.[11] The cutting, tearing, or pulling of other patient tissues is also a risk. Surgical steel in the presence of other metals or alloys may cause electrolytic reactions and, therefore, is not a safe choice in these circumstances. The size of the steel wires is classified by the Brown and Sharpe gauge, ie, 18 (largest diameter) to 40 (smallest diameter). The standard United States Pharmacopeia classification is also used to denote wire diameter. Synthetic Nylon: This is a polyamide polymer suture material available in monofilament (Ethilon/Monosof) and braided (Nurolon/Surgilon) forms. The elasticity of this material makes it useful in retention and skin closure. Nylon is quite pliable, especially when moist. Of note, a premoistened form is available for cosmetic plastic surgery. The braided forms are coated with silicone. Nylon suture has good handling characteristics, although its memory tends to return the material to its original straight form. Nylon has 81% tensile strength at 1 year, 72% at 2 years, and 66% at 11 years. The material is stronger than silk suture and elicits minimal acute inflammatory reaction. Nylon is hydrolyzed slowly, but remaining suture material is stable at 2 years, due to gradual encapsulation by fibrous connective tissue. Polyester fiber (Mersilene/Surgidac [uncoated] and Ethibond/Ti-cron [coated]): This suture material is formed from polyester, a polymer of polyethylene terephthalate. The multifilament braided suture also comes coated with polybutilate (Ethibond) or silicone (Ti-cron). The coating reduces friction for ease of tissue passage and improved suture pliability and tie-down. The suture elicits minimal tissue reaction and lasts indefinitely in the body. Polyester fiber sutures are stronger than natural fibers and do not weaken with moistening. The material provides precise consistent suture tension and retains tensile strength. This suture is commonly used for vessel anastomosis and the placement of prosthetic materials. Polybutester Suture (Novafil): The polybutester is a block copolymer that contains butylene terephthalate and polytetramethylene ether glycol. The polybutester suture has unique performance characteristics that may be advantageous for wound closure.[12] This monofilament synthetic

nonabsorbable suture exhibits distinct differences in elongation compared with other sutures. With the polybutester suture, low forces yield significantly greater elongation than is seen in the other sutures. In addition, its elasticity is superior to the other sutures, allowing the suture to return to its original length once the load is removed. Coated Polybutester Suture (Vascufil): The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer (Vascufil). [13] The coating is a polytribolate polymer that is composed of 3 compounds: gylcolide, -caprolactone, and poloxamer 188. Coating the polybutester suture markedly reduces its drag force in musculoaponeurotic, colonic, and vascular tissue. Polypropylene (Prolene): This monofilament suture is an isostatic crystalline stereoisomer of a linear propylene polymer, permitting little or no saturation. The material does not adhere to tissues and is useful as a pull-out suture (eg, subcuticular closure). Polypropylene also holds knots better than other monofilament synthetic materials. This material is biologically inert and elicits minimal tissue reaction. Prolene is not subject to degradation or weakening and maintains tensile strength for up to 2 years. This material is useful in contaminated and infected wounds, minimizing later sinus formation and suture extrusion. Surgipro II: A polypropylene suture has been developed that has increased resistance to fraying during knot rundown, especially with smaller diameter sutures. These sutures are extremely inert in tissue and have been found to retain tensile strength in tissues for as long as 2 years. These sutures are widely used in plastic, cardiovascular, general, and orthopedic surgery. They exhibit a lower drag coefficient in tissue than nylon sutures, making them ideal for use in continuous suture closure. [14]