Sutures Materials

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Anaesthesia & Exodontia
Third Year

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  • 1. Suture Materials and Suturing Techniques Dr.Adel I. Abdelhady BDS, MSc, (Eg.), PhD (Eg.,USA) Oral and Maxillofacial surgery Dept. College of Dentistry University of Dammam, KSA
  • 2. 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
  • 3. 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
  • 4. 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
  • 5.  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
  • 6.   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)
  • 7.  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 ‫ -ليونة‬Ease of handling of suture material; ability to adjust knot tension and to secure knots (related to suture material, filament type, and diameter)
  • 8.  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
  • 9. Suture Materials
  • 10. Classification of Sutures Synthetic Natural, Biological Monofilament Multifilament Absorbable Non - Absorbable
  • 11. 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
  • 12.  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
  • 13.  Monofilament  Polypropylene  Polydioxanone  Nylon  Multifilament  Silk (braided)  Vicryl
  • 14.       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
  • 15. 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)
  • 16. Silk  Natural   Catgut Silk, linen, catgut Synthetic polymer  Polypropylene, Polypropylene Polyester
  • 17. 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.
  • 18. 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. 
  • 19. Non - Absorbable Advantages • Permanent wound Support Disadvantages • Foreign body left • They can be used to suture • Suture removal can tissues which need long term support, they provide permanent wound support. • For example, prosthetic heart valve implants must obviously be held in place by a suture that will never lose its strength be costly and inconvenient • Sinus & Extrusion if left in place
  • 20. 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
  • 21. Monofilament Advantages      Disadvantages Smooth surface single strand which can be wiry with a strong material Less tissue trauma memory leading to handling No bacterial harbours difficulties and a tendency No capillarity for knots to unravel Fluids are unable to travel along the length of  Handling & knotting a monofilament as is  Ends/knot burial possible in multifilaments  Stretch Monofilaments tend because of the spaces to be more stiff than between multiple strands. multifilament materials
  • 22. Multifilament Advantages     inherently strong because of their braided construction soft and pliable which provides excellent handling and knotting properties Good handling Good knotting Disadvantages    Bacterial harbours Capillary action Tissue trauma
  • 23. Monofilament  memory  less tissue drag  doesn’t wick  poor knot security  less tissue reaction Vs. Multifilament easy to handle more tissue drag wicks/ bacteria good knot security more tissue reaction
  • 24. Natural Vs. Synthetic  Natural:      Gut Chromic Gut Silk Collagen All are absorbable
  • 25.      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.
  • 26. 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
  • 27. Gut/ Chromic Gut      Chromic: tanned, lasts longer, less reactive Easy handling Plain: 5 -7days Chromic: 10-15 days Bacteria love this stuff!
  • 28. Collagen and Silk    Natural sutures VERY reactive, absorbable Ophthalmic surgery only
  • 29. 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
  • 30. 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
  • 31. NYLON  Synthetic  Surgilon, Ethilon, Dermalon  Mono or Multifilament  Memory  Inert, Very little tissue reaction  Pronounced memory  Poor knot security- lots of knots  Uses- skin closure, drains fixation
  • 32. 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
  • 33. Stainless Steel  Monofilament  Strongest !  Great knot security  Difficult handling  Can cut through tissues  Very little tissue reaction, won’t harbor bacteria
  • 34. Absorbable Suture Chromic gut  Tensile strength for 2 to 3 weeks  High tissue reactivity  Poor tensile strength for a given tissue diameter  Monofilament
  • 35. 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
  • 36. 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
  • 37. Absorbable Suture Monocryl  Virtually inert in tissue  Tensile strength for 2 to 3 weeks  Less suture absesses  Great for mucosa and skin closures
  • 38. Packaging… Imperial Gauge Metric Gauge Product (re-order) Code Needle size & curvature Needle type Needle point Needle profile Sterilized Ethylene Oxide Do Not Re-use See Instructions for use Batch Number Expiry date
  • 39. Gauge of the suture materials 2 Thick 1 0 00 000 0000 00000 Fine
  • 40. Selection of Sutures Material      Scalp Oral cavity Lip Face Eyelid 3/0, 4/0 3/0 , 4/0 4/0, 5/0 5/0, 6/0 6/0
  • 41. 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.
  • 42.   Needle Diameter: The gauge or thickness of the needle wire. Needle Diameter varies 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.
  • 43.  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.
  • 44. Anatomy of a Surgical Needle
  • 45. Types of Needles  Eyed needles  More Traumatic  Only thread through once  Eyeless, Swaged-on needles  Much less traumatic  More expensive suture material  Sterile
  • 46. Types of Needles
  • 47. 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
  • 48. 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.
  • 49. Cutting vs Reverse Cutting  Cutting  Reverse cutting
  • 50. Shapes of Needles     3/8 circle 1/2 circle Straight Specialty
  • 51. Using needle holder, grasp needle
  • 52. Use of Needle Holders Loading Needle Needle passing through skin
  • 53. How to use suture instrument?
  • 54. Needle Holder  Remember!!! Thumb & ring finger into needle holder’s rings (NOT your middle finger!)
  • 55. 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.
  • 56. Smooth or teethed forceps?  Smooth   Hold knots, tying suture or vessels Tooth (teethed)  Hold tissue
  • 57. 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.
  • 58. 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.
  • 59. 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”
  • 60. HEMOSTATIC SUTURES:
  • 61. Suture Techniques
  • 62. Method of Skin Suture  Simple interrupted   Vertical mattress   Looks bad early Continuous with lock   Good for thick and thin skin Horizontal mattress   Good for irregular wounds Cosmetic demand Simple running    Quick, for linear wounds Subcuticular The knot should be tied adequately and cause no blanching
  • 63. 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
  • 64. Simple Interrupted Definition: Equal full thickness bites thru skin and subcutaneous layers
  • 65. 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
  • 66. Simple Interrupted vs. Vertical Mattress  This suture is best used in creases & areas of natural inversion
  • 67. Horizontal Mattress: Definition: Simple interrupted ,but additional parallel bites are taken in reverse Purpose: Everts skin edges in wounds under tension
  • 68. 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!
  • 69. 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.
  • 70. 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.
  • 71. 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 behind. no tail
  • 72. 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
  • 73. Timing of Sutures Removal      Eyelid Face Oral cavity Scalp Lip 3-5 (days) 3-5 7-8…or dissolve 7-12 3-5
  • 74. Skin Staples  Very common in human medicine  Expensive  Very easy  Very secure  Very little tissue reaction  Removal =  Special tool required