Suture materials

Prepared and presented by: Dr Hamid Rahman
Sabawoon, MD, LMIH,MN
Supervised by: Dr Qadir Omar, MD, Trainer of G.Surgery
‫افغانســــــــتان‬ ‫اســـــــالمی‬ ‫جمــــــــــهوری‬
‫عـــــــــــــــامه‬ ‫صحـــــت‬ ‫وزارت‬
‫تخــــصـــــص‬ ‫اکمــــــــــال‬ ‫ریاســــت‬
‫بلــــــخی‬ ‫رابعـــــــه‬ ‫کمپــــلکس‬ ‫شفـــــاخانه‬
‫عمــــــومی‬ ‫جــــــراحی‬ ‫دیپــــــارتمنـــت‬

What is Suture?
Suture is a strand used to ligate the blood vessels and
approximate the tissues.
A suture is a thread used for uniting wound edges
Materials that had been tried included: gold, silver and
steel wire, silk, linen, hemp, flax, tree bark, animal and
human hair, bowstrings,and gut strings from sheep
and goats.
DR HAMID RAHMAN SABAWOON 3

‫بخیه‬ ‫تاریخچه‬
‫استف‬ ‫شدن‬ ‫منتن‬ ‫غیر‬ ‫و‬ ‫شفایابی‬ ‫بخشیدن‬ ‫سرعت‬ ‫بمنظور‬ ‫وسیع‬ ‫بصورت‬ ‫امروز‬ ‫بخیه‬‫اده‬
‫میشود‬.‫داکترها‬ ‫توسط‬ ‫بخیه‬,‫ها‬ ‫نرس‬,‫دندان‬ ‫داکتران‬,‫عاجل‬ ‫پرسونل‬,‫دوکتوران‬‫نظامی‬
. ‫گردشگران‬ ‫و‬ ‫سیاحان‬ ‫و‬‫میگردد‬ ‫استفاده‬ ‫حرفوی‬.
‫حیوانات‬ ‫استخوان‬ ‫و‬ ‫ازچوب‬ ‫عبارت‬ ‫میگردیده‬ ‫استفاده‬ ‫زدن‬ ‫بخیه‬ ‫برای‬ ‫موادیکه‬ ‫اولین‬
‫میگردید‬ ‫استفاده‬ ‫امروز‬ ‫از‬ ‫قبل‬ ‫سال‬ ‫هزاران‬ ‫که‬ ‫بوده‬.
‫از‬ ‫عبارت‬ ‫بود‬ ‫مروج‬ ‫ان‬ ‫در‬ ‫زدن‬ ‫بخیه‬ ‫که‬ ‫تمدن‬ ‫اولین‬‫مصری‬‫ها‬ ‫مصری‬ ‫که‬ ‫بود‬
‫آنها‬ ‫بدن‬ ‫کردن‬ ‫باز‬ ‫از‬ ‫بعد‬ ‫ها‬ ‫مرده‬ ‫دیگر‬ ‫و‬ ‫شاهان‬ ‫کردن‬ ‫بسته‬ ‫برای‬ ‫تخنیگ‬ ‫ازین‬
‫میکردند‬ ‫استفاده‬ ‫کردن‬ ‫مومیایی‬ ‫برای‬.‫نیز‬ ‫ها‬ ‫زنده‬ ‫برای‬ ‫بلکه‬ ‫مردگان‬ ‫برای‬ ‫تنها‬ ‫نه‬
‫میگردید‬ ‫استفاده‬ ‫جروحات‬ ‫کردن‬ ‫بسته‬ ‫جهت‬.
‫یونان‬ ‫فیلسوف‬‫هیپوکرات‬‫است‬ ‫نمود‬ ‫استفاده‬ ‫ان‬ ‫از‬ ‫زدن‬ ‫بخیه‬ ‫بمنظور‬ ‫موادیکه‬ ‫اولین‬
‫است‬ ‫کرده‬ ‫یاد‬ ‫خود‬ ‫تحقیقات‬ ‫در‬ ‫و‬ ‫نباتی‬ ‫محصوالت‬ ‫از‬ ‫را‬.‫منتن‬ ‫از‬ ‫عالم‬ ‫این‬ ‫و‬‫شدن‬
‫جرحه‬‫و‬‫اسکار‬ ‫تشکل‬‫است‬ ‫نموده‬ ‫یاد‬ ‫نیز‬ ‫زدن‬ ‫بخیه‬ ‫از‬ ‫بعد‬.

‫ولی‬ ‫نیست‬ ‫معلوم‬ ‫زدن‬ ‫بخیه‬ ‫جهت‬ ‫حیوانی‬ ‫به‬ ‫نباتی‬ ‫مواد‬ ‫تبدیل‬ ‫دقیق‬ ‫تاریخ‬ ‫هم‬ ‫هنوز‬ ‫گرچی‬
‫بنام‬ ‫موادی‬ ‫از‬ ‫عبارت‬ ‫است‬ ‫شده‬ ‫ثبت‬ ‫تاریخ‬ ‫در‬ ‫که‬ ‫معلومات‬ ‫اولین‬‫گوت‬ ‫کت‬‫توسط‬ ‫که‬ ‫بوده‬
‫بنام‬ ‫عالم‬‫گالن‬‫در‬ ‫که‬‫پرنگ‬‫ا‬‫م‬‫و‬‫ن‬‫میال‬ ‫از‬ ‫بعد‬ ‫دوسال‬ ‫میکرد‬ ‫زندگی‬‫د‬‫است‬ ‫شده‬ ‫داده‬ ‫نسبت‬.‫کت‬
‫مثل‬ ‫حیوانات‬ ‫روده‬ ‫از‬ ‫دارد‬ ‫وسیع‬ ‫استفاده‬ ‫هم‬ ‫هنوز‬ ‫که‬ ‫گود‬‫بز‬‫و‬‫گوسفند‬‫که‬ ‫میشد‬ ‫ساخته‬
‫میگردد‬ ‫استفاده‬ ‫آن‬ ‫از‬ ‫و‬ ‫شده‬ ‫ساخته‬ ‫صنعتی‬ ‫بصورت‬ ‫امروز‬.‫برداشتن‬ ‫برای‬ ‫ضرورت‬ ‫که‬
‫میگردد‬ ‫جذب‬ ‫بدن‬ ‫در‬ ‫خودبخود‬ ‫و‬ ‫نداشته‬.
‫داشتن‬ ‫زدن‬ ‫بخیه‬ ‫مواد‬ ‫با‬ ‫صحی‬ ‫کارمندان‬ ‫و‬ ‫داکتران‬ ‫که‬ ‫مشکالت‬ ‫بزرگترین‬ ‫از‬ ‫یکی‬‫د‬,‫پاک‬
‫میگردید‬ ‫انتانات‬ ‫و‬ ‫تخریش‬ ‫سبب‬ ‫معمول‬ ‫که‬ ‫بود‬ ‫جرحه‬ ‫شدن‬ ‫منتن‬ ‫و‬ ‫مواد‬ ‫این‬ ‫نبودن‬.
‫سال‬ ‫در‬1860‫بنام‬ ‫عالمی‬‫لیستر‬ ‫جوسف‬‫و‬ ‫مواد‬ ‫عالم‬ ‫این‬ ‫نمود‬ ‫حل‬ ‫حدی‬ ‫تا‬ ‫را‬ ‫مشکل‬ ‫این‬
‫بنام‬ ‫موادی‬ ‫بین‬ ‫در‬ ‫را‬ ‫خود‬ ‫دوخت‬ ‫محصوالت‬‫اسید‬ ‫کاربولیک‬‫حل‬ ‫راه‬ ‫یک‬ ‫که‬ ‫مینمود‬ ‫تعقیم‬
‫بود‬ ‫انتان‬ ‫رفتن‬ ‫ار‬ ‫برای‬ ‫مفید‬ ‫بسیار‬.‫اسید‬ ‫کرومیک‬‫ظاهر‬ ‫مواد‬ ‫تعقیم‬ ‫جهت‬ ‫صحنه‬ ‫در‬ ‫بعدا‬
‫شد‬.‫باالخره‬‫ایودین‬‫سال‬ ‫در‬ ‫نیز‬1902‫گردید‬ ‫معرفی‬.‫دراز‬ ‫سالیان‬ ‫از‬ ‫شده‬ ‫تعقیم‬ ‫گوت‬ ‫کت‬
‫دوکتورا‬ ‫هم‬ ‫هنوز‬ ‫اما‬ ‫میشود‬ ‫استفاده‬ ‫هم‬ ‫هنوز‬ ‫و‬ ‫شده‬ ‫استفاده‬ ‫جروحات‬ ‫بخیه‬ ‫در‬‫ن‬‫یافتن‬ ‫جهت‬
‫هستند‬ ‫بهتر‬ ‫و‬ ‫برتر‬ ‫دیگر‬ ‫مواد‬‫چ‬‫راکه‬‫مشکالت‬‫از‬ ‫عبارتند‬ ‫دارند‬ ‫مواد‬ ‫این‬ ‫که‬‫نبودن‬ ‫معلوم‬
‫جذب‬ ‫دقیق‬‫همچنان‬ ‫و‬ ‫بدن‬ ‫در‬ ‫مواد‬ ‫این‬‫زود‬ ‫شدن‬ ‫باز‬‫میباشد‬ ‫دوختن‬ ‫از‬ ‫بعد‬ ‫جرحه‬.‫بوجود‬
‫امدن‬‫اسکار‬ ‫نسج‬‫میباشد‬ ‫مواد‬ ‫این‬ ‫مشکالت‬ ‫از‬ ‫یکی‬ ‫نیز‬.

Qualities of an ideal suture: It should
◦ Remain intact until union occurs.
◦ Cause minimum tissue reaction.
◦ Be non-capillary in action.
◦ Be of uniform thickness.
◦ Be knotable.
◦ Have smooth surface.
◦ Have sufficient tensile and functional strength.
◦ Easily sterilizable.
◦ Cheap and readily available
◦ Easy to handle.
‫مطلوب‬ ٔ‫ه‬‫بخی‬ ‫نخ‬
‫نباشد‬ ‫زا‬‫سرطان‬
‫باشد‬ ‫نفوذپذیر‬
‫نکند‬ ‫بافتی‬ ِ‫ت‬‫حساسی‬ ‫ایجاد‬
‫باشد‬ ‫داشته‬ ‫اعتماد‬‫قابل‬ ‫های‬‫گره‬
‫شود‬ ‫جذب‬ ،‫مطلوب‬ ٔ‫ه‬‫نتیج‬ ‫دادن‬ ‫از‬ ‫پس‬
‫نباشد‬ ‫مناسب‬ ‫باکتری‬ ‫رشد‬ ‫جهت‬
‫باشد‬ ‫کردن‬‫استریل‬ ‫قابل‬ ‫راحتی‬‫به‬.
(‫گاز‬ ‫با‬‫اکساید‬ ‫اتیلن‬

Supplies
Materials Needed for
Suturing

Suture Material category
Generally categorized by three
characteristics:
◦ Absorbable vs. non-absorbable
◦ Natural vs. synthetic
◦ Monofilament vs. Multifilament
‫دسته‬ ‫دو‬ ‫به‬ ‫بدن‬ ‫جذب‬ ‫نظر‬ ‫از‬:‫جذب‬‫غیرقابل‬ ‫و‬ ‫جذب‬‫قابل‬
‫دسته‬ ‫دو‬ ‫به‬ ‫ساخت‬ ‫منبع‬ ‫نظر‬ ‫از‬:‫مصنوعی؛‬ ‫و‬ ‫طبیعی‬
‫دسته‬ ‫دو‬ ‫به‬ ‫فیزیکی‬ ‫شکل‬ ‫نظر‬ ‫از‬:‫ی‬‫و‬ ‫ای‬‫رشته‬‫ک‬
‫ای؛‬‫چندرشته‬

CLASSIFICATION OF SUTURES
ABSORBABLE NONABSORBABLE
MONOFILAMENT MULTIFILAMENT (BRAIDED)
SYNTHETIC NATURAL

Characteristics of Sutures Materials
Suture materials can be divided into two categories: absorbable and non-
absorbable.
Absorbable materials have the advantage in that they are less likely to cause an
immune response by the body
Non-absorbable materials can be left in the body permanently if needed.

Absorbable Suture Materials
Absorbablesuturematerials are
broken down by the patient’s body.
The original absorbable material was
chromic catgut (still used today).
This is made from animal intestines and
breaks down after 7 days.
Because it breaks down, there is less of a
likelihood of an immune reaction.

Non-absorbable Suture Materials
Non-absorbablesutures are made of
materials that are not readily broken down by
the body’s enzymes or by hydrolysis.
Non-absorbable materials can be removed or
left in place permanently
 Source: Boston University Medical Campus

Absorbable Suture-description
Kangaroo tendon: It is obtained from the tendon of tail of
kangaroo and is used for suturing joint capsule
Fascia lata: It is obtained from the bovine Fascia lata
‫قاب‬‫ــ‬‫ج‬‫ل‬‫ــ‬‫ذب‬

Absorbable Suture-description
Cargile membrane: it is obtained from bovine caecum
Amniotic membrane: It is prepared from amniotic membrane of fetuses

Collagen: It is prepared from bovine flexor tendon
filament .
Polyglactin 910 (vicryl): It is a synthetic absorbable
suture material, prepared from glycolic lactic acid polymer.
Polyglycolic acid (Dexon): It is synthetic suture material
prepared from glycolic acid

Catgut
Absorption in tissues can be delayed by treating with
chromic acid.
Catgut therefore available as plain and chromic catgut.
chromic catgut

Type Degree of
Chromicity
Approx No.Of
days taken for
absorption
Type A Plain 10 Days
Type B Mild chromic 15 Days
Type C Medium
chromic
20 Days
Type D Extra chromic 40 Days

Catgut cont.
Depending on preservative used catgut is available eitheras
boilable or non boilable catgut.
1. Boilable catgut is preserved in xylol,toulene-99.75%,phenyl
merecuric acetate.025%.
2. Non boilable catgut is supplied in tubes containing90-
95%alcohol.

Sizes of
catgut
Diameter in
mm(average)
Use
2/0 0.30 Peretoneum,bowel wall(small
animals)and ligaturing vessels
0 or
1/0
0.40 -do-
1 0.48 Muscle
fascia(SA)ligature
larger vessels
2 0.50 -do-
3 0.60 Fascia,muscles(LA)
4 0.70
5 0.80 Rumen uterus
abdomen

Catgut size selection
Bowel: 2/0 - 3/0
Fascia: 1 - 0
Ligatures: 0 - 3/0
Pedicles: 2 - 0
Skin: 2/0 - 5/0
Arteries: 2/0 - 8/0
Micro surgery 9/0 - 10/0
Corneal closure: 9/0 - 10/0

Non-absorbable Suture
Not degraded, permanent
may be organic; inorganic or synthetic in
nature and are used as both the internal
and external suture materials.
‫جذب‬‫غیرقابل‬
Non absorbable sutures

Ethicon
Braided silk black
Trulon
Monofilament polyamide
Trulene
Monofilament polypropylene

Non-absorbable Suture
Examples:
◦ Prolene
◦ Nylon
◦ Stainless steel nylon
◦ Silk*
(*not a truly permanent material; known to be broken
down over a prolonged period of time—years)

Non-absorbable Organic suture materials
‫عضوی‬
Cotton:capillary in nature it clings to
surgeon’s gloves and they spread infection
in wound when applied to skin and luminal
surfaces.
Silk: it may be plain or braided and
capillary in nature
Silk worm gut: non-capillary and useful
for cutaneous sutures

cont.
Horse hair: It is cheap, non-capillary, flexible and is
easily sterilized. It causes little tissue reaction.
Linen: It is capillary in nature and produces more tissue
reaction than cotton and silk.
Umbilical tape: used to tie the umbilical cord of the
new born or as vulvar suture in cases of prolapse of
vagina of uterus.

Polyester:is a non absorbable, sterile, surgical
suture composed of Poly (ethylene terephthalate).
It suture elicits a minimal acute inflammatory
reaction in tissues.
Polyamide: Being monofilament, Linex is
remarkably smooth and gives excellent knotsecurity.
Posses good tensile strength.
Easy removal with no tissueadherence.

Non-absorbable Inorganic suture
material
‫عضوی‬ ‫غیر‬
Metallic suture: Wire of different
metals like tantalum, silver,
copper, stainless steel and vitallium
Tantalum: It is inert to tissues like
stainless steel

Natural Suture ‫طبیعی‬
Biological origin
Cause intense inflammatory reaction
Examples:
◦ “Catgut” – purified collagen fibers derived from intestine of healthy sheep or
cows
◦ Silk(non absorbable)
‫دسته‬ ‫دو‬ ‫به‬ ‫ساخت‬ ‫منبع‬ ‫نظر‬ ‫از‬:‫مصنوعی‬ ‫و‬ ‫طبیعی‬

Synthetic Suture ‫مصنوعی‬
Synthetic polymers
Do not cause intense inflammatory reaction
Examples:
◦ Vicryl(absorbable)
◦ Monocryl
◦ Prolene
◦ Nylon

Stainless steel suture

cont..
Silver: It becomes ionized in tissues and cause inflammation.
Copper: It is more suitable to repair fractures due to its
flexibility.
Aluminium wire: It is more flexible than stainless steel.

Multifilament (braided)
Suture Classification ‫شکل‬ ‫نظر‬ ‫از‬ ‫تصنیف‬
‫فزیکی‬:‫ای‬ ‫رشته‬ ‫چند‬ ‫و‬ ‫ای‬ ‫رشته‬ ‫یک‬
Monofilament

Monofilament Suture
Grossly appears as single strand of suture material; all fibers run
parallel
Minimal tissue trauma
Resists harboring microorganisms
Ties smoothly
Requires more knots than multifilament suture
Examples:
Monocryl, PDS, Prolene, Nylon

Multifilament Suture
Fibers are twisted or braided together
Greater resistance in tissue
Provides good handling and ease of tying
Fewer knots required
Examples:
Vicryl (braided)
Chromic (twisted)
Silk (braided)

Braided v/s Monofilament
Has capillary action
Increased infection risk
Less smooth passage
Less tensile strength
Better handling
Better knot security
No capillary action
Less infection risk
Smooth tissue passage
Higher tensile strength
Has memory
More throws required

Silk Catgut
Natural
◦ Silk, linen, catgut
Synthetic polymer
◦ Polypropylene, polyester,
polyamide
Polypropylene Polyester

nylon
Monofilament
◦ Polypropylene
◦ Polydioxanone
◦ Nylon
Multifilament
◦ Catgut (twisted)
◦ Polyester
◦ Silk (braided)
Polyester Silk

Suture Degradation
Suture Material
Method of
Degradation
Time to
Degradation
“Catgut”
Proteolytic
enzymes
Days
Vicryl, Monocryl Hydrolysis
Weeks to
months

Suture Size
Sized according to diameter with “0” as reference size
Numbers alone indicate progressively larger sutures
(“1”, “2”, etc)
Numbers followed by a “0” indicate progressively
smaller sutures (“2-0”, “4-0”, etc)
Smaller --------------------------- Larger
.....”3-0”...”2-0”...”1-0”.....”1”...”2”...”3”.....

The Suture Packaging
STRAND
SIZE
MATERIA
L
STRAND
LENGTH
PRODUC
T CODE
NEEDLE
CODE
WITH
LIFE SIZE
PICTURE
OF
NEEDLE
NEEDLE
LENGTHCOLOU
R
POINT
TYPE
NEEDLE
CIRCLE

Needle Qualities
 Surgical needles are produced from stainless steel alloys,
resistance to corrosion.
 contain a minimum of 12% chromium, which allows a thin,
protective surface layer of chromium oxide to form when the steel
is exposed to oxygen.
 Surgical needles made of a high nickel managing stainless steel
have a greater resistance to bending and breakage than stainless
steels without nickel.
Needles

  High-quality stainless steel
  Smallest diameter possible
  Stable in the grasp of the needle holder
  Capable of implanting suture material through tissue with
minimal trauma
  Sharp enough to penetrate tissue with minimal resistance
  Sterile and corrosion -resistant to prevent introduction of
microorganisms or foreign materials into the wound
Ideal surgical needle characteristics

Point
This portion of the needle extends from the tip to the
maximum cross-section of the body.
Body
This part of the needle incorporates most of the needle
length. The body of the needle is important for interaction
with the needle holder and the ability to transmit the
penetrating force to the point. The needle factors that affect
this interaction include needle diameter and radius, body
geometry, and stainless steel alloy.
Anatomy of a Needle

Swage:
The suture attachment end creates a single, continuous unit
of suture and needle. The swage may be designed to permit
easy release of the needle and suture material.
Needle coating:
The needle may be coated with silicone to permit easier
tissue passage. The coating helps reduce the force needed
to make initial tissue penetration and the frictional forces as
the body of the needle passes through the tissue.
Needle Cont…

Anatomy of a Needle

◦ Atraumatic needles- to suture delicate tissues like
intestine, stomach, bladder, uterus etc.
◦ Double curved and loopuyt needles -for skin
closure of cattle or buffalo and for deeper structures.
Needle Cont…

Needles
Straight
◦ Often hand held
◦ Used to secure
percutaneously placed
devices (e.g. central and
arterial lines)
Compound curved:
This needle curvature
was originally
designed for anterior
segment ophthalmic
surgery. The body has
a tight 80° curvature
at the tip, which
becomes a 45°
curvature throughout
the remainder of the
body. A microvascular
compound curved
needle also may
facilitate vessel
approximation in
microvascular
surgery.
Curved
◦ Designed to be held with a
needle holder
◦ Used for most suturing

Needles
•
• Eyed needles
– More Traumatic
– Only thread through
once
– Suture on a reel
– Tends to unthread itself
easily

Needle Curvature

Taper-Point
Suited to soft tissue
Dilates rather than cuts
Reverse
cutting
Very sharp
Ideal for skin
Cuts rather than dilates
Conventional
Cutting
Very sharp
Cuts rather than dilates
Creates weakness allowing suture
tearout
Taper-cutting
Ideal in tough or calcified tissues
Mainly used in Cardiac & Vascular
procedures.
Needle point Geometry

Blunt
Also known as “Protect Point”
Mainly used to prevent needle stick
injuries i.e. for abdominal wall closure.
Premium point
spatula
Ophthalmic Surgery
Spatula
Ophthalmic Surgery
DermaX*
NEW: ½ The Penetration force
½ The Penetration force
Superior Cosmetic Effect

The appropriate needle choice for any situation is
.......................The needle that will cause least
possible trauma to the tissue being sutured.
The Right Needle Choice

Using needle holder, grasp needle about
2/3rds of the way back from point.

Index finger stabilizes the instrument by resting on the shaft.

Surgical Scissors

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.

Steri-strips
Sterile adhesive tapes
Available in different
widths
Frequently used with
subcuticular sutures
Used following staple
or suture removal
Can be used for
delayed closure

Staples
Rapid closure of wound
Easy to apply
Evert tissue when placed
properly

Dermabond®
A sterile, liquid topical skin
adhesive
Reacts with moisture on skin
surface to form a strong, flexible
bond
Only for easily approximated skin
edges of wounds
punctures from minimally
invasive surgery
simple, thoroughly cleansed,
lacerations

AMCRYLATE® Gel
Iso-amyl-2-cyanoacylate
Method of application
Control hemorrhage on cutaneous incision on skin
and keep dry using swabs.
Apply few drops of Iso-amyl-2-cyanoacylate over the
wound edges.
Hold skin edges in proper opposition for about 20
seconds to achieve union of skin wound

1. Scalp: 6-8 days
2. Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
3. Ear: 10-14 days
4. Chest and abdomen: 8-10 days
5. Back: 12-14 days
6. Extremities: 12-14 days
7. Hand: 10-14 days
8. Foot and sole: 12-14 days
9. Penis: 8-10 days
10. Condition delaying Wound Healing: 14 to 21 days
1. Chronic Corticosteroid use
2. Diabetes Mellitus
Suture Removal Timing

Knots
A suture knot has three components
1- The loop created by the knot
2- The knot itself, which is composed of a number of tight
“throws”, each throw represents a weave of the two
stands
3- The ears, which are the cut ends of the suture

Suture Packaging

Ethicon
Braided silk black
Trulon
Monofilament polyamide
Trulene
Monofilament
polypropylene

Absorbable sutures

Bibliography
Postlethwait, R.W.: Wound healing and surgery. Somerville, New Jersey,
Ethicon, Inc., 1971
Varma, S., et al.: Comparison of seven suture materials in infected wound.
An experimental study. J. Surg. Res., 17:165, 1974
Chaiken, R.W.: Elements of surgical treatment in the delivery of
periodontal therapy. Chicago, Quintessence, 1977
Ethicon, Wound closure manual. Somerville, New Jersey, Ethicon, Inc,
1985, p.9
www.suturs.com
www.myoclinic.com
http://cal.vet.upenn.edu/surgery/index.html
Dr. Sameer A. Mokeem faculty.ksu.edu.sa/sameer/411 PDS

Suture materials

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