Suture materials techniques ih

SUTURE MATERIALS
&
SUTURING TECHNIQUES
PRESENTER – Dr. ITRAT HUSSAIN
MODERATOR – Dr. PANKAJ KUKREJA

CONTENTSIntroduction
History
Definition
Goals of suturing
Suture materials
- Introduction
- Requisites of ideal suture
- Classification
- Selection of suture material
- Absorption of suture material
- Biological response of body to suture.
Principles of suturing
Suturing Techniques
Knots
Suture Removal
Other methods of wound closure

• Suture means to ‘sew’ or ‘seam’. In
surgery suture is the act of sewing
or bringing tissue together and
holding them in apposition until
healing has taken place.
• A suture is a strand of material used
to ligate blood vessels and to
approximate tissues together.
INTRODUCTION

HISTORY
History of the Surgical Suture “I dress the wound,
God heals it.“
Ambroise Pare, surgeon
16th century

• The act of sewing is probably older then
Homo sapiens, because Neanderthal man
wore some sort of clothing.

HISTORY
 Perhaps the world’s oldest suture was placed by an
embalmer on the body of a twenty first dynasty mummy
about 1100 B.C.

• A south American method of wound
closure used large black ants which bite
the wound edges together and the ants
body is then twisted off leaving the head
in place.
• East African tribes ligated blood vessels
with tendons and closed wounds with
acacia thorns.

• The first detailed
description of a wound
suture and suture
materials used in it is by
the Indian physician
Sushruta, written in 500
BC.

 Galen, the physician to
Roman gladiators in the
second century A.D. used
silk for hemostasis.
Andreas Vesalius first
advocated the suture of all
fresh wounds as well as
severed tendon and nerves.

• Joseph Lister (1827-1912)
discovered that bacteria
present in suture strands
cause wound infection. He
disinfected sutures with
carbolic acid. He made
sterile sutures possible to
bury it in clean wounds
without infection.

• Sometime around 30 A.D., a
medical encyclopedia was written
by a Roman named Aurelius
Cornelius Celsus. His work, De Re
Medicina, tells the reader that
sutures should be “soft, and not
over twisted, so that they may be
more easy on the part.” He is
also credited with first
substantiated mention of ligating
by recommending it as a
secondary means of stopping a
hemorrhage.

• Rhazes of Arabia was credited
in 900 A.D. with first employing
‘kit gut’ to suture abdominal
wounds. The Arabic word ‘kit’
means a dancing master’s fiddle,
the musical strings of which ‘kit
string’ were made up of sheep
intestines. Over the years ‘kit’
was confused with kitten or cat,
and the misuse of the term was
propagated.

DEFINITIONS
• DEFINITION: suture material is a fibre used
to keep wound together until they hold
sufficiently well by themselves by natural fibre
(collagen) which is synthesized and woven into a
stronger scar
• Suture is a Stitch/Series of Stiches made to
secure apposition of the edges of a
Surgical/Traumatic wound (Wilkins)
• Any Strand of Material utilised to ligate blood
vessels or approximate Tissues (Silverstein L.H
1999)

GOALS OF SUTURING
Suturing is performed to
Provide adequate tension
Maintain hemostasis
Provide support for tissue
margins
Prevent bone exposure
Permit proper flap
position

• The basic purpose of a suture is to hold
severed tissues in close approximation
until the healing process provides the
wound with sufficient strength to
withstand stress without the need for
mechanical support.
• Since wounds do not gain strength until
4-6 days after injury, the tissues are
approximated till then by sutures.

The amount of tension or pull the
suture can withstand before
breaking is important.
Tensile St α diameter of suture
If the diameter of suture is
doubled, T.S is quadrupled.

Suture material should be atleast as
strong as the tissues in which they
are used. By the end of 2nd week,
when most skin sutures are removed,
the wound would have attained 3%-
7% of final Tensile St.
3rd week – 20% of T.S
4th week – 50% of T.S
Wounds will never regain more than
80% of Tensile St. of intact skin

REQUISITES OF AN IDEAL
SUTURE
• Tensile st: adequate material strength
will prevent suture breakdown & use of
proper knots for the material used will
prevent untying or knot slippage.
• Tissue biocompatibility: sutures made
from organic material will evoke a higher
tissue response than synthetic sutures.
tissue reaction α amount & size of
suture material.

• Low capillarity: multifilament type soak
up tissue fluid by capillary action
providing a rich medium for microbes
increasing chances of inflammation &
infection.
• Good handling & knotting properties:
ease of tying & a thread type that
permits minimal knot slippage also
influence thread selection.
• Sterilization without deterioration of
properties: most sutures available in
packages are sterilized by dry heat &
ethylene oxide gas.

• Non allergic, non electrolytic and non
carcinogènic
• Its use should be possible in any
operation.
• Low cost
• It should not fray, should slide through
tissues readily & knot should not slip after
tying.

• It should be readily visualized , should not
shrink & should not be extruded from the
wound.
• On break down ,it should not release toxic
agents.
• It should disappear without excessive
reaction once its task is completed.

CLASSIFICATION OF SUTURE
MATERIALS
According to source:
1. Natural
2. Synthetic
3. Metallic

According to structure 1. Monofilament
2. Multifilament
According to fate:
1. Absorbable (undergo degradation and
lose T.S. < 60 days)
2. Non absorbable ( maintain T.S > 60
days)
According to coating: 1. Coated
2. Uncoated

NATURAL
Absorbable
Catgut
Chromic catgut
Collagen
Fascia lata
kangaroo tendon
Beef tendon
Cargile membrane
Non Absorbable
Silk
Linen
Cotton
Ramie
Horse hair

SYNTHETIC
 Absorbable
 Polyglycolic Acid
 Polyglactic Acid
 Polyglactin 910(Vicryl)
 Polydioxanone(PDS)
 Non Absorbable
 Nylon/ polyamide
 PolyPropylene
 Polyesters
 Polyethelene
 Polybutester
 Polyvinylidene fluoride /
PVDF Sutures

MONOFILAMENT
Advantages
• Smooth surface
• Less tissue trauma
• No bacterial
harbours
• No capillarity
Disadvantages
• Handling and
knotting
• Any nick or crimp in
the material leads
to breakage.

MONOFILAMENT
 Absorbable
 Surgical Gut- Plain,
Chromic
 Polydiaxanone
 Polyglactin 910
 Non Absorbable
 Polypropylene
 Polyester
 Nylon/polyamide
 Polyvinylidene fluoride /
PVDF Sutures

MULTI FILAMENT
Advantages
• Strength
• Soft and pliable
• Good handling
• Good knotting
Disadvantages
• Bacterial harbours
• Capillary action
• Tissue trauma

MULTIFILAMENT
 Absorbable
 Polyglactin 910
 Polyglycolic Acid
 Non Absorbable
 Silk
 Cotton
 Linen

Metallic
SS
Tantalum
Gold
Silver
Aluminium

Non absorbable sutures are categorized
by the United States Pharmacopeia
(USP) as
Class I - Silk or synthetic fibers of
monofilaments with twisted or braided
construction
Class II - Cotton or linen fibers, coated
natural or synthetic fibers in which the
coating does not contribute to T.S
Class III - Metal wire of monofilament or
multifilament construction.

Principles of suture selection
The selection of suture material by a
surgeon must be based on a sound
knowledge of
• Healing characteristics of the tissues
which are to be approximated,
• The physical and biological properties of
the suture materials,
• The condition of the wound to be closed
and
• The probable post-operative course of
the patient.

1. Rate of healing of tissues:
• When a wound has reached maximal strength,
sutures are no longer needed.
• Tissues that ordinarily heal slowly such as skin,
fascia and tendons should usually closed with non –
absorbable sutures.
• Tissues that heal rapidly such as peritoneum, liver,
small intestine, muscles, stomach ,colon and
bladder may be closed with absorbable sutures.
• Suture should be stronger than the sutured
tissues, and it is unwise to implant more material
than necessary.

2.Tissue contamination:
• Avoid multifilament sutures as
bacteria can linger with them and
may convert a contaminated wound
into an infected one.
• Use monofilament absorbable or
nonabsorbable sutures in
potentially contaminated tissues.
Monofilament polypropylene is
ideal

3. cosmetic results :
• Where cosmetic results are important,
close and prolonged apposition of
wounds and avoidance of irritants will
produce the best results. Therefore use
a smallest, inert monofilament suture
materials such as poly amide and
polypropylene.
• Avoid skin sutures and close
subcuticularly whenever possible
• Under certain circumstances, to secure
close apposition of skin edges , skin
closure tape may be used

4. cardiovascular surgery:
• Monofilament polypropylene, polyester,
coated and un coated and braided
surgical silk are recommended.
• Monofilament polypropylene being smooth,
possess high TS is the material of choice
for vascular anastomosis. This material
does not encourage any thrombus
formation.
• Polyester is preferred for suturing
artificial heart valves, myocardium and
vascular prosthesis.

5. Microsurgical procedure:
• Most commonly used suture is 10-0 poly
amide monofilament
6.wound repair in patients following
irradiation
• In this group of patients ,not only the
normal healing process is delayed but the
tolerance to the trauma of irradiated tissue
is markedly reduced . So
• Extremely careful and gentle
surgical technique
 Avoid tension sutures and
mattress sutures as they further increase
the degree of ischemia.

 Closure in layers
 Avoid continuous and constant
pressure on irradiated tissues.
 Fascial layer –non-absorbable
sutures, polypropylene is ideal

BIOLOGIC RESPONSE
OF BODY
TO
SUTURE MATERIALS

BIOLOGIC RESPONSE OF BODY TO
SUTURE MATERIALS
• The initial body response to sutures is almost
identical in the first 4-7 days, regardless of the
suture material.
• The early response is a generalized acute aseptic
inflammation, involving primarily polymorphonuclear
leukocytes.
• After few days mononuclear cells, fibroblasts &
histiocytes become evident.
• Capillary formation occurs at the end of this initial
phase.

• Natural Absorbable – Proteolytic
degradation. Intense tissue response
• Synthetic Absorbable – Hydrolysis. Less
Intense
• Non Absorbable – Encapsulation. Acellular
Response

RAILROAD SCAR
 Sutures passing through mucous membrane or
skin provide a ‘wick’ or pathway through which
bacteria track down, and bacteria gain access
to underlying tissues.
 The longer the suture remains, the deeper the
epithelial invasion of the underlying tissue.
When suture removed, epithelial tract remains.
 These cells may eventually disappear or remain
to form keratin and epithelial inclusion cysts.
The epithelial pathway result in typical
‘railroad scar’ formation.

ABSORBABLE -NATURAL
Gut / cat gut
 Oldest known absorbable suture.
 Galen referred to gut suture as early as 175
A.D.
 Derived from sheep intestinal sub mucosa or
bovine intestinal serosa.
 Submucosa of sheep has a rich elastic tissue
content which accounts for high tensile strength
of the catgut. It is monofilament and is available
in the plain form as well as “tanned” in chromic
acid. The tanning process delays the digestion by
white blood cell lysozymes.

• Catgut should not be boiled or autoclaved as heat
destroys its tensile strength.
• Catgut is sterilized during preparation and kept in a
preservative solution (isopropyl alcohol) inside spools
or foils. Unused and reusable catgut is hygroscopic
so, catgut will swell due to water absorption and its
tensile strength will be reduced .
• Absorption :40-60 days
• When placed intra orally sutures are digested in 3-
5days.

• It is available pre-sterilized in
aluminium-coated sterile foil overwrap
pack with ethicon fluid as a
preservative.
• Colour: Plain catgut is yellow.
• Absorbtion: Catgut is absorbed by
proteolytic digestive enzymes released
from inflammatory cells collected
around the catgut. So, in the
presence of infection catgut is rapidly
absorbed.

CHROMIC CATGUT
Coated with thin layer of chromium salt
solution to minimize tissue reaction,
increase TS, slow the absorption rate,
better knot security, and ease of
handling.
TS – 10-14 days
Absorbed in 90 days
Uses:Opthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues

As it is an organic material and
susceptible to enzymatic degradation,
packed in isopropyl alcohol as a
preservative. Also condition or soften
it.
Suture absorbs alcohol and swells. It is
combustible and is also irritating to
tissues. It is removed by a quick rise
in saline prior to use.

COLLAGEN SUTURE
Natural, absorbable, monofilament
Obtained by homogenous dispersion of
pure collagen fibrils from the flexor
tendons of cattle.
Absorption – 56 days
TS - < 10% after 10 days.
Used in opthalmic surgery
Disadvantage of premature absorption.

POLYGLACTIN 910 (VICRYL) Polyglactic
acid
 Coated and uncoated
 Synthetic suture
 Monofilament/multifilament
 Lactide has hydrophobic qualities→delaying loss of
TS
 TS - 14 – 21 days.
 Absorption – 56-70 days.
SYNTHETIC ABSORBABLE

 Minimal tissue reactivity and can be used in
infected tissues
 Available in purple and undyed. Undyed used on
face.
 Coated with polyglactin 370 and calcium stearate
which allows easy passage through tissues as well
as easier knot placement.

VICRYL –RAPIDE
• It is braided synthetic absorbable suture material.
• Colour: White.
• It has a similar initial high tensile strength as that of
the normal vicryl suture.
• It gives wound support upto 12 days. It shows 50% of
the original tensile strength after 5 days and all of its
tensile strength is lost after 14 days.
• Its absorption is associated with minimal tissue reaction
facilitating improved cosmetics and reduction of
postoperative pain.

• The absorption is essentially complete
within 35-42 days.
• Uses: Low tensile strength and Rapid
absorption rate --Ideal for intra-oral
use (dental surgeries).

VICRYL plus ANTIBACTERIAL SUTURE
• Handles and
performs same as
normal vicryl.
• In vitro studies
shown that triclosan
on VICRYL plus
creates a zone of
inhibition around
the suture.

GLYCOLIC ACID HOMOPOLYMER
(DEXON) POLYGLYCOLIC ACID
 Polymer of glycolic acid with greater knot pull
and TS than gut.
 Synthetic, absorbable, braided
 Absorption- hydrolysis, which results in
minimal tissue reactivity.
 Braided and so catches on itself, and knot
tying and passage through tissues difficult.
 Does not tolerate wound infection and not
percutaneous suture.

GLYCOLIC ACID (MAXON) POLYGLYCONATE
-Synthetic, absorbable, monofilament.
-Polyglycolic acid and trimethylene carbonate
-TS – 14-21 days (>Dexon)
Absorption – Hydrolysis in 180 days
In vitro studies by Edlich and co-workers (1973)
have suggested that the degradation products of
polyglycolic acid and nylon sutures - glycolic acid,
1,6-hexane diamine and adipic acid are
antibacterial agents.

POLYDIOXANONE (PDS II)
 Synthetic,absorbable,monofilament.
 Polyester derivative poly P dioxanone.
 TS -14-42 days
 Absorption – Hydrolysis in 6 months.
 Passes through tissues easily.

Significant memory – compromises the
ease of knot-tying and knot security.
Minimal tissue reaction
For wounds under tension and
contaminated wounds.
May extrude through the wound over
time. So used only in tissues deeper
than subcuticular layer.

NON ABSORBABLE SUTURES
• Natural – silk, silk worm gut, cotton ,
ramie,linen
• Synthetic-polyester, polyamide, poly
propylene, polybutester,polyethelene
• Metals : SS
Tantalum
platinum
silver wires
gold
aluminium

SURGICAL SILK
-Braided or twisted
-Made from the filament spun by silkworm larva
to form its cocoon.
After processing and braiding, the strands are
dyed, stretched and impregnated with a
mixture of waxes and silicone.
NATURAL NON-ABSORBABLE

Advantage:
 Ease of handling – more for braided
 Good knot security
 made non capillary in order to withstand action
of body fluids & moisture.(wax or silicon coated)
 Cost effective
Contraindications:
Should not be used in presence of infection

Uses:
Plastic surgery, ophthalmic and general
surgeries, ligating body tissues.
Although characterized as non-absorbable,
studies show that it loses most of their
TS after 1 yr. and cannot be detected
in tissues after 2 yrs.

SURGICAL COTTON
Natural, multifilament, non absorbable
From stable Egyptian cotton fibers
good knot security
Not good in presence of contaminated
wounds or infection
Rarely used nowadays
Uses:
Most body tissues for ligating and
suturing

LINEN
Natural, multifilament, non absorbable
Made from stable flax fibers
Poor TS and so not for suturing under
tension
Uses:
Ligation of superficial vessels
Mucosal suturing without stress

POLYPROPYLENE (PROLENE)
-Polymer of propylene.
-Inert and TS for 2 yrs
-Holds knots better than other synthetic
sutures.
Advantages
-Minimal suture reaction and so used in infected
and contaminated wounds.
-Do not adhere to tissues and is flexible.
Uses:
General, plastic, cardiovascular surgery, skin
closure, ophthalmology.
SYNTHETIC NON-ABSORBABLE

NYLON – BRAIDED (SURGILON, NURILON)
Synthetic, non absorbable
Inert polyamide polymer
Braided and sealed with silicon coating
Looks, handles and feels like silk, but
more stronger
Multifilament nylon is weaker and less
secure when knotted, offering little
advantage over monofilament nylon.

NYLON MONOFILAMENT (DERMALON,
ETHILON)
Uncoated, but inert and non irritating to
the tissues.
High TS and low tissue reactivity
Some memory and return to original
linear shape over time. Because of this
more throws (4 throws) indicated.
Moistened nylon monofilament are more
easily handled and are packaged wet.
Uses:
Skin closure, plastic, ophthalmic and
microsurgery.

POLYESTER – BRAIDED
Tycron, Mersilene -Uncoated
Dacron, Ethibond - Coated (with polybutilate)
 Multifilament fibers of polyester
 Excellent TS which is maintained indefinitely
 Uncoated is rougher and stiffer than coated form
 Coated provides -low infection rate
-secure knotting
-smooth removal
-low reactivity
-easy passage through
tissues
 More expensive
 In deeper layers, may last indefinitely.

GOR-TEX
Nonabsorbable, synthetic, Monofilament
From,expanded polytetrafluoroethylene
(ePTFE)
Extremely low tissue reaction, good knot
tensile strenghtand ease of handling.
Uses
All type of soft tissue approximation and
cardiovascular surgeries.

MONOCRYL
Absorbable, synthetic, monofilament
Poliglecaprone 25; copolymer of glycolide
and caprolactone
Hydrolysis 90-120 days
Tissue reaction – minimal
Good knot strength
Used for soft tissue closure
Most pliable material ever made

POLYBUTESTER (NOVOFIL)
-New, monofilament, nonabsorbable, synthetic
-Made of polyglycol trephthate and polybutylene
terephthalate and is considered as a modified polyester
suture.
-No significant memory compared to polypropylene and
nylon. Easier to manipulate and greater knot security.
-Unique feature is their ability to elongate or stretch
with increasing wound edema. When edema subsides,
suture resumes original shape; so it is an ideal suture
for lacerations secondary to blunt trauma.

-TS high and lasts longer
-Minimal tissue reactivity.
-Popularity in cutaneous surgery is gradually
increasing.

SURGICAL STEEL
 Natural, monofilament/multifilament, non
absorbable
 Alloy of iron, nickel and chromium
 Good TS even in infection
 Difficult to handle and tendency to cut
through tissues. Very hard to tie, and knot
ends require special handling.

 Potential to corrode or break at points
of twisting, bending or knotting.
 Not to be used with a prosthesis of
another alloy.
 Used in sternal closure, orthopedic
surgeries.
 OMFS- for suspension of splints or
arch bars and not as suture material.

Packaging………
METRIC GUAGE IMPERIAL GUAGE
PRODUCT CODE
NEEDLE SIZE &
CURVATURE
NEEDLE TYPE
NEEDLE TIP
NEEDLE PROFILE
STERILIZED
ETHELENE OXIDE
DO NOT REUSE
SEE INSTRUCTIONS FOR USE
EXPIRY DATE BATCH NO

SUTURE SIZES
• Largest size 3 to extremely fine 11-0.
Increasing number of zeroes correlates with
decreasing suture diameter and strength.
• Thicker sutures are used for approximation of
deeper layers, wounds in tension prone areas
and for ligation of blood vessels.
• Thin sutures are used for closing delicate
tissues like conjunctiva and skin incisions of the
face. Size is chosen to correlate with the
tensile strength of the tissue being sutured.

3-0 or 4-0 OMFS, muscle, deep skin
5-0 or 6-0 facial skin closure
9-0 or 10-0 microsurgery

SUTURE NEEDLES
Surgical needles are designed to lead
suture material through tissue with
minimal injury. Needles can be
- straight (GIT) or curved
- swaged or eyed
Made up of either SS or carbon steel.
Needle is selected according to:
-type of tissue to be sutured
-tissue’s accessibility
-diameter of suture material.

CLASSIFICATION OF SURGICAL NEEDLES
 1.According to eye -eye less needles
-needles with eye
 2.According to shape -straight needles
. -curved needles
 3.According to cutting edge
a) round body
b) cutting -conventional
-reverse cutting

• 4.According to its tip -triangular tip
-round tip
-blunt tip

Ideal Properties Of Needles
• High quality stainless steel
• Smallest diameter possible
• Capable of implanting sutures with minimal trauma
to tissues.
• Stable in the needle holder
• Should be sharp.
• Sterile and corrosion resistant.

Term Definition
Chord
Length of needle
Radius
Diameter
The linear distance between eye and
tip.
The distance between eye and tip
following the curvature
The distance of the body of the
needle from the centre of the circle
Gauge or thickness of the metal wire
out of which the needle is made.

Tapered
Cutting
Reverse cutting

RADIUS OF CURVATURE OF THE
BODY(NEEDLE)
CLINICAL USE
Straight Needle
¼ circle
3/8 circle
½ circle
5/8 circle
Needle of choice for the skin
Limited use in oral surgery
May be used in surgery of the
nose, pharynx, tendons
Needle of choice for microsurgery
associated with very fine sutures;
ophthalmology
Oral surgery, flap surgery, wound
closure after placement of
osseointegrated implants and GTR
procedures
May be used in all surgical wounds
Needle of choice in oral surgery
Wide range of uses in many
surgical wounds
Wounds of the urogenital tract

PRINCIPLES OF SUTURING
1.Needle grasped at 1/4th to half the
distance from eye.
2.Needle should enter perpendicular to
tissue surface

3.Needle passed along its curve
4.The bite should be equal on both sides of the
wound margin and the point of the entry of the
needle should be closer to the wound edge than
its point of exit on the deep surface
5.The bite should be about 2-3 mm from the wound
margin of the flap because after wound closure
the edge of the wound softens due to
collagenolysis and the holding power is impaired.

6. Usually the needle to be passed from mobile side to the
fixed side and from thinner to thicker & from deeper to
superficial flap.
7.The tissues should not be closed under tension , since they
will either tear or necrose around the suture

8.Tie to approximate; not to blanch
9.Knot must not lie on incision line
10.The distance b/w one suture to
another should be about 3-4 mm apart
to prevent strangulation of the tissue &
to allow escape of the serum or
inflammatory exudate & to get more
strength of the wound.

11.Sutures placed at a greater depth than distance
from the incision to evert wound margins
12.Close deep wounds in layers
13.Avoid retrieving needle by tip
14.Adequate tissue bite to prevent tearing
15.sutures should have correct tension while tying
knot for provision of the slight edema post
operatively, more tensioned sutures cause
ischemia of the edges of the incision
causes tearing of the tissues
may leave suture mark
edges may get overlapped

16.Occasionally extra tissue may be present on
one side of incision and cause DOG EAR to be
formed in the final phase of wound closure.
• Simply extending the length of the incision to
hide the exists will produce an unsatisfactory
result.
• Thus after undermining excess tissue incision
is made at approx. 300 to parent incision
directed towards undermined side. Extra
tissue is pulled over incision and appropriate
amount is excised. Incision is closed in normal
manner.

1.INTERRUPTED SIMPLE SUTURE
Most commonly used. Inserted singly through side
of the wound and tied with a surgeon’s knot.

Advantages
Strong and can be used in areas of stress
Placed 4-8 mm apart to close large wounds, so that
tension is shared
Each is independent and loosening one will not
produce loosening of the other
Degree of eversion produced
In infection or hematoma, removal of few sutures
Free of interferences b/w each stitch and easy to
clean

2. SIMPLE CONTINUOUS / RUNNING
A simple interrupted
suture placed and needle
reinserted in a continuous
fashion such that the
suture passes
perpendicular to the
incision line below and
obliquely above. Ended by
passing a knot over the
untightened end of the
suture.

Advantages
 Rapid technique and distributes tension
uniformly
 More water tight closure (Shoen, 1975)
 Only 2 knots with associated tags
Disadvantages
If cut at one point, suture loosens along
the whole length of the wound which will
then gape open.

3.CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
withdrawing the suture through its own loop.
Indicated in long edentulous areas, tuberosities
or retromolar area.
Advantages
Will avoid multiple knots
Distributes tension uniformly
Water tight closure
Prevents excessive tightening.
Disadvantage :prevents
adjustment of tension over
suture line as tissue swelling
occurs.

4.VERTICAL MATTRESS
 Specially designed for use in
skin. It passes at 2 levels, one
deep to provide support and
adduction of wound surfaces at a
depth and one superficial to
draw the edges together and
evert them.
 Used for closing deep wounds
 This approximates subcutaneous
and skin edges

Needle passed from one edge to the other and again from
latter edge to the fist and knot tied.
When needle is brought back from second flap to the first,
depth of penetration is more superficial.

Advantages :
• for better adaptation and maximum tissue
approximation
• To get eversion of wound margins .
• Where healing is expected to be delayed for any
reason, it is better to give wound added support by
vertical mattress. Used to control soft tissue
hemorrhage.
• Runs parallel to the blood supply of the edge of the
flap and therefore not interfering with healing.
• Uses: abdominal surgeries & closure of skin wounds.

5.HORIZONTAL MATTRESS
 It everts mucosal or skin margins, bringing
greater areas of raw tissue into contact. So used
for closing bony deficiencies such as oro-antral
fistula or cystic cavities.
 Disadvantage: constricts the blood supply to
edges of incision.

Needle passed from one
edge to the other and
again from the latter to
the first and a knot is tied.
Distance of needle
penetration and depth of
penetration is same for
each entry point, but
horizontal distance of the
points of penetration on
the same side of the flap
differs.

6. FIGURE OF 8 SUTURE
Used for extraction socket closure and for
adaption of gingival papilla around the tooth
Suturing begun on buccal surface 3-4mm from
the tip of the papilla so as to prevent tearing of
papilla.
Needle first inserted into the
outer surface of the buccal flap
and then the lingual flap.
Needle again inserted in same
fashion at a horizontal distance
and then both ends tied.

7. SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots
will be inverted or buried, so that the knot
does not lie between the skin margin and
cause inflammation or infection.
To bury the knot, first pass of the needle
should be from within the wound and
through the lower portion of the dermal
layer. Needle then passed through the
dermal layer and emerge through
subcutaneous tissue and knot tied

8.CONTINUOUS SUBCUTICULAR SUTURE
Continuous short lateral
stitches are taken beneath
the epithelial layer of the
skin. The ends of the suture
come out at each end of the
incision and are knotted.
Advantages
 Excellent cosmetic result.

9.PURSE STRING SUTURE
A circular pattern that draws together
the tissue in the path of the suture when
the ends are brought together and tied.

KNOT TYING
Sutured knot has 3 components
1.Loop created by knot
2.Knot itself which is composed
of a number of tight throws
3.Ears which are the cut ends of
the suture

KNOT TYING
Principles of knot tying
 Use the simplest knot that will prevent slippage.
 Tying the knot as small as possible and cutting the
ends of the suture as short as reasonable to
minimize foreign body reaction.
 Avoid friction or sawing
 Avoid damage to suture material
 Avoid excessive tension
 Tying sutures too tightly strangulates the tissue

Maintenance of traction at one end of the
suture after the first loop is thrown, to avoid
loosening of the knot.
Placing the final throw as horizontally as
possible to keep knot flat
Limiting extra throws to the knot, as they do
not add strength to a properly tied knot.

KNOTS
SQUARE KNOT
Formed by wrapping the
suture around the needle
holder once in opposite
directions between the
ties. Atleast 3 ties are
recommended.
Best for gut, silk, cotton
and SS

SURGEON’S KNOT
Formed by 2 throws on the first tie and one
throw in the opposite direction in the second
tie. Recommended for tying polyester suture
materials such as Vicryl and Mersiline

GRANNY’S KNOT
A tie in one direction followed by a tie in
the same direction and a third tie in the
opposite direction to square the knot and
hold it permanently.

SUTURE REMOVAL
Skin wounds regain TS slowly. It can be
removed in 3-10 days when the wound
gained 5%-10% of final TS. Skin sutures on
face removed between 3-5 days. Alternate
sutures removed on 3rd day and remaining
sutures after 2 days.

 Intra oral
- Mucoperiosteal closure (without tension)
5-7 days
- Where there is tension on the suture
eg : Oro-antral fistula- 7-10 days
 Back and legs where cosmesis is less important –
10-14 days.
 Continuous subcuticular can be left for 3-4
weeks without formation of suture tracks
 A good guide is that as soon as they begin to get
loose they should be taken out.

 Suture area is first cleaned with normal saline.
 The suture is grasped with non-tooth dissecting forceps
and lifted above the epithelial surface.
 Scissors are then passed through one loop and then
transected close to the surface to avoid dragging
contaminated suture material through tissues.
 The suture is then pulled out towards incision line to
prevent dehiscence.If suture entrapped in a scab,
application of hydrogen peroxide or saline solution is
necessary.
 If pieces of suture left, infection or granuloma
formation can ensue.

• Possible Complication Of Leaving Suture For
Many Days :
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst

Other Methods of Wound Closure
• Ligating clips
• Skin staples
• Surgical tape
• Surgical adhesives

Mechanical wound closure
devices
Ligating clips :
• can be resorbable or non resorbable.
• Made up of SS,tantalum or titanium or
polydioxanone.
• Designed for the ligation of tubular
structures.

Surgical staples:
• Used for skin closure .
• Made up of SS.
• They are placed uniformly to span
the incision line.
• They have minimal tissue reaction .
• Can be used for routine skin closure
any where in the body.

Advantages
• As the clips do not penetrate skin, yet give
apposition, the cosmetic result is excellent.
• Speed and efficacy of stapling is more
compared to sutures.
• Suturing causes more necrosis than stapling in
myocutaneous flaps.
• Most significant advance is the introduction of
absorbable staples (Lactomer).

• Contra indicated when it is not
possible to maintain atleast 5mm
distance from the stapled skin to the
underlying bone and blood vessels.

SURGICAL TAPE
 Microporous tape is used alone or in conjugation
with skin sutures to decrease tension at the wound
margins.
 The surgical tapes have a backing of viscous rayon
fibers coated with an adhesive copolymer and they
are pervious to sweat but not to blood or purulent
material.
 Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin
margin is prepared with tincture of benzoin to
provide better adhesiveness for tape.
 Used to decrease skin tension on cheek, forehead,
chin.

Advantages
 Minimizes wound dehiscence and allows earlier
suture removal
 Provides continuous support for the wound and
minimizes scar expansion
 Avoids the ordeal of suture replacement and
removal in children
 Less inflammatory reaction, lower rate of wound
infection, greater TS and better cosmetic results.
 No needle puncture marks and suture canals
 Strangulation and necrosis of tissue are eliminated
 Sterile paper tape is non expensive

Disadvantage
 Do not evert edges of the wound, and readily loosen
when wet by blood or serum.
 Prior to placement, a thin coat of antibiotic ointment
is placed on wound margin to protect wound from
skin oils and bacteria.
 While removing, to avoid epithelial margin
separation, the ends should be lifted equally towards
the wound margin and then lifted evenly from the
wound.

Cyanoacrylates
- n-butyl cyanoacrylate is the active ingredient.
Advantages :
 Strong bonding to tissues in presence of moisture
 Biodegradable, bacteriostatic & hemostatic.
 Reduced post operative pain & facilitates healing.
 Good shelf life.
 Produces little or no heat during polymerisation.
 Bonding is by secondary intermolecular forces aided
by mechanical interlocking of irregular forces.

 Quick, atraumatic and cost effective with good cosmesis
 No LA injection, suturing and post-op suture removal.
Disadvantages
1.When applied for skin closure, the polymer acts as barrier,
prevents wound apposition, delays healing, and increases
the infection rate.
2.Should not be allowed to come in contact with tissue
under skin as it causes necrosis.

REFERENCE
• Laskin vol-1
• Textbook of oral & maxillofacial surgery-
Neelima Anil Malik
• Minor Oral Surgery- Goeffrey L.Howe
• Plastic surgery – Mathes.

Suture materials techniques ih

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