suturing techniques

1. SUTURE MATERIALS
AND
SUTURING TECHNIQUES
-DR. GOURAV SIWAS
DNB TRAINEE
PLASTIC AND COSMETIC SURGERY

2. CONTENTS
• Introduction
• Definition
• History
• Goals of suturing
• Suture materials
- Requisites of ideal suture
- Classification
- Selection of suture material
- Size of sutures
• Suture armamentarium- needles, needle holder, scissors
• Principles of suturing
• Suturing Techniques
• Knots
• Suture Removal
• Suture marks
• Other methods of wound closure

3.  SUTURE MEANS TO ‘SEW’ OR ‘SEAM’. IN SURGERY
SUTURING 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
APPROXIMATE TISSUES TOGETHER AND TO LIGATE
BLOOD VESSELS.
INTRODUCTION

4.  SUTURE IS A STITCH/SERIES OF STITCHES MADE TO SECURE
APPOSITION OF THE EDGES OF A SURGICAL/TRAUMATIC WOUND.
 SUTURE MATERIAL IS AN ARTIFICIAL FIBER USED TO KEEP WOUND
TOGETHER UNTIL THEY HOLD SUFFICIENTLY WELL BY THEMSELVES
BY NATURAL FIBER(COLLAGEN) WHICH IS SYNTHESIZED AND WOVEN
INTO A STRONGER SCAR.
DEFINITION

5. HISTORY
• THE EARLIEST RECORDS OF SURGICAL SUTURE DATE BACK TO 3500 B.C. IN EGYPT.
THE SCRIPT IS NOW KNOWN AS THE EDWIN SMITH SURGICAL PAPYRUS.
• THE OLDEST PHYSICAL EVIDENCE OF SURGICAL SUTURE DATES TO BETWEE N
500-1000 B.C. EVIDENCED BY SEVERAL MUMMIES WHO HAD BEEN SUTURE D
WHICH WERE FOUND IN EGYPT.
• A SOUTH AMERICAN METHOD OF WOUND CLOSURE USED LARGE BL ACK
ANTS WHICH BITE THE WOUND EDGES TOGETHER AND THE ANTS BODY IS
THEN TWISTED OFF LEAVING THE HEAD IN PLACE.
• THE FIRST DETAILED DESCRIPTION OF A WOUND SUTURE AND SUTURE
MATERIALS USED IN IT IS BY THE INDIAN SURGEON SUSHRUTA, WRITTEN IN
500 BC.
• HIPPOCRATES FIRST USED THE TERM ‘SUTURE’ IN 400 B.C.
• THE FIRST SUTURES WERE FASHIONED FROM HAIR, COTTON, TENDON, OR S ILK.
THEY WERE USED ON NEEDLES MADE OF BONE, STONE, OR WOOD.
• JOSEPH LISTER (1827-1912) DISCOVERED THAT BACTERIA PRESENT IN SUTURE
STRANDS CAUSE WOUND INFECTION. HE DISINFECTED SUTURES WITH CARB OLIC
ACID. HE MADE STERILE SUTURES POSSIBLE TO BURY IT IN CLEAN WOUN DS
WITHOUT INFECTION.

6. GOALS OF SUTURING
 Provide adequate tension
 Maintain hemostasis
 Provide support for tissue margins
 Prevent bone exposure
 Permit proper flap position

7. BASIC REQUISITE OF SUTURE MATERIALS
 High tensile strength
 Good tissue biocompatibility
 Good handling & knotting properties i.e.
Good plasticity (ability to deform)
High pliability (ease of manipulation)
 Low capillarity
 Sterilization without deterioration of properties
 Non allergic, non electrolytic and non carcinogenic
 Low cost

8. Classification of Suture Material
Suture materials are classified on the basis of:
Natural
Synthetic
Metallic
Monofilament
Multifilament
Absorbable
Non- absorbable
Coated
Un-coated
Structure
Source Coating
Fate

9. NATURAL
Absorbable
• Catgut
• Chromic catgut
• Collagen
• Fascia lata
• kangaroo tendon
• Beef tendon
Non Absorbable
• Silk
•Silk worm gut
• Linen
• Cotton
• Ramie
• Horse hair

10. SYNTHETIC
Absorbable
• Polyglycolic Acid
• Polyglactic Acid
• Polyglactin 910(Vicryl)
• Polydioxanone(PDS)
• Polyglecaprone 25
Non Absorbable
• Nylon/ polyamide
• PolyPropylene
• Polyesters
• Polyethelene
• Polybutester
• Polyvinylidene fluoride/
PVDF Sutures

11. Advantages
 Smooth surface
 Less tissue trauma
 No bacterial harbours
 No capillarity
Disadvantages
 Handling and knotting
 Stretch
 Any nick or crimp in the
material leads to breakage.
Absorbable
 Surgical Gut- Plain,
Chromic
 Polydiaxanone
 Polyglactin 910
Non Absorbable
 Polypropylene
 Polyester
 Nylon/polyamide
 Polyvinylidene fluoride /
PVDF Sutures

12. Advantages
 Strength
 Soft and pliable
 Good handling
 Good knotting
Disadvantages
 Bacterial harbors
 Capillary action
 Tissue trauma
Absorbable
 Polyglactin 910
 Polyglycolic Acid
Non Absorbable
 Silk
 Cotton
 Linen
 Nylon

13. Plain Gut / Catgut
 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.
Sub-mucosa 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.
 Unused and reusable catgut is hygroscopic so, catgut will swell due to
water absorption and its tensile strength will be reduced .
ABSORBABLE –NATURAL

14. • It is available pre-sterilized in aluminium-coated sterile foil overwrap
pack with Ethicon fluid as a preservative.
• Color: Plain catgut is yellow
• Absorption: 40-60 days. 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.
• When placed intra orally sutures are digested in 3- 5days.
• Use: Used for ligating superficial blood vessels & subcutaneous
fatty tissues.

15.  Coated with thin layer of chromium salt solution to minimize tissue
reaction, increase Tensile strength, slow the absorption rate, better knot
security, and ease of handling.
 As it is an organic material and susceptible to enzymatic degradation,
packed in isopropyl alcohol as a preservative.
 Absorbs alcohol and swells. It is combustible and is also irritating to
tissues. So, it is removed by a quick rinse in saline prior to use.
 Absorbed in 90 days
 Color: Tan
 Uses : Ophthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues
Chromic Catgut

16.  Natural, absorbable
 Monofilament
 Obtained by homogenous dispersion of pure collagen fibrils
from the flexor tendons of cattle.
 Absorption – 56 days
 Tensile Strength - < 10% after 10 days.
 Used in ophthalmic surgery
 Disadvantage of premature absorption.
Collagen suture

17.  Available in purple and undyed. Undyed used on face.
 Coated with polyglactin 370(copolymer of 90% glycolide & 10%
lactide) and calcium stearate which allows easy passage through
tissues as well as easier knot placement.
 Minimal tissue reactivity and can be used in infected tissues.
 On skin wounds, associated with delayed absorption as well as
increased inflammation.
 Used in general soft tissue approximation, intestinal anastomosis,
vessels ligation in all surgical specialties
Polyglactin 910 (Vicryl)
ABSORBABLE –SYNTHETIC

18. VICRYL–RAPIDE
 It is braided synthetic absorbable suture material.
 Color : 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.
 Use: Low tensile strength and Rapid absorption rate-
-Ideal for intra-oral use (dental surgeries).

19. VICRYL PLUS ANTIBACTERIALSUTURE
 Coated VICRYLPlus Antibacterial suture contains one of the purest forms
of broad-spectrum antibacterial agent triclosan
 Handles and performs same as normal vicryl.
 In vitro studies shown that triclosan on VICRYL Plus creates a zone
of inhibition around the suture.
 Degree of inflammation is less as seenin plain/chromic catgut sutures.

20. POLYGLECAPRONE
 Trade name – “Monocryl”
 It is asynthetic, absorbable suture material made up of co-polymer of 75% glycolide
and 25% epsilon-caprolactone.
 Monofilament
 It undergoes hydrolysis and absorption by 90-120days.
 Minimal tissuereaction.
 It hasgood knotstrength.
 It is the most pliable suture and is used in mucosa and soft tissue closure.

21. POLYDIOXANONE (PDS)
 Synthetic, absorbable, monofilament suture.
 Polyester derivative of poly P-dioxanone.
 Passes through tissues easily.
 Minimal tissue reaction. So, can be easily used in contaminated wounds.
 Significant memory– compromises the ease of knot-tying and knot
security.
 May extrude through the wound over time. So, used only in tissues
deeper than subcuticular layer.
 Absorption – Hydrolysis in 6 months.

22.  Purple/cream homo-polymers of glycolide.
 Avoid in adipose tissue
 Losses tensile strength more rapidly than
vicryl.
Polyglyconic acid (Dexon)
 Dexon and Vicryl, when braided are the strongest of the absorbable
suture materials.

23.  Braided or twisted
 Made from the filament spun by silkworm larva to form its cocoon.
 Dry silk suture is stronger than wet silk suture.
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
Contraindication:
 Should not be used in presence of infection
NON-ABSORBABLE-NATURAL
Surgical Silk

24. Uses:
Plastic surgery, ophthalmic and general surgeries for
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.

25. SURGICAL COTTON
 Natural, multifilament, non absorbable
 From stable Egyptian cotton fibers
 Good knot security
 Not good in presence of contaminated wounds
or infection
 Use: Most body tissues for ligating and suturing
 Rarely used now-a-days.

26. LINEN
 It is also natural, multifilament and non-absorbable suture.
 It is derived from staple flaxfibers.
 Somewhat stronger than cotton but otherwise has similar
characteristics of cotton.
 Tissue reaction is minimal.
 Because of its poor tensile strength, cannot be used for suturing
under tension.

27. 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.
 Not to be used with a prosthesis of another alloy.
 Potential to corrode or break at points of twisting, bending or
knotting.
Uses: Used in abdominal wall and skin closure, sternal closure,
tendon repair, orthopedic and neurosurgery.

28. Major Disadvantages:
 Linear artifacts caused by substances with
high atomic number on CT images
 Possible movement of metal suture during MRI
 Patch test for nickel sensitivity should be
done.

29. NON-ABSORBABLE -SYNTHETIC
 Is a polyamide polymer
 Mono/multifilament.
 Color: Blue
 TS: 81% at 1yr & 66% at 11yrs
 Elicits minimal tissue reaction
 Has good memory
 Pliable when moist
 Pre-moistened form is used plastic & cosmetic surgery
 Its elasticity makes it useful for skin closure & Herniorhapy
Nylon (Ethilon):

30. POL
YPROPYLENE(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. So used for ‘pull-out’
type of sutures.
Uses:
General, plastic, cardiovascular surgery, skin closure,
ophthalmology.

31. Dacron, Mersilene, Ethibond”(polyester) are braided suture materials.
 Composed of polymers of polyethyleneterephthalate.
 Exhibits the greatest tensile strength and knot holding ability of the non-
metallic suture materials.
 Minimal tissue reaction and is unaffected by the presence of an inert coating
or impregnation with silicon or Teflon.
Polyester

32. GORE-TEX
 It isthe most recent material tobeusedassuture material.
 Synthetic, Non-absorbable, Monofilament
 Obtained rom expanded polytetrafluoroethylene (ePTFE)
 Extremely low tissue reaction
 Good knot tensile strength and ease of handling.
 Uses: All type of soft tissue approximation and cardiovascular
surgeries.

33.  New, monofilament, nonabsorbable, synthetic suture
 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.
POLYBUTESTER (NOVOFIL)

34. SUTURE SELECTION
 The condition of the wound,
 The tissues to be repaired,
 The tensile strength of the suture
material
 Knot-holding characteristics of the
suture material
 The reaction of surrounding tissues to
the suture materials.

35. SUTURE SIZES
 Largest size 1 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.
Smaller<------------------------------------->Larger
.....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

36. SIZE OFSUTURES
DIAMETER IN MM
OLD GAUGE(USPD)
8/0 0.05
7/0 0.O7
6/0 0.1
5/0 0.15
4/0 0.2
3/0 0.3
2/0 0.35
0 0.4
1 0.5
2 0.6
3 0.7
4 0.8

37. P
ACKAGING………
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

38. ARMAMENTARIUM FOR SUTURING
 Suture needle
 Needle holder
 Tissue holding forceps
 Suture cutting scissors

39. SUTURE NEEDLE
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 stainless steel or carbon steel.
Needle is selected according to:
-type of tissue to be sutured
-tissue’s accessibility
-diameter of suture material.

40. CLASSIFICATION OF SURGICALNEEDLES
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
5.Others -spatula needles
-micro point needles
-cuticular needles
-plastic needles

42. NEEDLE ANATOMY
• The point is the sharpest portion
and is used to penetrate the tissue.
Shape varies. Delicate!
• The body represents the mid portion of the
needle. Solid Steel. Strongest portion.
• The swage is the portion to which the suture
material is attached. Instrumentation here will
break or weaken the suture.
Term Definition
Chord
The linear distance
between eye and
tip.
Length of needle The distance
between eye and
tip following the
curvature
Radius
The distance of the
body of the needle
from the centre of the
circle
Diameter
Gauge or thickness
of the metal wire
out of which the
needle is made.

43. THE POINT
Point runs from tip to the max. cross sectional area
of the body.
Can be -triangular tip/cutting
-round tip
-blunt tip
Cutting needles are Ideal for suturing keratinized
tissues like skin, palatal mucosa, subcuticular layers
and for securing drains.
Round/tapered needles used for closing mesenchymal
layers such as muscle or fascia that are soft and
easily penetrable

44. The conventional cutting
point has two opposing
cutting edges and third
edge on the inside
curvature of the needle.
The reverse cutting
point has two opposing
cutting edges and third
cutting edge on the
outer curvature of the
needle.

45. The tapered point is used primarily on soft,
easily penetrated tissues . it leaves small hole
and can be used in vascular surgery as well as
fascial soft tissue surgery.
The blunt point has a rounded end which does
not cut through the tissue. It is used in friable
tissue suturing or to the parotid duct or lacrimal
canaliculi.

46. Shapesof suture needles

47. StraightNeedle
¼circle
3/8 circle
½circle
5/8 circle
Needle of choice for the skin
Limited usein oral surgery
May be used in surgery ofthe
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
GTRprocedures
May be used in allsurgical
wounds
Needle of choice in oralsurgery
Wide range of usesin many
surgical wounds
Wounds of the urogenitaltract

48. NEEDLE HOLDER
 The needle holder is used to handle the
suture needle and thread while suturing
the surgical wound.
 Must be made of non corrosive, high
strength good quality steel alloy with
jaws designed for holding the suture
needle securely.
 It may be short or long, broad or
narrow, slotted or flat and concave or
convex.

49. GRIPPING OF NEEDLE HOLDER
The scissor grip
Palm Grip

50. PRINCIPLES OFSUTURING
 Needle grasped at 1/4th to half the distance from the swaged end.
 Needle should enter perpendicular to tissue surface.
 Needle passed along its curve
 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
 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.
 Usually the needle to be passed from mobile side to the fixed side but not
always(exception in lingual mucoperiosteum flap) and from thinner to thicker & from
deeper to superficial flap.
 The tissues should not be closed under tension , since they will either tear or necrose
around the suture

51.  Tie to approximate; not to blanch
 Knot must not lie on incision line
 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.
 Sutures placed at a greater depth than distance from the incision to evert wound
margins
 Close deep wounds in layers
 Avoid retrieving needle by tip
 Adequate tissue bite to prevent tearing
 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

52. SUTURING TECHNIQUES

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

54.  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

55. 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.

56. Advantage
 Rapid technique and distributes tension
uniformly
Disadvantage
If cut at one point, suture slackens along the
whole length of the wound which will then
gape open.

57. CONTINUOUS LOCKING/BLANKET SUTURE
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.

58. VERTICALMATTRESS
 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

59. 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.

60. Advantages :
for better adaptation and maximum tissue approximation
To get eversion of wound margins slightly
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.

61. 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.

62. 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.

63. Advantages:
Will evert mucosal or skin margins, bringing greater
areas of raw tissue into contact.
-So used for closing bony deficiencies such as
antral fistula or cystic cavities, extraction
oro-
socket
wounds.
Prevents the flap from being inverted into the cavity.
To control post-operative hemorrhage from gingiva
around the tooth socket to tense the mucoperiosteum
over the underlying bone.

64. It does not cut through the tissue, so used incase
of tissue under tension (inadequate tissue)
Disadvantages:
More trouble to insert
Constricts the blood supply to the incision if
improperly used, cause wound necrosis and
dehiscence

65. 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.

66. 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

67. 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.

68. Advantages
Excellent cosmetic result
Useful in wounds with strong skin tension,
especially for patients prone to keloid formation.
Anchor suture in wound and, from apex, take
bites below the dermal-epidermal layer
Start next stitch directly opposite the one that
precedes it.

69. 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.

70. KNOTS
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

71. PRINCIPLE OF KNOTTING
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
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.

72. 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
Surgeons 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.

73. SUTURE REMOVAL

74. HOW TO REMOVE SUTURE
 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.

75. POSSIBLE COMPLICATION OF LEAVING SUTURE
FOR MANY DAYS
1.Suture abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst

76. SUTURE MARKS
Suture marks are caused by 3 factors
1. Skin sutures left in place longer than 7 days,
resulting in epithelialisation of suture track
2. Tissue necrosis from sutures that were tied
too tightly or became tight due to tissue edema
3. Use of reactive sutures in the skin.

77. NEW ADVANCEMENTS IN SUTURING
Ligating clips
Skin staples
Surgical tape
Surgical adhesives

78. Ligating clips :
can be resorbable or non resorbable.
Made up of SS or titanium or
pidioxanone.
Designed for the ligation of
tubular structures.

79. 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
anywhere in the body.

81. 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).
Contraindicated when it is notpossible to maintain at least
5mm distance from the stapled skin to the underlying
bone and blood vessels.

82. SURGICAL TAPE / Steri-Strips:
 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.

83. 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

84. 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.

85. Cyanoacrylates
N-butyl cyanoacrylate is the active ingredient.
Advantages :
 Quick, atraumatic and cost effective with good cosmesis
 No injection, suturing and post-op suture removal.
 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 polymerization.
 Bonding is by secondary intermolecular forces aided by
mechanical interlocking of irregular forces.
Disadvantages:
 When applied for skin closure, the polymer acts as barrier, prevents wound apposition,
delays healing, and increases the infection rate.
 Should not be allowed to come in contactwith tissue under skin as it causes necrosis.

86. 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

87. CONCLUSION
 Human body is very delicate & important. When
surgeries are needed to improve our health, it is
very important to select a suitable suture. Today,
we know a lot of biomaterials to select, but is
important to always think of biocompatibility.

88. THANK YOU
THANK YOU