Suturing involves using threads or strands to approximate tissue surfaces and wound edges to assist in healing. There are absorbable and non-absorbable suture materials, including catgut, polyglycolic acid, polypropylene, and nylon. Absorbable sutures like polyglycolic acid degrade within 4-6 months by hydrolysis, while non-absorbable sutures like polypropylene must be removed after wound healing. Proper suturing technique includes perpendicular needle entry, equal depth and distance of placement, and avoidance of tension on tissues.

1. Suturing

2. • Suture:- any thread or strand which brings the
opposite surfaces together
• Purpose:
– To replace the tissue layers and wound edges in passive
approximation assisting in healing.
– To limit the size of wound and therefore reduce the
chances of contamination and infection

3. Classification of sutures
• Absorbable and non absorbable
• Polyfilamentous and monofilametous
• Synthetic and natural
• Coated and uncoated

4. • Absorbable suture materials include the original catgut as
well as the newer synthetics polyglycolic acid , polylactic
acid, polydioxanone, and caprolactone.
• They are broken down by various processes
including hydrolysis (polyglycolic acid) and proteolytic
enzymatic degradation.
• Depending on the material, the process can be from ten days
to eight weeks.
• They are used in patients who cannot return for suture
removal, or in internal body tissues.
• In both cases, they will hold the body tissues together long
enough to allow healing, but will disintegrate so that they do
not leave foreign material or require further procedures.
• Occasionally, absorbable sutures can cause inflammation and
be rejected by the body rather than absorbed.

5. • Non-absorbable sutures are made of special silk or the
synthetics polypropylene, polyester or nylon.
• Stainless steel wires are commonly used in orthopedic
surgery and for sternal closure in cardiac surgery.
• These may or may not have coatings to enhance their
performance characteristics.
• Non-absorbable sutures are used either on skin wound
closure, where the sutures can be removed after a few
weeks, or in stressful internal environments where
absorbable sutures will not suffice.
• Non-absorbable sutures often cause
less scarring because they provoke less immune
response, and thus are used where cosmetic outcome
is important.
• They must be removed after a certain time, or left
permanently.

6. • Catgut (rarely used now)
– Derived from sheep intestinal mucosa
– Poor tensile strength
– Poor knot security
– Quickly absorbed within 4-5 days
– High tissue reactivity (absorbed by proteolysis)
• Chromic acid treated catgut (Mild Chromic Gut)
– Tensile strength more than that of cat gut
– Moderate tissue reactivity (absorbed by proteolysis)
– Poor knot security

7. • Polyglycolide or Polyglycolic acid (PGA) is
a biodegradable, thermoplastic polymer and the
simplest linear, aliphatic polyester.
• It can be prepared starting from glycolic acid by means
of poly-condensation or ring-opening polymerization.
• PGA has been known since 1954 as a tough fiber-
forming polymer.
• Owing to its hydrolytic instability, however, its use has
initially been limited.
• Currently polyglycolide and its copolymers(poly-lactic-
co-glycolic acid) with lactic acid, poly(glycolide-co-
caprolactone) with ε-caprolactone, and poly (glycolide-
co-trimethylene carbonate) with trimethylene
carbonate) are widely used as a material for the
synthesis of absorbable sutures and are being
evaluated in the biomedical field.

8. Degradation
• Polyglycolide is characterized by hydrolytic instability
owing to the presence of the ester linkage in its
backbone.
• The degradation process is erosive and appears to take
place in two steps during which the polymer is
converted back to its monomer glycolic acid: first water
diffuses into the amorphous (non-crystalline) regions of
the polymer matrix, cleaving the ester bonds; the
second step starts after the amorphous regions have
been eroded, leaving the crystalline portion of the
polymer susceptible to hydrolytic attack
• Upon collapse of the crystalline regions the polymer
chain dissolves.

9. • When exposed to physiological conditions,
polyglycolide is degraded by random hydrolysis and
apparently it is also broken down by
certain enzymes, especially those with esterase
activity.
• The degradation product, glycolic acid, is non toxic
and it can enter the tricarboxylic acid cycle after
which it is excreted as water and carbon dioxide.
• A part of the glycolic acid is also excreted by urine.
• Studies undergone using polyglycolide-made sutures
have shown that the material loses half of its
strength after two weeks and 100% after four weeks.
• The polymer is completely resorbed by the organism
in a time frame of four to six months.

10. • Polyglactin 910 is coated in order to create a
smoother synthetic absorbable suture that will pass
through tissue readily.
• Coated Polyglactin 910 sutures facilitate:
– Easy tissue passage
– Precise knot placement
– Smooth tie down
– A decreased tendency to irritate tissue
– Greater tensile strength
– A longer absorption period
• After 3 weeks post operation, in clinical trials,
Polyglactin 910 sutures still maintain approximately
50% of their tensile strength.

11. Silk
• Category
– Natural Nonabsorbable
Suture (braided)
• Indications:
– lip skin surgery
– Intraoral surgery
• Advantages
– Best handling and tying of
any Suture Material
• Disadvantages
– Least tensile strength of
any Suture Material
– High tissue reactivity
(similar to Catgut Suture)
– Increases risk of infection
due to high capillarity

12. Nylon
• Category
– Synthetic Nonabsorbable Suture (monofilament)
• Advantages: Good choice for skin closure
– High tensile strength
– Minimal tissue reactivity
– Excellent elasticity
– Low cost
• Disadvantages
– High memory (requires 3 to 4 knot throws to hold)
• Pliabilized ethilon in Alcohol reduces memory
• Absorption (Hydrolyzes in skin at very slow rate)
– Year 1: 89% of tensile strength
– Year 2: 72% of tensile strength
– Year 11: 66% of tensile strength
•

13. • Prolene is a synthetic, monofilament,
nonabsorbable polypropylene suture.
• It is indicated for skin closure and general soft tissue
approximation and ligation.
• Its advantages include high tensile strength, minimal tissue
reactivity, and slipperiness (allowing easy removal from tissues).
• Disadvantages include high plasticity, high expense, and difficulty
of use compared to standard nylon sutures.
• A ball-and-stick model of polypropylene.
• Composed of an isotactic crystalline stereoisomer of
polypropylene, Prolene sutures are intended to be durable and
long lasting.
• They are dyed blue, allowing for easy visibility against skin and
when operating.
• It is composed of a single filament.
• A polypropylene mesh is also marketed under the name Prolene
by Ethicon.
• It is used for repairing hernias and other injuries to the fascia.

15. Needles
• Traumatic needles are needles with holes or eyes which are supplied to the
hospital separate from their suture thread.
• The suture must be threaded on site, as is done when sewing at home.
• Atraumatic needles with sutures comprise an eyeless needle attached to a
specific length of suture thread.
• The suture manufacturer swages the suture thread to the eyeless
atraumatic needle at the factory.
• There are several advantages to having the needle pre-mounted on the
suture.
• The doctor or the nurse or odp does not have to spend time threading the
suture on the needle.
• More importantly, the suture end of a swaged needle is smaller than the
needle body.
• In traumatic needles with eyes, the thread comes out of the needle's hole
on both sides.
• When passing through the tissues, this type of suture rips the tissue to a
certain extent, thus the name traumatic
• . Nearly all modern sutures feature swaged atraumatic needles.

16. Needle point Geometry
Taper-Point
•Suited to soft tissue
•Dilates rather than cuts
Reverse
cutting
•Very sharp
•Ideal for skin
•Cuts rather than dilates
Convention
al 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.

17. Needle Point Geometry
Blunt
•Also known as “Protect Point”
•Mainly used to prevent needle stick
injuries i.e. for abdominal wall closure.
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19. Knots in suturing
• Square knot: two ties are given ,the second throw
being opposite the first throw
• Surgeon’s knot: because of the double throw in the
first tie, this prevents spillage of first tie while 2nd tie
is put in place
• Granny’s knot: this knot involves a tie in one
direction, followed by single tie in same direction, a
third tie squared on the second must be made to
hold the knot permanently

21. Principles of suturing
1. The needle holder should grasp the needle at
approximately 3/4th of the distance from the point.
The suture end of the needle is the weakest area
because either it is hollow, as in swaged needle or
it contains eye. Grasping the suture end might
result in broken needle.
2. The needle should enter the tissue perpendicular
to the surface.
3. The needle should be passed through the tissue
following the curve of the needle. Treating the
curved needle as a straight needle will resut in
tearing of tissues.

22. 4. The suture should be placed equidistance from the
incision on both sides at an equal depth. However in
cases where tissue edges to be sutured at different
levels, passage of suture closer to the edge of lower
side and farther from edge of higher side will tend to
approximate the levels. Another method involves
passage of the suture at an equal distance from
wound margins on both sides but deeper into the
tissue on the lower side and more superficially on
higher side.
5. If one tissue is free and other is fixed then the needle
should pass from free to fixed side.
6. If one tissue side is thinner than the other the needle
should be passed from thinner to thicker side

23. 7. If one tissue plane is deeper than the other then
the needle should pass fromdeeper to superficial
side.
8. The distance that needle is passed into the tissues
should be greater than the distance from the tissue
edge. This will ensure a degree of tissue eversion
which is desirable to counter scar contracture.
9. The tissue should not be closed under tension,
since they will either tear or necrose around the
suture. If tension is present the tissue layer should
be undermined to relieve it.
10. The suture should be tied sa that tissue edged are
merely approximated no blanched.

24. 11. The knot should not be placed over the incision
line.
12. Suture should be placed approximately 3-4mm
apart. If placed too closely they strangulate the
tissue and interfere with escape of inflammatory
exudates. Closer spaced sutures are indicated in
areas of muscular activity such as tongue or areas
of increased tension.
13. Sometimes extra tissue may be present on one
side of incision and cause a dog ear formation
during wound closure. Extending the length of
incision to hide excess will produce an
unsatisfactory result.

25. Techniques of suturing
• Simple interrupted
– Indications
• For a strong closure
• Areas of tension
– Advantages
• Strong
• Successive sutures can be placed in
a manner to fit individual
requirements of the situation
• Each suture is independent of the
other,so loosening of one suture will
not produce loosening of others
• Distance between each suture and
between suture and suture line can
be easily varied
• If the wound become infected,
removal of few selected sutures may
be satisfactory treatment

26. • Simple continuous
– Indications
• Areas of intraoral bone grafting
• Watertight suture
– Contraindications
• Areas of existing tension
– Advantages
• Rapid technique for closure
• Even distribution of tension over
the entire suture line( if
hematoma develops in one area,
remaining sutured area can
provide a degree of slack that will
help relieve the pressure)

27. • Locking continuous
– Indications
– Advantages
• Suture will align itself
perpendicularly to the incision
• The locking fracture prevents
continuous tightening of
suture as wound closure
progress
– Disadvantages
• Excessive tightening of the
individual lock can produce
tissue necrosis
• The locking feature may
prevent adjustment of tension
over the suture line as tissue
swelling occurs

28. • Horizontal mattress
– Indications
• Areas where wound contraction
dehiscence or a broad scar formation
– advantages
• Produces broad contact of wound
margins
– Disadvantages
• Constricts the blood supply to the
edges of the incision, may cause
necrosis and dehiscence

29. • Continuous horizontal
mattress
– Indications
• After intra oral bone grafting as
eversion and continuity provide
a very watertight closure
– Advantages
• Minimally limits the blood
supply to the wound edge
• Does not interfere with wound
healing

30. • Vertical mattress
– Indications
• It is used I neck closures
– Advantages
• Runs parallel to the blood
supply of the edge of
wound, thus doesn’t
interfere with healing

31. • Figure of 8
– Indications
• Used over the extraction
site and protects the
surgical area and adapts
the gingival papillae
around adjacent teeth

32. • Purse string suture
– Indications
• Are usually used in cases of
removal of tumours and cysts
– Rarely given
– In case of oroantral fistula
these sutures are given

33. Suture Removal
Time frame for removing sutures:
Average time frame is 7-10 days
FACE: 4-5 days
BODY & SCALP: 7 days
SOLES, PALMS, BACK OR OVER JOINTS: 10 days
Any suture with pus or signs of infections should be
removed immediately.

34. Suture Removal
1. Clean with hydrogen peroxide to remove any
crusting or dried blood
2. Using the tweezers, grasp the knot and snip
the suture below the knot, close to the skin
3. Pull the suture line through the tissue- in the
direction that keeps the wound closed - and
place on a 4x4

35. Suture Removal
Once all sutures have been removed, count the
sutures
The number of sutures needs to match the
number indicated in the patient's health
record

36. Thank YOU

37. /thesarcasticsurgeon
/thesarcasticsurgeon
@sarcsticsurgeon