Your high maintenance cosmetic patient wants you to use the
best suture for the prettiest wound. (Yael Shapira)
PRS 1996;98:814
PRS 2001;107:38
The most common complications of wounds in plastic surgery are:
1. tissue reactivity – Significant inflammation reduces the resistance to infection
and delays the onset of wound healing
2. infection
3. dehiscence
in order to achieve good healing with best scarring one should attempt to avoid
these complications.
Factors that affect wound healing process and may predispose or protect
from these complications:
1. Patient factors - age & sex
2. Patient comorbidities - e.g. diabetes mellitus, vasculopathies, steroid use,
connective tissue diseases
4. Wound factors – site & length
5. Suture material – type of suture (absorbable Vs. nonabsorbable, , mono Vs.
multifilament, synthetic Vs. natural), caliber of the suture
6. Suture technique
7. surgeon experience
Of all these factors, only the choice of suture and suturing technique is in the
hands of the surgeon (notwithstanding experience…) .
The considerations when choosing a suture material:
Absorbable Vs. non-absorbable: absorbable sutures do not have to be removed
(advantage in children) but lose their strength with time, sometimes in an
unpredictable manner (e.g. gut)
Natural Vs. synthetic: natural sutures cause inflammatory tissue reaction
(absorbed by proteolysis) while synthetic sutures are absorbed by hydrolysis
and generally cause less tissue reactivity.
Monofilament Vs. multifilament: multi filament/braided sutures are easier to
handle, but can sometimes cause tissue drag, even occasionally sawing through
tissue. In addition, the spaces between the filaments can harbor bacteria.
Monofilaments tend to have significant memory and can be difficult to handle.
Suture caliber: the smaller the suture the weaker its tensile strength is (the more
it tends to tear).
conclusions of the 2001 article “suture material and other factors
associated with tissue reactivity, infection, and wound dehiscence among
plastic surgery outpatients” PRS 2001;107:38:
a multi variant analysis of a 1000 plastic surgery outpatients comparing the
factors mentioned above reached the following results:
age - it has been shown that old age predisposes to tissue reactivity and
infection, while younger ages (25>) predispose to dehiscence, perhaps due to
higher levels of physical activity.
Sex - male sex has a higher risk of tissue reactivity in two layer sutures and
dehiscence in one layer sutures
Wound length – longer wounds are associated with higher rates of tissue
reactivity ( in one layer sutures).
Wound site – wounds in lower limbs are less prone to tissue reactivity, wounds
on the back are prone to dehiscence.
Suture material & technique – the type and caliber of sutures and suturing
technique were not related to any clinically significant extent to short term
postoperative complications.
Surgeon experience – less experienced surgeons have a higher rate of
dehiscence and tissue reactivity.
Conclusions of the 1996 article “comparison of polydeoxanone and
polyglactin 910 in intradermal repair” PRS 1996;98:814:
A prospective clinical study that compared scars of 80 surgical sites sutured
alternately with these two types of sutures.
No statistically significant difference was found between the types of sutures
regarding erythema, induration, scar spread and hypertrophic scarring 5
months and 1 year postoperatively.
Properties of absorbable suture material
Property
Gut
Polyglycolic
Acid
Polyglactin
Polydioxanone
Polytrimethylene
Carbonate
tradename
-
dexon
vicryl
PDS-II
maxon
monocryl
Handling
Fair
Fair-good
Good
Poor
Good
Excellent
filament
multi
Mono/multi
multi
mono
mono
mono
Knot
security
Poor
Fair-good
Fair
Poor
Good
Good
Tensile
strength
Low
proteolysis
at 60-90
days,
unpredicta
ble
High
hydrolysis at
90-120 days
High
hydrolysis at
60-90 days
Moderate
hydrolysis at
180-210 days
High
hydrolysis at
180-210 days
High
Medium
Low
Low
Low
Coefficient
of friction
Poliglecaprone
High
hydrolysis at
90-120 days
Memory
Low
Low
Low
High
Low
Low
Tissue
reactivity
High
Low-moderate
Lowmoderate
Low
Low
Low
Absorption
time (d)
30
90
90
210
180
28
Effective
wound
support (d)
8-9
21
21
60
60
20
Sutures in
mucosal
tissues,
vessel
ligation
Buried sutures
Buried
sutures
Buried sutures in
wounds requiring
longer dermal
support
Buried sutures in
wounds requiring
longer dermal
support
Buried sutures
Low elasticity,
clear or green
Low
elasticity,
clear or
violet
Clear or violet
Clear or green
High elasticity,
clear
Uses
Other
Properties of non-absorbable suture material
Silk
Nylon,
Monofilament
Nylon,
Multifilament
Polyester
Polypropylene
tradename
mersilk
ethilon
nurolon
Mersilene/
ethibond
prolene
Handling
Excellent
Poor
Fair-good
Good
Poor
Good
Knot
security
Excellent
Poor
Fair-good
Good
Poor
Fair-good
Tensile
strength
Low
High
High
High
Moderate
High
Coefficient
of friction
High
Low
High
High
Very Low
Very Low
Memory
Low
High
Medium
Medium
High
Low
Tissue
reactivity
High
Low
Moderate
Lowmoderate
Low
Low
Sutures in
mucosal tissues
or conjunctive or
intertriginous
zones to elevate
or retract tissues
Percutaneous
sutures, buried
sutures if
prolonged dermal
support is needed
Minimal use in
dermatologic
surgery
Properties
Uses
Other
Black
Black, green, or
clear
Polybutester
novafil
Minimal
use in
dermatologic surgery
Percutaneous
sutures, buried
sutures if
prolonged
dermal support
is needed,
running
subcuticular
closures
Percutaneous
sutures, running
subcuticular
closures
Green or
clear
High plasticity,
blue or clear
High elasticity,
blue or clear