1. Suture Materials and
Suturing Techniques
Dr.Adel I. Abdelhady
BDS, MSc, (Eg.), PhD (Eg.,USA)
Oral and Maxillofacial surgery Dept.
College of Dentistry
University of Dammam, KSA
2. Objectives and Outlines
Ideal requirement of suture materials
Type
of Suture materials
Absorbable versus non-absorbable
Natural versus synthetic
Principles of Wound Closure
Surgical Instruments used in suturing
Obtaining Haemostasis
3. Essential suture characteristics
All sutures should be manufactured to assure
several fundamental characteristics, as follows:
Sterility
Uniform diameter and size
Pliability for ease of handling and knot security
Uniform tensile strength by suture type and size
Freedom from irritants or impurities that would
elicit tissue reaction
4. The Ideal Suture Material
Causes minimal tissue injury or tissue reaction
( nonelectrolytic, noncapillary, nonallergenic,
noncarcinogenic)
Easy to handle
Holds securely when knotted (no fraying نسل ثوبor
cutting)
High tensile strength
Favorable absorption profile
Resistant to infection
Can be used in any tissue
Good knot security
Minimal tissue reaction
5. Absorbable
- Progressive loss of mass and/or
volume of suture material; does not correlate
with initial tensile strength
Breaking strength - Limit of tensile strength at
which suture failure occurs
Capillarity - Extent to which absorbed fluid is
transferred along the suture
Elasticity - Measure of the ability of the material
to regain its original form and length after
deformation
Unfriendly to bacteria
6.
Fluid absorption - Ability to take up fluid after
immersion
Knot-pull tensile strength - Breaking strength of
knotted suture material (10-40% weaker after
deformation by knot placement)
Knot strength - Amount of force necessary to cause a
knot to slip (related to the coefficient of static friction and
plasticity of a given material)
Memory - Inherent capability of suture to return to or
maintain its original gross shape (related to elasticity,
plasticity, and diameter)
7.
Nonabsorbable - Surgical suture material that is
relatively unaffected by the biological activities of the
body tissues and is therefore permanent unless removed
Plasticity - Measure of the ability to deform without
breaking and to maintain a new form after relief of the
deforming force
Pliability -ليونةEase of handling of suture material;
ability to adjust knot tension and to secure knots (related
to suture material, filament type, and diameter)
8.
Tensile strength - Measure tissue's ability to resist
deformation and breakage
Wound breaking strength
- Limit of tensile
strength of a healing wound at which
separation of the wound edges occurs
Cheap
11. Suture Material and Structure
Natural versus synthetic
Natural sutures may cause tissue reaction and suture antigenicity
lead to inflammatory reactions
synthetic materials
• less reaction
• less inflammatory reaction
absorbable versus nonabsorbable
nonabsorbable sutures offer longer mechanical
support
Absorbable sutures provide temporary wound support,
until the wound heals well enough to withstand normal
stress
12.
Monofilament versus multifilament
Monofilament suture is made of a single strand
Infection is avoided
This structure is relatively more resistant to harboring
microorganisms. The monofilament sutures exhibit
less resistance to passage through tissue than
multifilament suture.
Multifilament suture is composed of several filaments
twisted or braided together
Multifilament suture generally has greater tensile
strength and better pliability and flexibility than
monofilament suture. This type of suture handles and
ties well. Because multifilament materials have
increased capillarity, the increased absorption of fluid
may act as a tract for the introduction of pathogens
14.
Absorption occurs by enzymatic degradation in
natural materials and by hydrolysis in synthetic
materials.
Hydrolysis causes less tissue reaction than
enzymatic degradation
gut last 4-5 days in terms of tensile strength
chromic form, gut can last up to 3 weeks
Vicryl and Dexon maintain tensile strength for 7-14
days
complete absorption takes several months
15. Types of Suture Materials
Absorbable
catgut, polydioxanone, polyglycolic acid
Used for deep tissues, membranes, &
subcuticular skin closure
Non-Absorbable
polyester, nylon, stainless steel
Used for skin (removed) & some deep
structures (tendons, vessels, nerve repairs –
not removed)
17. Natural or Biological
materials are those derived from naturally occurring
sources such as animal / plant tissues
Advantages
Biological sutures are usually quite economical and
tend to have good handling and knotting
characteristics.
Disadvantages
Because biological materials are identified by the body
as foreign proteins, proteolytic enzymes are produced
which attack the collagen.
The process of attack on the collagen causes localised
cell necrosis in the region of the implanted material.
This is a tissue reaction, which can produce pain and
discomfort in skin tissue.
18. Synthetic
Synthetic materials are man – made, produced by industrial processes.
Advantages
•
Synthetic non-absorbable materials do not elicit tissue reaction as they are
not absorbed.
•
Synthetic absorbable are polymers which resemble sugars in their
chemical structure, therefore they are eliminated easily.
•
Absorption is by hydrolysis, which causes very little tissue reaction.
This is in contrast to the biological group where absorption or suture
breakdown is caused by enzymatic action.
•
Finally, synthetic materials tend to be stronger than their biological
equivalents for similar gauge sizes.
Disadvantages
•
The drawbacks of synthetic material tend to be related to their structure
rather than their chemical composition.
•
They can be more difficult to handle in the monofilament structure and at
times, encapsulation can result in the suture being extruded or expelled by
the body.
19. Non - Absorbable
Advantages
•
Permanent wound Support
Disadvantages
• Foreign body left
•
They can be used to suture
• Suture removal can
tissues which need long term
support, they provide permanent
wound support.
•
For example, prosthetic heart
valve implants must obviously be
held in place by a suture that will
never lose its strength
be costly and
inconvenient
• Sinus & Extrusion if
left in place
20. Non-absorbable Suture
Primarily Skin
Needs to be removed later
Stainless steel = exception
Can be used internally
• Ligature
Can be left in place for long periods
21. Monofilament
Advantages
Disadvantages
Smooth surface
single strand which can be wiry
with a strong material
Less tissue trauma
memory leading to handling
No bacterial harbours
difficulties and a tendency
No capillarity
for knots to unravel
Fluids are unable to
travel along the length of Handling & knotting
a monofilament as is
Ends/knot burial
possible in multifilaments
Stretch Monofilaments tend
because of the spaces
to be more stiff than
between multiple strands.
multifilament materials
22. Multifilament
Advantages
inherently strong
because of their braided
construction
soft and pliable which
provides excellent
handling and knotting
properties
Good handling
Good knotting
Disadvantages
Bacterial harbours
Capillary action
Tissue trauma
23. Monofilament
memory
less tissue drag
doesn’t wick
poor knot security
less tissue reaction
Vs. Multifilament
easy to handle
more tissue drag
wicks/ bacteria
good knot security
more tissue reaction
25.
These natural materials are broken down by the
body after using
Advantages
Main advantage is that no foreign body is left
permanently in the patient which could
precipitate long term problems.
Disadvantages
A suture must provide support to a tissue for as
long as it’s necessary. If the suture absorbs too
quickly, it could lead to wound failure.
26. Catgut / Chromic Gut
Tensile strength for 4-5 days only
high tissue reactivity ,poor tensile
strength for a given suture diameter
monofilament uses: tubal ligation,
ligation of blood vessels
Made of submucosa of small
intestines
Breaks down by phagocytosis:
inflammatory reaction common
27. Gut/ Chromic Gut
Chromic: tanned, lasts
longer, less reactive
Easy handling
Plain: 5 -7days
Chromic: 10-15 days
Bacteria love this stuff!
29. Vicryl (Polyglactin 910)
Braided, synthetic, absorbable
Stronger than gut: retains strength
3
weeks
Broken down by enzymes, not
phagocytosis
Break-down products inhibit bacterial
growth
Can use in contaminated wounds, unlike
other multifilaments
30. Dexon and PGA
Polymer of glycolic acids
Braided, synthetic, absorbable
Broken down by enzymes
Both PGA and dexon have increased
tissue drag, good knot security
Both are stronger than gut
31. NYLON
Synthetic
Surgilon, Ethilon, Dermalon
Mono or Multifilament
Memory
Inert, Very little tissue reaction
Pronounced memory
Poor knot security- lots of knots
Uses- skin closure,
drains fixation
32. Polypropylene
Prolene, Surgilene
Monofilament, Synthetic
Won’t lose tensile strength over time
Good knot security, requires extra knots
Inert, very little tissue reaction
High plasticity - expands to prevent
strangulation, but loosens when edema
subsides (use with steri-strips)
Will stretch when pulled
33. Stainless Steel
Monofilament
Strongest !
Great knot security
Difficult handling
Can cut through tissues
Very little tissue reaction, won’t harbor
bacteria
34. Absorbable Suture
Chromic gut
Tensile strength for 2 to 3 weeks
High tissue reactivity
Poor tensile strength for a given tissue
diameter
Monofilament
35. Absorbable Suture
Dexon, Vicryl, Polysorb
Synthetic polymers with modest tissue reactivity
Tensile strength for 2 to 3 weeks
10% strength at 28 days
Low elasticity - may cut soft tissue
Braided - handle well but wick fluid
Good for subcuticular closure and fascia
36. Absorbable Suture
PDS, Maxon
Monofilament
Delayed absorption
59% strength at 28 days
Minimal tissue reaction
Less suture abscesses and cut through
than vicryl
Complete absorption by 180 days
38. Packaging…
Imperial Gauge
Metric Gauge
Product (re-order) Code
Needle size
& curvature
Needle type
Needle point
Needle profile
Sterilized
Ethylene Oxide
Do Not Re-use
See Instructions
for use
Batch Number
Expiry date
39. Gauge of the suture materials
2 Thick
1
0
00
000
0000
00000 Fine
40. Selection of Sutures Material
Scalp
Oral cavity
Lip
Face
Eyelid
3/0, 4/0
3/0 , 4/0
4/0, 5/0
5/0, 6/0
6/0
41. The Anatomy of a Surgical Needle
Needle Point: Penetration of a needle is dependant on
the point.
Chord Length: The straight line distance from the point
of a curved needle to the swage. .
Swage: This is the area in which the suture is attached to
the needle. The swage area is of specific importance to
the relationship of needle and suture thicknesses. It is
also the weakest point of the needle.
42.
Needle Diameter: The gauge or thickness of the
needle wire. Needle Diameter varies from 30
microns to over 1mm.
Needle Radius: If the curvature of the needle
were to continue to make a full circle, the radius
of the curvature is the distance from the centre
of the circle to the body of the needle. Think of
the needle as part of a circle.
43. Needle Body: Is the portion between point
and swage and is used as the grasping
area.
Needle Arming: The needle should be
grasped in the middle to 1/3 of the
distance from the swage area to the point.
After the needle has penetrated the tissue,
the needle holder can be used to pull the
needle and suture through.
45. Types of Needles
Eyed needles
More Traumatic
Only thread through
once
Eyeless, Swaged-on
needles
Much less traumatic
More expensive suture
material
Sterile
47. Point of the Needles
Round designed to separate
tissue fibres rather than cut
them
traumatic
Internal organs
Cutting,
Atraumatic
Cutting edge on inside of circle
Reverse Cutting
Cutting edge on outside of
circle
Less traumatic than
cutting
48. Cutting Needles
Cutting needles are required whenever dense or
tough tissue is encountered.
CONVENTIONAL CUTTING: needles have the third
cutting edge on the inside curvature of the
needle.
REVERSE CUTTING needles have a cutting edge on
the outer convex curvature of the needle.
Reverse cutting needles are stronger than
conventional cutting needles because of their
different triangular shape.
55. Toothed 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.
56. Smooth or teethed forceps?
Smooth
Hold knots, tying suture or vessels
Tooth (teethed)
Hold tissue
57. Principles of Wound Closure:
1.Equal Bites on each side of the wound
2.Distance between sutures = distance
suture is from wound edge
3.Apposition,Eversion (skin), not inversion of
wound edges vertical mattress sutures
are used in skin surgery to produce
eversion of the wound edges, which
produces a better, cosmetically
acceptable scar.
58. Principles of Wound Closure:
4.Follow curve of Needle, levering causes
damage
5.Approximation not Strangulation : avoid
excessive stitches placed too close
together, be careful of post-op swelling
with running and running locking sutures.
59. Principles of Wound Closure:
6.Principle of Halving: 1st suture placed
centrally.Next suture placed halfway
between end of wound and 1st suture.And
so on.
Avoids mismatch of wound edges with
“Dog Ear”
62. Method of Skin Suture
Simple interrupted
Vertical mattress
Looks bad early
Continuous with lock
Good for thick and thin skin
Horizontal mattress
Good for irregular wounds
Cosmetic demand
Simple running
Quick, for linear wounds
Subcuticular
The knot should be tied
adequately and cause no
blanching
63. Suturing Technique
Atraumatic technique
Avoid crushing with forceps
Avoid sutures and needles unnecessarily
large
Avoid bites of tissue unnecessarily large
Avoid strangulation with knots too tight
Avoid drying of tissues
65. Vertical Mattress:
Definition: Far-Far
Reverse, Near-Near
Purpose: Everts skin edges
with precise
approximation and little
tension
Uses: Any setting where
you want good approx.
with no tissue ischemia
66. Simple Interrupted vs. Vertical Mattress
This suture is best used
in creases & areas of
natural inversion
71. Important points to think about
Tightly tied sutures can cause ischemia & wound edge
necrosis.Gentle but firm knots & minimal wound
tension will minimize these factors.
Remember, keep skin edges everted, NOT inverted!
77. How many knots?
With a
braided material, such as silk, a
3rd throw (replicating the first) would be
placed to secure the knot.
If a slippery monofilament material,
such as nylon were being used, one
would place 5 or 6 throws of alternating
construction in order to minimize knot
slippage.
78. KNOT TYING
Is it really all that important?
A patient’s life may depend on the security
of one ligature. Slippage of a tie may
result in a life-threatening hemorrhage.
79. Cutting Sutures
With skin sutures, leave
3-4mm tail.
Tail = amount of suture left above knot
Tail is left because it helps prevent loosening
or undoing of sutures.
Buried sutures are left within the body.
Cut the suture on the knot, leaving
behind.
no tail
80. Placement of Dermal Sutures
Note that the knot is buried in the depth of the wound
and the suture is in the dermis not fat
82. Skin Staples
Very common in human medicine
Expensive
Very easy
Very secure
Very little tissue reaction
Removal =
Special tool required