SUTURE MATERIALS AND SUTURING TECHNIQUE

Materials required

• Suture set containing bowl, needle holder, scissors, tissue forceps
• Disposable syringe(5-10ml)
• Local anesthetic (xylocaine 2% with or without adrenaline
• Suture material
• Povidone iodine
• Sterile gauze piece
• Sterile gloves
• Sterile eye towel

Skin suturing

• Wound should be closed with minimum tension
• Edges of skin should gape slightly to allow swelling due to inflammation. If wound is closed tightly edge  necrosis may occur
• Needle should be held at a point 2/3rd  from tip of  the needle
• Needles are inserted at right angles to the skin for simple suture using a supination pronation movement of the wrist
• Entry and exit points should be nearly the same distance from the wound edge as the thickness of skin being closed

• The edge of wound is gently lifted with forceps while the needle is inserted
• Edges should be everted slightly. If suture is enters and exits from the skin at an acute angle wound may become inverted with poor healing 
• As the suture is tightened, knot should be drawn to one side to facilitate suture removal
• When a non-absorbable suture is to be removed, it is cut immediately beneath the knot and pulled out by knot. This results in contaminated part of suture  material being lifted away without  being drawn through the wound

• The ends of knot should be left long enough to be easy to grasp while removing yet not too long to get tangled with nearby structures
• As a general rule each suture should be separated by a gap that is twice the  thickness of skin
• Stay sutures should be applied in wounds with curves or zigzags for correct orientation
• Non absorbable skin sutures should be removed when wound has healed to prevent scarring, infection and irritation. It is removed from face after 3-5 days, 5-7 days from scalp, 7 days from back, 10 days from abdomen and 10-14 days from limbs
• Any suture with pus or signs of infections should be removed immediately

Types of wound closure

Simple interrupted– most commonly used, good for shallow wounds without edge tension

Continuous (running sutures)– good for long wounds with minimal tension

Locking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edges

Subcuticular – good for cosmetic results

Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing tension across the wound

Horizontal mattress – good for fragile skin and high tension wounds

Tension suture – for support in wound under very high tension

Classification of suture material

Non-absorbable

• Not biodegradable and permanent
• Tensile strength lasts for more than 60 days
• Nylon
• Prolene(polypropylene)
• Stainless steel
• Silk (natural, can break down over years)

Absorbable

Degraded via inflammatory response

• Vicryl (polyglactin)
• PDS (polydioxanone)
• Chromic Cat gut (natural)

Natural Suture

Biological
Cause inflammatory reaction

• Silk (from silkworm fibers)
• Catgut (connective from cow or sheep)
• Chromic catgut

Synthetic

Synthetic polymers

Do not cause intense inflammatory reaction

• 
  Vicryl
• 
  PDS
• 
  Prolene
• 
  Nylon

Monofilament

• Single strand of suture material
• Minimal tissue trauma
• Smooth tying but more knots needed
• Harder to handle due to memory
• Less chance of infection
• Examples: nylon, prolene, PDS

Multifilament (braided)

• Fibers are braided or twisted together
• More tissue resistance
• Easier to handle
• Fewer knots needed
• More chances of infection
• Examples: vicryl, silk, chromic catgut

Suture Selection

• Do not use dyed sutures on the skin
• Use monofilament on the skin as multifilament harbor BACTERIA
• Non-absorbable cause less scarring but must be removed
• Location and layer, patient factors, strength, healing, site and availability 
• Silk and synthetic sutures are employed most often
• Gut sutures are used only when retrieval is difficult.

Other materials

Metal sutures, clips and staples are available