Suture material & suturing technique

GOALS OF SUTURING
Wound edge apposition.
Provide adequate tension.
Maintain hemostasis.
Aid in wound healing.
Avoid wound infection.
Produce aesthetically pleasing scar by approximating skin edges.

CLASSIFICATION OF SUTURE
MATERIALS According to source
NATURAL SYNTHETIC
Absorbable
• Catgut
• Chromic catgut
• Collagen
• Fascia lata
• kangaroo tendon
• Beef tendon
• Cargile
membrane
Non Absorbable
• Silk
• Silk worm gut
• Linen
• Cotton
• Ramie
• Horse hair
Absorbable
• Polyglycolic Acid
• Polyglactic Acid
• Polyglactin 910(Vicryl)
• Polydioxanone(PDS)
• Polyglecaprone 25
• Non Absorbable
• Nylon/ polyamide
• PolyPropylene
• Polyesters
• Polyethelene
• Polybutester
• Polyvinylidene fluoride
/ PVDF Sutures

CLASSIFICATION OF SUTURE
MATERIALS According To Structure
MONOFILAMENT MULTI FILAMENT
Advantages
Smooth surface
Less tissue trauma
No bacterial harbors
No capillarity
Disadvantages
Handling and knotting
Stretch
Any nick or crimp in the
material leads to
breakage.
Advantages
Strength
Soft and pliable
Good handling
Good knotting
Disadvantages
Bacterial harbors
Capillary action
Tissue trauma

CLASSIFICATION OF SURGICAL
NEEDLES
ACCORDING TO EYE
• Eye less needle
• Needle with eye
ACCORDING TO SHAPE
• Straight
• curved
ACCORDING TO CUTTING EDGE
• Round
• Conventional cutting
• Reverse cutting
ACCORDIND TO ITS TIP
• Triangular
• Round
• blunt
OTHER
• Plastic needle
• Micro point needle
• Cuticular needle
• Spatula needle

IDEAL PROPERTIES OF NEEDLES
• High quality stainless steel
• Smallest diameter possible
• Capable of implanting sutures with minimal trauma to tissues.
• Stable in the needle holder
• Should be sharp.
• Sterile and corrosion resistant.

BODY OF NEEDLE
•Body is the widest portion of the needle
•It is known as grasping area.
•Most commonly used are 3/8 circle. They can be
easily manipulated in large and superficial wounds
and require only less wrist movement.
•1/2 circle used for suturing tissues in small wounds,
and body cavities and orifices. Require less space,
but more supination and pronation of wrist.
•5/8 used in oral cavity.

SUTURE SIZES
•Largest size 1-0 to extremely fine 11-0.
•Increasing number of zeros correlates with decreasing
suture diameter and strength.
•Thicker sutures approximation of deeper layers, wounds in tension prone areas and ligation
of blood vessels.
•Thin sutures 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.

SUTURE Package
Needle SHAPE
Name
Size
NEEDLE TIP

THE POINT
•Point runs from tip to the maximum 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

THE POINT
•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.
• 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 facial 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.

NEEDLES TIPS
Cylindrical needle with rounded tip. Needle with triangular tip and three
cutting edges.
Reverse cutting needle: the third cutting
edge is on the back of the needle, which
helps to reduce tissue trauma.

THE EYE OF THE NEEDLE
The eye can be
Shape of the eye may be - round
Open French-eye needle is easy to load with varying caliber, but has additional bulk.
Eyed require threading prior to use, results in pulling a double strand through tissue.
Tying the suture to the eye increases bulk of suture material drawn through tissues.
So they are also called ‘traumatic needles’.
Most suture materials and needles are difficult to sterilize.
Needles are also difficult to clean after use and become blunt and work hardened so that they snap
- closed
- swaged
- chanelled/drilled
- oblong
- square

NEEDLE
Cylindrical attachment between needle and thread:
the step between needle and thread is dearly visible.
Electron-microscopic image
showing the importance of
the congruity between needle
and thread. After the needle
has passed through the
tissue. the space is almost
entirely filled by the thread.
If the diameter of the needle
is markedly greater than that
of the thread, there is a gap
between tissue and thread
which may cause problems
with healing.

PRINCIPLES OF SUTURE
SELECTION
The selection of suture material by a surgeon must be based on a sound knowledge of :
Healing characteristics of the tissues which are to be approximated
 The physical and biological properties of the suture materials
 The condition of the wound to be closed and
 The probable post-operative course of the patient.

Gut/ Chromic Gut
Chromic: tanned, lasts longer, less reactive
Easy handling
Plain: 3-5 days
Chromic: 10-15 days
Bacteria love this stuff!

SILK
Braided or twisted
Made from the filament spun by silkworm larva to form its cocoon.
Processed to remove the natural waxes and gum.
After braiding, the strands are dyed, stretched and impregnated with a
mixture of waxes and silicone.
Dry silk suture is stronger than wet silk suture.

Collagen SUTURE
Natural, absorbable, monofilament
Obtained by homogenous dispersion of pure collagen fibrils
from the flexor tendons of cattle.
Absorption – 56 days
TS < 10% after 10 days.
Used in ophthalmic surgery
Disadvantage premature absorption.

Vicryl (Polyglactin 910)
Braided, synthetic, absorbable
Stronger than gut: retains strength 3 weeks
Broken down by enzymes, not phagocytosis and be Absorbed at 56-70 days
Break-down products inhibit bacterial growth Can use in contaminated
wounds, unlike other multifilaments
Minimal tissue reactivity and can be used in infected tissues
Available in purple and undyed (Undyed face).
Coated with polyglactin 370 and calcium stearate which allows easy passage
through tissues as well as easier knot placement.
On skin wounds, associated with delayed absorption as
well as increased inflammation.

Dexon and PGA
Polymer of glycolic acids with greater knot pull and TS than gut.
Braided, synthetic, absorbable
Broken down by enzymes which results in minimal tissue reactivity.
dexon have increased tissue drag, good knot security
Does not tolerate wound infection and not percutaneous suture.

SURGICAL COTTON
Natural, multifilament, non absorbable
From stable Egyptian cotton fibers
Good knot security
Not good in presence of contaminated wounds or infection
Rarely used nowadays
Uses:
Most body tissues for ligating and suturing SURGICAL COTTON

GLYCOLIC ACID (MAXON)
POLYGLYCONATE
Monofilament- memory Synthetic ,Absorbable & Very little tissue
drag.
Polyglycolic acid and trimethylene carbonate
TS : 14-21 days (>Dexon)
Absorption : Hydrolysis in 180 days
Degradation products of polyglycolic acid and nylon sutures : glycolic
acid, 1,6-hexane diamine and adipic acid are antibacterial agents.
Poor knot security and Very strong

PDS II (polydioxanone)
Monofilament (less drag, worse knot security – lots of “memory”)
Synthetic, absorbable
Very good tensile strength (better than gut, vicryl, dexon) which lasts months
Absorbed completely by 182 days

NYLON
Synthetic
Mono or Multifilament
Memory
Very little tissue reaction
Poor knot security

Polymerized Caprolactam
Vetafil, Braunamid, Supramid
Multifilament suture with protein coating
Synthetic
Good knot security, easy handling
Not very reactive
Don’t use in contaminated wound
Usually comes on a reel

Polypropylene
Prolene, Surgilene
Monofilament, Synthetic
Won’t lose tensile strength over time
Good knot security
Very little tissue reaction

Stainless Steel
Monofilament
Strongest !
Great knot security
Difficult handling
Can cut through tissues
Very little tissue reaction, won’t harbor bacteria

Anesthetic Solutions
CAUTIONS: due to its vasoconstriction properties never use Lidocaine with
epinephrine on:
◦ Eyes, Ears, Nose
◦ Fingers
Lidocaine (Xylocaine®)
◦ Most commonly used
◦ Rapid onset
◦ Strength: 0.5%, 1.0%, & 2.0%
◦ Maximum dose:
◦ 5 mg / kg, or
Lidocaine (Xylocaine®) with epinephrine
◦ Vasoconstriction
◦ Decreased bleeding
◦ Prolongs duration
◦ Maximum individual dose:
◦ 7mg/kg

Anesthetic Solutions
BUPIVACAINE:
◦ Slow onset
◦ Long duration
◦ Strength: 0.25%
◦ DOSE: maximum individual dose 3mg/kg

Injection Techniques
Check for allergies
Insert the needle at the inner wound edge
Aspirate
Inject agent into tissue SLOWLY
Wait…
After anesthesia has taken effect, suturing
may begin

Wound Evaluation
Time of incident
Size of wound
Depth of wound
Tendon / nerve involvement
Bleeding at site

When to Refer
 Deep wounds of hands or feet, or unknown depth of penetration
 Full thickness lacerations of eyelids, lips or ears
 Injuries involving nerves, larger arteries, bones, joints or tendons
 Crush injuries
 Markedly contaminated wounds requiring drainage

Contraindications to Suturing
• Redness
• Edema of the wound margins
• Infection
• Fever
• Puncture wounds
• Animal bites
• Tendon, nerve, or vessel involvement
• Wound more than 12 hours old (body) and 24 hrs (face)

Wound Preparation
Most important step for reducing the risk of wound infection.
Remove all contaminants and devitalized tissue before wound closure.
◦ IRRIGATE w/ NS or TAP WATER (AVOID H2O2)
◦ CUT OUT DEAD, FRAGMENTED TISSUE
If not, the risk of infection and of a cosmetically poor scar are greatly increased
Personal Precautions

Principles And Techniques
Minimize trauma in skin handling
Gentle apposition with slight eversion of
wound edges
◦ Visualization
Make yourself comfortable
◦ Adjust the chair and the light
Change the laceration
◦ Debride crushed tissue

Wound antisepsis and sterile
technique
It is rarely necessary to remove significant quantities of body hair prior to repair of a simple
laceration. In fact, razor removal of hair has been shown to damage surface skin follicles and lead
to increased rates of wound infection. Occasionally, for repair of scalp lacerations, for example,
scissor trimming will allow for easier identification of wound margins and will facilitate later
wound care. Due to inconsistent regrowth of eyebrow hair, it should never be shaved when
repairing lacerations in that area.
Actual preparation of the wound involves cleansing and debridement. The ideal wound cleanser
should have broad antimicrobial activity, but should not delay healing or reduce tissue resistance
to infection. There is controversy about the potentially adverse effects of the readily available
skin cleansing antiseptic solutions when introduced directly into the wound. What is certain,
however, is that 0.9% normal saline is a very effective and non-toxic irrigating solution.
Therefore, 0.9% normal saline should be used as the final solution when cleaning a wound and
one should minimize spillage of other solutions into the wound during preparation.

Wound antisepsis and sterile
technique
Wound irrigation is a form of mechanical wound cleansing that is known to effectively remove
bacteria and other debris. A 10 c.c. or 20 c.c. syringe can be fitted with a commercially available
splash cover, and the wound can then be irrigated with either normal saline or Ringer's lactate.
These solutions are used because they do not irritate body tissues. Following irrigation,
remaining debris and devitalized tissue can be removed with fine forceps or with a scalpel.
Ensuring sterile technique while repairing a wound is, perhaps, the most difficult concept for the
inexperienced person to grasp. A break in sterile technique, with contamination of the field, is a
common procedural error. It leads to an increased incidence of wound infection and breakdown.

Instruments for use in surgery
procedures
Castroviejo needle holder
modified by Simion. Detail of
the handle.
Mayo needle
holder.
Sharp tipped
scissors.
Blunt tipped
scissors.

Gripping needle holders and
scissors
The scissors grip, as shown in the photograph, enables the needle holder to
be guided very precisely in the anterior part of the mouth and in areas of
easy access. The instrument is stabilized with the index finger that guides the
tip of the needle holder.
Scissors may be gripped in a similar way, taking care to keep the index
finger dose to the junction between the two blades, so as to guide the
instrument and avoid acaaenta/ harm.

The interrupted suture
The first step consists of
passing the needle through
the first flap from the outside
inwards. Where there is one
free flap and one fixed flap,
the needle should pass first
through the free flap
The needle then pierces the
second flap from the inside
outwards. Approximately the
same penetration distance of
the flap must be maintained so
as to avoid asymmetry between
the two flaps, which might
compromise the esthetic
results.
The depth of penetration and thus
the distance from the margin,
must be evaluated for each
specific case. With healthy
tissues, this is generally 1.5-2 mm
from the free margin, while in
more fragile tissues the distance
may be increased. It is good
practice in any case not to take
this stitch too deep, as it can
constrict smaller blood vessels.
The single detached stitch is
dosed with a full surgeon 5
knot, which should not be
placed on the line of the
incision but
lateral to it.

The full surgeon s knot
When the suture is completed (in the case illustrated,
this is a single stitch), the full surgeon 5 knot begins.
This knot should be made as follows: the thread is
passed around the tip of the needle holder making a
loop in the clockwise direction.
This is then repeated, so that there are two loops around the tip of
the needle holder. It is this step that differentiates the different
types of surgical knots: the number of loops that are made around
the needle holder (single, double or triple).

A frequent error is applying traction to tighten the knot holding the thread at a distance from the
center oft he knot. If this is done, its impossible to control tension and precision is lost ; there is also a
risk of lacerating the flap. It is equally important to ensure that the thread has been pulled right
through and the knot is tightening where desired Especially when using thread with poor gliding
capabilities for example natural multifilament it will not be possible to tighten the knot correctly with
subsequent maneuvers and its clinical utility will therefore be reduced or lost entirely. During this
phase, it is important to check that the flaps have been properly approached, without superimposition
or Invagination.
The two ends of the thread are then pulled outwards, trying to maintain a
constant pressure on them. From the technical standpoint it is important
to grasp the proximal ends of the thread, that is those closest to the knot,
using the needle holder and forceps or fingers.

The knot must be positioned on one of the flaps, lateral to
the line of the incision.
After having tightened the first half knoct the next step is to
secure the knot
Another loop of thread is passed around the tip of the needle holder, but this
time in the anticlockwise direction. The further subdivision of surgical knots
depends on this
phase, that is on how many loops are made around the tip of the needle
holder (single or double) and what is the alternation (clockwise/anti-
clockwise) they are given

As described above, the two ends of the knot are tightened This step gives
security and stability to the knot and stops it from coming undone. The
intrinsic characteristics of the thread determine the type and number of
steps required to achieve security.
When, based on the type of thread used, the surgeon judges that good stability
has been ensured, the operation is concluded If this procedure is repeated
several times, security increases but, at the same time, so does the size of the
knot. The correct balance must be achieved for each
individual suture.

The simple or spiral continuous suture
technique
The starting point,
common to all continuous
sutures in this family is
the single stitch with a
surgeon's knot.
After having cut only the
short end of the thread the
needle enters the first flap,
which in actual clinical
situations is generally the
free or apical flap, at about
1.5-2 mm from the free
margin.
After passing across the free space
between the two flaps, the needle
pierces the second flap from inside
outwards, the aim being to exit at a
distance of 1.5-2 mm. Inreal clinical
situations, this willbe the fixed or
coronal flap. By piercing the flaps
individually and not with one single
movement, the stitch can be placed
more precisely and a correct design
can be given to the suture.
The needle is passed externally
ta the flap, it describes a loop
and is turned through 180 . The
purpose of this maneuver is to
enable the needle to pierce the
first flap again.

technique
As described above, if the needle is taken through both flaps at the same time, the
precision of symmetry of the suture is reduced, which is not advisable. The figure
shows the two flaps being pierced in a single movement simply to avoid an
excessive number of diagrams. The reader Will please take the technical indications
given here into account.
After repeating this step, with the help of surgical forceps- the surgeon applies
traction to the end of the thread so as to make the tension uniform throughout the
suture and avoid areas where the thread remains loose.

technique
The needle and thread are again passed external to the wound, and having inverted the
direction of the needle by 180 degree , the first and second flaps are again pierced
separately. The correct design of this suture can be evaluated after having placed at least
three consecutive stitches. Ideally , all the entry holes in the free flap and all the exit holes
in the fixed flap lie along two imaginary parallel lines. These two lines should also be parallel
to the line of the incision and equidistant from it.
The axis of the portion of thread lying external to the flaps, which joins the two ideal lines
must not be perpendicular to the margin of the incision, but at 45° or 135 ° This inclination
provides a slight repositioning effect to the flap, in the first case with slight traction mesially
and in the second case distally. The arrangement of the simple continuous spiral suture
performed according to these principles guarantees the uniform distribution of forces along
the entire line of the incision. Obviously at each step the thread must be pulled through
carefully using surgical forceps on the long end of thread

technique
The steps described are
repeated until the entire
length of the flaps involved
is covered and protected by
the suture.
The long end is now held
with the surgical forceps
without pulling the last
portion of thread completely
through leaving the last loop
loose, dearly visible and
accessible.
With the long end a first
loop is made around the
tip of the needle holder to
begin a three-end surgical
knot.
The thread is passed around
the tip of the needle holder a
second time, and the tip of
the needle holder is aimed
towards the loop that was left
loose at the end of the spiral
suture.

technique
This loop is now grasped firmly
between the jaws of the needle
holder and, taking care to pull the
ends in opposite directions in the
correct manner, the procedure to
tighten the knot is begun.
The ends of thread are pulled through
until the knot is properly positioned A
series of half knots may now be tied in
alternating directions to provide the
suture with stability. One knot is
generally enough, and avoids producing
an excessively voluminous knot.
This is the appearance of the simple
continuous suture or spiral suture at
completion. For reasons of clarity we have
left the ends of the thread rather long,
whereas in clinical practice they should be
shortened (1.5 mm). The knot should be
positioned lateral to the line of incision and
not on the line.

The locked continuous suture
This stitch must be
positioned at one of the two
ends of the incision line. In
clinical practice, this is the
most distal end, because
technically it is easier to
work from distal to mesial.
The second stitch enters the
free flap from the outside
inwards, and the needle
emerges in the free space
between the two flaps.
Maintaining perpendicular axis
with regard to the incision line,
the needle enters the second
flap from the inside and passes
outwards.
Having passed through the second
flap, the needle is now turned and
moved backwards so that it can
pass beneath the loop formed by
the thread, situated external to
the planes to be sutured This step
differentiates the continuous
locked suture from the continuous
spiral suture.

Using the needle holder and
forceps, the surgeon must pull
the thread through
completely to provide
constant and correct tension,
so as not to leave any areas
with a poor seal.
The third stitch begins exactly
as the second and is its
continuation.
Again a loop is formed that
will later be pulled back in to
block the suture.
The needle again passes
beneath the second loop to
lock the suture.

Using the needle holder, a certain
tension is given to the thread, as
was done at the first step. Only in
this way can the surgeon approach
the flaps properly, and be sure to
pull the thread through completely.
At each step this must be repeated:
it cannot be left until the end of
the procedure- as the final result
would be unstable.
The final anchorage stitch
begins in the usual way, with
the needle passing through
the two flops. For simplicity of
presentation, the diagram
shows the needle passing
through both flops together,
but in reality it should be
passed through one flop at a
time, as described earlier.
Initially the needle holder can be
passed inside the lost loop to
check that the tension of the
suture is properly uniform. At the
some time the surgeon must
apply traction to the long end
(that attached to the needle) with
a pair of forceps, while the tip of
the needle holder holds the lost
loop tight
After having removed the
needle holder from the loop,
the surgeon's knot is begun;
this requires the long end of
the thread to be wound around
the tip of the needle holder
twice.

The technique continues exactly as
described for the full surgeons knot
associated with the single stitch.
The tip of the needle holder is now
aimed towards the last remaining
loop, which it grasps.
With the needle holder. the
loop, which is treated as a
"double short end'; is now
grasped, and the suture is
tightened
This knot may be secured following
the classic procedures described for
securing the full surgeons knot, that
is by making a series of half-knots in
clockwise and anticlockwise
directions alternately. In this case
too, the number of half knots
should be reduced to the minimum
so as not to make the knot
excessively voluminous.
This is the appearance of the
finished locked continuous suture.
In clinical practice the ends of the
knot wilI be shortened and the
knot will be given a lateral
position with regard to the
incision line.

The locked and secured
continuous suture
The difference between these
two techniques lies in the
positioning of surgeon s knots
along the line of the suture.
Instead of waiting until the
suture is completed before
placing a surgeons knot, in this
case knots are tied at intervals
along the line of the suture.
Only the short end of the
thread is cut off short for the
knots situated at intermediate
positions along the line of the
suture. The thread should be
cut fairly short (1-2 mm) to
decrease the patient's post-
operative discomfort.
The knot along the suture line is
placed so as to subdivide the
suture into smaller portions,
minimizing the risk of the
suture opening completely
should a part of it give way
Technically, this suture is
performed by repeating the
phases described above. After
positioning each surgeon's knot,
suturing is continued in the same
manner.

The locked and secured
continuous suture
At each step, the needle and
thread pass through the loop,
taking care to pull the ends
through properly so as to
maintain constant tension on the
thread and, in consequence, on
the flaps.
To optimize this step, the surgeon
may employ both the
needle holder and appropriate
surgical forceps.
The steps described above are
repeated until the end of the
incision line is reached For
preference, the needle is passed
through the two flaps separately.
A full surgeon's knot is then tied,
and secured with half knots,
clockwise and anti clockwise, to
provide stability to the locked and
secured continuous suture.
Appearance of the locked and secured continuous suture on completion.

The external horizontal mattress
suture
The technique entails
piercing the first flap from
the external mucosa side,
at approximately 3 mm
from the incision line.
The needle passes across
the free space between the
two flaps and pierces the
second flap, attempting to
maintain the same distance
from the incision line.
Identical distances from the
wound margins ensure
uniform traction on the two
juxtaposed flaps
The needle is turned on a
plane parallel to that of the
free margin of the flap, and
pierces the second flap from
the mucosa side inwards. The
optimal distance from the
exit hole is approximately 2-3
mm, so as not to open the
'V“ shape of this suture
excessively
Lastly, the needle pierces the
first flap from the inside
outwards, seeking to emerge
at the same distance from
the margin of the incision
and parallel to the
first passage of the thread

suture
The proper horizontal "U“
shape of this suture can
easily be recognized
A full surgeon 5 knot is now
begun; this will seal the
suture in a conventional
manner.
Two clockwise loops are
made with the long end of
the thread around the tip of
the needle holder, the
long and short ends of thread
are pulled simultaneously,
closing the wound.
The ends are pulled in
opposite directions, taking
care always to grasp them
close to the knot, and
not at a distance.

suture
The horizontal mattress suture in section: the moderate introflection
(apicalizing) of the suture and its coronal gap may be seen.
If properly tied, the full surgeon's knot provides stability to this suture/
however, the most coronal portion is not completely dosed

The buried horizontal mattress
suture
The buried horizontal mattress suture has only a slight extroflecting action on the flaps, but holds together large surfaces
starting from the deeper planes. Since these sutures will remain in situ resorbable thread must be used.
The needle pierces the first flap on its inner face and comes out in the space
between the two flaps. The deeper this initial stitch is placed, the greater will be
the extroflection of the flaps, but also the coronal gaping will be more
pronounced If the entrance of this stitch is kept at approximately 2 mm from the
external margin the extroflecting action will be moderate, but the coronal
gaping will be minimal.
The thread is pulled through the first flop and the second flop is extroflected
with forceps, to enable it to be pierced.

suture
The needle must enter the second
flop at approximately the some depth
as the exit hole from the first flop.
This is necessary to give a correct
plane to the suture with regard to the
line of the incision and so as not to
create internal traction. Needle and
thread do not pierce the external side
of the flops, but remain within the
tissues throughout the entire
procedure.
The thread is again pulled
through the second flop
to enable proper visual
control,
The needle is turned and the second
flap is again pierced The entrance
hole is situated at the same depth as
the exit hole so that the two form a
single plane parallel to the plane of
the line of the incision. The distance
between these two holes affects the
extroflection of the flaps: a greater
distance produces more accentuated
extroflection.
The needle and thread now
pierce the first flap for the
second time. In this case, too,
the entrance hole of the first
step and the exit hole of the
last step are on a plane
parallel to that of the wound
The thread
remains intramural.

suture
The portion of flap pierced by the
needle and thread must be at least I
mm for each of the four steps
performed Otherwise the amount of
tissue embraced by the thread is too
little and it may lacerate. For buried
sutures. this is a serious risk since it
may cause laceration at a depth where
any bleeding is only later apparent,
with negative repercussions on the
healing process.
The surgeon s knot is started,
taking care to position
forceps and needle holder very
dose to the knot This is to
ensure that the knot is situated
deep within the tissues.
After a final careful check, the
knot is tightened
Holding the surgeons knot up with
forceps, that is trying delicately to
extroflect it from the wound for
better visibility, the ends are cut off
as short as
possible.

suture
A section view from above shows the steps that have been performed and the proper
position of needle and thread with regard to the thickness of the flaps. The first flap is pierced
at 2 mm from the free margin, and after the needle has traveled approximately 2 mm inside
that flap, its brought out with a rotary movement With regard to the free margin of the flap, a
depth of about 4 mm is reached The needle and thread leave the tissue to pass across the
free space between the two flaps. The second flap is pierced at a depth of approximately
4mm; the needle runs in the apico-coronal direction and emerges 2 mm from the free
margin. This pathway is again completely intramural. After re-emerging the needle follows a
path parallel to the free margin of the wound and again enters the second flap in the corona-
apical direction. This intramural pathway is parallel to that just described but runs in the
opposite direction. The needle is made to rotate and pierces the first flap at approximately 4
mm from its free margin, emerging again at 2mm. Thus the thread has intramural portions
and portions that lie between the two flaps that it is employed to stabilize. The amount of
tissue engaged by the intramural stretches of the thread is crucial both for a proper seal and
for proper positioning of the flap. If the intramural portion is too deep, correct repositioning
will not be achieved; on the contrary, ifit is too superficial there is a risk of erosion of the
suture and the seal will be poor or lacking, with consequent dehiscence. The tissue embraced
by the suture in its intramural portions must be at least 1 mm.

suture
The tension exercised on the ends of the threads with needle holder and forceps
in dosing the wound must be gradual and continuous. The instruments used must
be placed in the immediate vicinity of the ends to avoid lacerating the internal
portions of the flaps.
The entire suture is completely buried las/de the flaps and will not be accessible from the
outside. Thus the threads must be cut off very short to avoid excess material having to be
resorbed unnecessarily. The coronal part gapes open, which is unfavorable in the oral
environment

The buried vertical mattress
suture
The buried vertical mattress suture is derived from dermatological surgery, and produces an extroflecting action that can be
modulated depending on the position of the knot.
There are several different variants of the buried vertical mattress suture, and these differ in the final
position of the knot on the internal plane, the degree of extroflection of the flaps, and the amount of
tissue embraced by the suture. We will describe the two most widely-used techniques to modify the
final position of the knot. The first variant concludes With a more superficial knot. The first flap is
therefore pierced by the needle and thread at a depth approximately 4-6 mm from the free margin in
its internal portion. The path is intramural.
The thread is pulled gently through the first flap, taking care that the intramural portion
embraced by the thread is sufficient to avoid laceration.

suture
The needle pierces the second flap,
again from its internal side, in the
apico-coronat direction at about 4-6
mm from its free margin.
The thread is pulled through taking
care to check that it engages
correctly in the depth of the flap.
The needle again pierces the second flap
from the inside in a more coronal position
taking care to come out at least 7-7.5 mm
from the free margin. A variant of the
buried vertical mattress suture avoids this
step, concluding with the step described
above.

suture
The path followed by the thread thus comprises two intramural passages and one extramural
passage that, although not within the tissue, is within the flap. There is a technique for
performing these buried mattress sutures. which we will not describe in detail, in which the
needle enters and leaves the tissues with a single movement In other words, the needle and
thread describe a half circle within the tissue of the second flap with a single point of
entrance and a single exit point In this case the path of the suture maintains the apico-
corona! direction, but the pathway is entirely intramural. This variant is quicker to perform
and in many clinical situations it is easier, but it is also less secure. In the variant we have
described there are two buried anchorage points on each side, and thus four in all,-in the
other variant there are only two. This means that in the first case, should an intramural
stretch of the suture give way, there are three others that can replace it, whereas in the other
variant this would not be the case. Since the greatest risk in all buried sutures is late
recognition of their having given way, the recommended technique is preferable in all
conditions where it is possible to employ it

suture
The needle is turned and
engages the first flap apical of
the entrance hole, taking care
to remain at a minimum
distance of 1 .5 mm from the
free flap.
The needle is turned and
engages the first flap apical
of the entrance hole, taking
care to remain at a minimum
distance of 1 .5 mm from the
free flap.
The two ends of thread must
be held with appropriate
instruments as dose as
possible to their points of
emergence from the tissue,
to avoid lacerating thread or
tissues, and to improve
precision of movement
A full surgeon 5 knot is now
begun; it should be positioned at
the center of the margin of the
incision of the wound.

suture
The ends of the knot are cut off very short, since they Will be concealed within the
tissues.
This section view shows the potential advantages and disadvantages of this variant of the
buried vertical mattress suture. The full surgeon 5 knot remains closer to the gaping margin
of the suture and may act as a source of disturbance to healing. However, during the
maneuvers to tighten the knot, its coronal position accentuates the coronal displacement
this suture can provide, making it appropriate in regeneration techniques. The coronal gap
can be sealed with additional sutures, as will be described in the following pages.

suture
The path of the suture in this variant is shown in this diagram. The inner part of the first flap is
pierced, at depth, in the corona-apical direction (first intramural 'port/on): the thread passes
across the free space between the two flaps to enter the second flap, at depth, running in the
apico-corona! direction (second intramural portion). After emerging from the second flap it
enters the same flap again more apically (third intramural portion) taking care to remain at
least 1mm from the free margin. The needle is turned and pierces the first flap, coronally
with respect to the first hole, running in the apico-coronal direction (fourth intramural portion)
again remaining at the recommended distance from the free margin.
The two ends of thread are brought to the center of the wound in a coronal position.

suture
Tightening the full surgeons knot helps to displace the flaps in the coronal direction. As was
already mentioned, this technique may also be performed with a different sequence,
shown below in section.
The first entrance hole is on the inner face of the external flap in an apical position.
Otherwise the pathway through the flaps is the same as that described above. On
completion, however, the two ends are at depth with regard to the margins of the wound.

suture
Traction on these two ends will enable the full surgeon 5 knot to be positioned at depth,
where there is less risk of its becoming exposed; however, it will interfere with deep-tissue
healing to a greater extent.
The knot positioned apically with regard to the free margin of the wound decreases the
extroflecting effect of this suture.

suture
The point at which the buried vertical mattress suture will begin is not chosen at random; it enables the degree of extroflection
of the flaps to be modulated. As we have said, the resistance of the suture to traction of the tissues can be increased or reduced
by varying the number of steps as well as the number of intramural portions in this technique For the reasons given, these
sutures may be made with a smaller number of steps and with a simpler technique, to the detriment of stability, as will be
shown on the following pages.

suture
These three diagrams show another variant of the buried vertical mattress suture with the knot placed superficially. The first step is
the same as described above, while the second flap is only pierced once/ thus in this variant there are only three intramural portions.
These three diagrams show the buried vertical mattress suture with the knot at depth in the variant with two intramural portions. Needle and
thread only enter each flap once, making the steps simpler and quicker to perform. However; there are only two intramural portions, and
should one of these give way, that seal of the suture is not guaranteed.

The simple anchored (sling)
suture
The advantages of the simple sling suture lie in its relative speed, and in the simplicity of repositioning the flap, which is adapted
closely to the tooth to which it is attached . The compressive action applied by this method, although less marked than that of other
types of anchored suture, enables bleeding and post-operative edema to be checked. The most significant disadvantage is that a
considerable portion of thread is passed around the neck of the tooth , which may increase the formation of bacterial plaque and thus
potentially increase the risk of infection, as well as the risk of damaging the tooth. Where both a vestibular and a palatine flap are present, the
flap not stabilized by this suture must subsequently be sutured, which increases the duration of surgery .
For the sake of clarity, a
theoretical wound is
illustrated to simplify
description of the clinical
steps.
The needle pierces the flop from the
vestibular side at approximately 1.5
mm from the coronal margin of the
line of the incision. If this suturing
technique
is begun from the mesial side of the
tooth, the situation will then be
favorable to position the full surgeon
s knot at completion of the suture.

suture
The thread passes around the
palatal or lingual part of the
tooth without engaging the
flaps. This portion of tooth
provides attachment
The needle is turned through
1800 and pierces the vestibular
flap distal to the tooth in
exactly the same manner as on
the mesial side.
Needle and thread again
pass to the palatal side
without piercing the tissues.
Before emerging again on the
vestibular side, the suture
thread passes through the flap
from the palatal to the
vestibular side at approximately
1.5 mm from the first entrance
hole.

suture
The second hole, that is the
exit hole of the suture
thread, is on the some
horizontal plane as the first
entrance hole .
Before tying the full surgeon 5" knot
to stabilize the suture, the two ends
of the thread must be pulled
through, taking core to check that on
the palatal side both ends are
positioned apical of the cingulum.
Otherwise the suture may slip off the
tooth, passing over the incisal margin
of the tooth coronal/y
View of the completed suture: it is
dear that the greater is the tension
applied to the filament which is
attached around the tooth, the greater
will be the compression applied to the
flop.

The sliding anchored (sling)
suture
This suturing technique combines the characteristic compression of all anchored sutures with an ability to reposition the flap, making it
particularly indicated in periodontal surgery, such as, for example, in lengthening the clinical crown. The flaps must be of partial
thickness. The suturing technique is generally reserved for operations on the maxilla .
The flexibility of this technique with regard to achieving individualized flap repositioning
makes it the first choice in many cases. both in periodontal surgery (regenerative
tedmiques. reseaive techniques) and in general oral surgery
It is important to remember here that surgery must be planned ahead of time with regard
to many parameters. The choice of type of incision, type of flap, the need for a
reconstructive or resective approach and, on completion, the suturing technique to be
used, are all factors that can improve and accelerate the healing processes.

suture
After having completed the phase of
reconstruction or demolition,
depending on the type of operation,
flap repositioning begins. This is a
crucial phase because, before applying
sutures. it is necessary to check carefully
that the margins of the wound are well
adapted to each other, that there is no
interposition of tissue and that no areas
are under tension.
The sliding sling suture begins
when the needle enters from the
vestibular side. The needle is held
perpendicular to the underlying
bone, it pierces the periosteum
and comes out at least 2 mm from
the entrance hole. The path is
similar to an external vertical
mattress suture, in terms of
orientation of the suture plane
with regard to the line of the flaps.
Bypassing beneath the
periosteum, the suture can
be anchored and thus
attached.
The thread passes completely outside the
flap to reach the palatal side. Here it pierces
the flap from the outside inwards, again
engaging the periosteum. The flap may be
pierced more coronally and the needle can
leave more apically, or the entrance hole can
be more apical and the exit hole more
coronal. Both methods are correct, although
the second is easier to perform. Anchorage to
the palatal periosteum is the second
anchorage point to attach this suture.

suture
If the full surgeon's knot is placed
more apically on the vestibular
side, the vestibular flap will be
displaced apically. This suturing
technique is indicated in resective
periodontal therapy, where the
suture helps to reposition the flap
apically
If the knot is positioned at the
level of the cemento-enamel
junction, the flap will be passive
with no tendency
to displacement.
If the knot is positioned palatally,
the suture will displace the
vestibular flap coronally. This
type of flap displacement is
preferable when the tooth in
question has undergone
regenerative surgery

The continuous sling
suture
The continuous sling suture is the ideal suturing technique when resective periodontal surgery involving two or more contiguous
teeth has left extensive areas that require remodeling.
After, for example: having completed
resective periodontal treatment on
two or more contiguous teeth and
having remodeled the bone ramps,
the needle pierces the vestibular flap
at its most mesial part. This should be
about 1.5 mm from the line of the
incision.
The needle and thread are pulled
through to the palatal side without
piercing the tissues and return through
the next contiguous inter-dental space
distally. The needle is turned through
180 ° passes through the vestibular
flap from the outside inwards, and
again passes through the inter-dental
space.
These steps are repeated in
exactly the same way along
the mesio-distal extension of
the flap.
During this phase, the suture
is attached to the teeth at the
palatal or lingual side, while it
is the vestibular flap that is
adapted.

suture
The suture continues in the
same way until the distal face
of the last tooth involved by
the flap is reached.
The needle then passes to
the palatal side of the most
distal tooth involved,
is turned through 180 ° and
engages the palatal flap.
The needle and thread now
pass to the vestibular side
without engaging the
vestibular flap; they pass
around the first vestibular
face of the last tooth and
emerge on the palatal side.
The needle is turned
through 180° and pierces
the reduced-thickness
palatal flap, leaving it
through the inter-dental
space and emerging on the
vestibular side.

suture
The procedure continues as
described During this phase,
attachment is only on the
vestibular face of the teeth,
while adaptation involves
the reduced thickness
palatal flap
To optimize the distribution of
tension on the two flaps, the
thread must be completely
pulled through at each step
Having reached the tooth
from which suturing began,
the procedure is continued
until the palatal side is
reached
If desired a full surgeon s knot
can now be tied to fasten the
suture. We have not shown
this variant, the procedure
being well understood .

suture
However, it is preferable to pierce
the vestibular flap once more with
the needle as for an external
horizontal mattress suture. In other
words, the vestibular flap is pierced
at the same height at which the first
stitch entered, at a distance of
approximately 2mm.
After a final check that all the
thread has been pulled
through properly, the
surgeons knot is begun. This
variant provides better tissue
seal in the most critical part
of the suture.
The completed suture.

Suturing Tips and Approaches
by Anatomic Location
The Chest, Back, and Shoulders :

The Arms :

The Legs :

The Hands and Feet :

The Scalp :

The Forehead :

The Eyelids :

The Nose :

The Lips :

The Ears :

How to Care for Stitches
(Sutures)
Patients should be instructed to keep their wounds clean. Most wounds should be covered with a protective,
non-adherent dressing for at least 24-48 hours to ensure sufficient epithelialisation to protect them from gross
contamination . After this period, patients may wash their wounds but should not scrub or soak them.
The routine use of prophylactic antibiotics is not recommendedAntibiotic use should be tailored to the
individual on the basis of:
 degree of bacterial contamination
 presence of infection-potentiating factors, such as soil
 mechanism of injury
 host factors

How to Care for Stitches
(Sutures)
Trott (1997) also found that the use of adhesive tapes was associated with decreased infection
rates. Wound adhesives are also associated with less microbial growth than sutures, partly
because they lack invasive matter. Antibiotic selection should be based on the suspected
microorganism. Over 90% of wound infections are caused by Staphylococcus aureus or
streptococcal bacteria. Soil contamination may result in infection with clostridium and gram-
negative organisms.
Tetanus prophylaxis must be considered for tetanus-prone wounds and also in relation to the
immunisation status of the patient

Removal of suture
 All sutures, being foreign bodies, cause irritation to the tissues & hence have the potential to cause scarring.
 Skin sutures are removed as soon as tissue healing allows.
 Non-absorbable sutures are best removed from the face after a period of 5-6 days. Tissues such as the scalp may require
a longer period(7-10 day)
Time of removal of suture according to place :
 Face 3-5 days
 Lip 3-5 days
 Oral cavity 6-8 days
 Neck 5-6 days
 Scalp 7-10 days
 Chest 10-14 days
 Abdomen 10-14 days
 Leg 10-14 days

Principle of suture removal
 Suture area is first clean with normal saline.
 The suture is grasped with non tooth dissecting forceps & lifted above the epithelial surface.
 Scissors are then passed through one loop & then transected close to the surface to avoid dragging contaminated suture
materials through tissues.
 The suture is then pulled towards the incision line to prevent dehiscence. If suture entrapped in a scab, application of
hydrogen per oxide/normal saline is necessary
 If pieces of suture left infection may occur.
Reasons for failure of sutures
 Breakage
 Cuts out
 Knot slips
 Extruded suture
 Resorbs too rapidly
 Removed too early

Possible complications of leaving
sutures for many days
Sutural abscess.
 Scar or stitch mark.
 Dermoid cyst.

Other Methods of Wound
Closure
• Ligating clips
• Skin staples
• Surgical tape
• Surgical adhesives
Ligating Clips
• Essentially “clips” to replace
sutures when occluding (closing)
the lumen (central canal) of a
vessel or tubular organ Blood
vessels Gynecological &
urological (GU) procedures
• Metallic or polymeric
• Requirements
 Nontoxic and biocompatible
 Absence of allergic and immunogenic effects
 Tolerated by wide range of tissue types
 High strength and low solubility
 Finite longevity
 Secure

Metallic Clips
First – Cushing neurosurgery clip, 1910
◦ Ag wire formed in the shape of a “U” and closed
around blood vessel
◦ Tantulum (1940)
◦ Tubule ligation
◦ Others
◦ Co-Cr
◦ Titanium
◦ Stainless Steel
◦ “Memory metal” – Ni-Ti alloy
Desirable properties in metallic clips
◦ High strength
◦ Malleability & ductility – can make fine wire
◦ Capacity for work-hardening
◦ Corrosion resistance
Some problems
◦ Allergic reaction
◦ Radio-opaque – can cause problems with CT, X-
ray, and MRI examinations

Polymeric Clips
Absorbable and non-absorbable
Viscoelastic
◦ Creep
◦ Stress-relaxation

Surgical Stapling
Introduced in the late 1970s
Used widely in human and veterinary
medicine
◦ Gynecological
◦ Cardiovascular
◦ Gastrointestinal
◦ Esophageal
◦ Pulmonary
Staples originally stainless but now Ti and
polymeric used
◦ Polymeric – 2 parts
◦ “U”-shaped fastener
◦ Figure “8” retainer

Surgical Staples
Staple Staple Gun Staple Remover

Staples & Clips vs. Sutures
 Speed
 Convenience
 Reduced infection rate
 Lower cost
 If done properly, no cosmetic difference

Tissue Adhesives
Sterilizable
Easy in preparation
Viscous liquid or liquid possible for spray
Nontoxic
Rapidly curable under wet physiological
conditions (pH 7.3, 37°C, 1 atm)
Reasonable cost
Strongly bondable to tissues
Biostable union until wound healing
Tough and pliable
Resorbable after wound healing
Nontoxic
Nonobstructive to wound healing or
promoting wound healing
Before Curing After Curing

Natural Tissue – Fibrin Glue
First reported in 1940
Mimics blood clot – major component fibrin network
Excellent tissue adhesive but insufficient in amount for larger wounds
Nontoxic if human protein sources are used to obtain fibrin

Synthetic Systems:
Poly-Alkyl-2-Cyanoacrylates
Discovered in 1951
“Crazy Glue”
H2C=C―CO2―R
CN
R = alkyl group
◦ CH3 (methyl)
◦ H3CCH2 (ethyl)
Release small amount of formaldehyde when
curing
◦ amount lessens with length of alkyl chain

Characteristics of Currently Available
Adhesive Systems
Fibrin Glue Cyanoacrylate
Handling Excellent Poor
Set time Medium Short
Tissue bonding Poor Good
Pliability Excellent Poor
Toxicity Low Medium
Resorbability Good Poor
Cell infiltration Excellent Poor

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Suture material & suturing technique

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