Posted in General Medicine for OMFS

Suture Materials

SUTURE MATERIALS USED IN ORAL & MAXILLOFACIAL SURGERY AND PRINCIPLES OF SUTURING

INTRODUCTION

Closure of the wound is one of the most important aspect of any operation and yet it is frequently one that is given least attention.

It is said that most common cause of postoperative infections is poor surgical techniques, usually related to devitalized tissues remaining in the wound and also inadequate closure.

Thus closure of wound by suturing helps to obliterate dead space where accumulation of blood or other tissue fluids could prevent direct apposition of tissues and provide an environment favourable for bacterial growth. Sutures also distribute the tension of wound closure over a larger volume of tissues.

Sutures have been used to close wounds as early as 50,000 B.C. It is said that an old method of wound closure has been using large black ants, which bite the wound edges together and the ants body being twisted off leaving the head in place.

A sutures is any thread or strand which brings into apposition no surfaces or tissues, while a ligature is any thread or strands obliterates the lumen of ductular structures. Characteristics of this elusive material are non-reactivity, retention of tensile strength until healing has occurred and easy handling.


CLASSIFICATION OF SUTURE MATERIALS

  • Absorbable:
  1. Natural
  2. Catgut           Pain

Chromic

  1. Fascia Lata
  • Kangaroo tendon
  1. Beef tendon
  2. Synthetic
  3. Polyglactin 910
  4. Polyglycolic acid
  1. Polyglecaprone 25 (monocryl)
  • Non-Absorbable:
  1. Natural silk, cotton, linen.
  2. Polyamide
  3. Monofilament
  4. Polyfilament (braided)
  5. Polyester – Polyfilament
  6. Coated (with polybutylate)
  • Polypropylene – monofilament (prolene)
  1. Polybutester – novafil.

 

  1. Metals:
  2. Stainless steel.
  1. Silver wire.

ABSORBABLE SUTURES:

Gut / Catgut

Gut is the oldest known absorbable suture material. It is a misnomer and has been derived from sheep intestinal submucosa or bovine intestinal serosa.

The origin of the word catgut is Arabic ‘KITSTRING’ or ‘KITGUT’, it is prepared from the submucosa of the sheep’s intestine. Submucosa of sheep has a rich elastic tissue content which accounts for high tensile strength of the catgut. It is monofilament and is available in the plain form as well as “tanned” in chromic acid. The tanning process delays the digestion by white blood cell lysozymes.

Sterilization:

Catgut should not be boiled or autoclaved as heat destroys the tensile strength. Catgut is sterilized during preparation and kept in a preservative solution (ethicon fluid contains 2.5% v/v formaldehyde plus 87.5% v/v denatured absolute alcohol) inside spools or foils. Unused and reusable catgut is hygroscopic so, catgut will swell due to water absorption and its tensile strength will be reduced (previously iodine method and chromic acid method were use for sterilization).

It is available pre-sterilized in aluminium-coated sterile foil overwrap pack with ethicon fluid as a preservative.

Colour: Plain catgut is yellow, while chromic catgut is tan.

Duration of gut in body tissues: Plain catgut retains its tensile strength for approximately 10 days, while chromic catgut for 20 days. Tensile strength of chromic catgut is zero after 30 days and gets absorbed completely in 100 days.

Absorbtion: Catgut is absorbed by proteolytic digestive enzymes released from inflammatory cells collected around the catgut. So, in the presence of infected catgut is rapidly absorbed.

Size: Catguts are made of varying thickness and according to the thickness, they are numbered like 1-0, 2-0 etc. as per BPC gauge system. The bigger the number the lesser. The thickness and smaller the number more the thickness.

Uses: Plain catgut is used for ligation of smooth blood vessels near skin surface and to suture subcutaneous tissue.

Chromic catgut:

1-0/2-0 : Used for ligation of medium sized blood.

3-0/4-0 : To close muscle layer in cleft lip repair.

5-0/6-0 : In plastic surgery.

AVAILABILITY

  • Plain Catgut:
  1. On needle – The curved needle may be round or cutting the curves of the needle body are ½, 3/8 and 5/8 of circles. Sizes are 6-0 to 2-0, length is 76cms, except No. 6-0 which is 38 cms long.
  2. Without needle: Size 5-0 to 4-0, length is 152cms strands are available in pieces e.g. Two pieces / three pieces.
    • Chromic catgut:
  3. On needle – Size 6-0 to 2-0, length is 76 cms except No. 6-0 which is 38 cms long. Needle may be curved or straight. Curved needles may be round bodied / cutting. Single armed / double armed and circle may be ½, 3/8 or 5/8.
  4. Without needle: Length is 152cms, size is 5-0 to 4-0 strands are available as one piece, two piece or three pieces.

POLYGLYCOLIC ACID (DEXON) :

It is a synthetic and absorbable suture material. It is a non-protein polymer of glycolic acid.

Absorption: By esterase enzyme system.

Packing: Available in pre-sterilized form in foil overwrap without a preservative.

Characteristics: It is white in colour and polyfilament braided suture.

Length: 76cms, available on needle.

Absorption time: 100 days.

Tensile strength is maintained for 30 days.

Advantages:

  • Minimum tissue reaction.
  • Less tissue oedema.
  • Uniform absorption.
  • Can be used in the presence of infection.
  • Better knot holding properties (braided).
  • Less fraying of ends (braided).

POLYCLACTIN 910 (Vicryl):

It is a synthetic absorbable suture material. Polyglactin 910 is a co-polymer of glycoline and lactide. It is braided to improve handling and is coated to reduce bacterial adherence and tissue drag.

Colour : Violet.

Size: 7-0 to 1-0.

Length: 7-0-30cms, 6-0 to 3-0 – 45cms, 2-0 to 1-0, 90cms.

Advantages: Minimum tissue reaction (It is synthetic)

  • No fraying.
  • Excellent handling characteristics.
  • Its distinct violet colour is highly visible in the wound.
  • Its unique molecular structure causes it to retain its strength over the critical healing period and then to be absorbed rapidly after suture has served its function.
  • Can be used in presence of infection.

Disadvantages: Only disadvantages is its roughness (causes swelling action).

Absorption: It is disintegrated by hydrolyses and then pieces of filaments are phagocytosed by PMN and other macrophages. Due to this, there is least tissue reaction and absorption is not affected by presence of infection.

Absorption is minimal until the 40th day. It is essentially complete between 60th and 90th days.

Tensile strength : Approximately 55% of original tensile strength of vicryl remains at 14 days and 20% at 21 days.

VICRYL RAPIDE (Irradiated Polyclactin 910)

It is braided synthetic absorbable suture material.

Colour: White.

Wound strength : It has a similar initial high tensile strength as that of the normal vicryl suture. It gives wound support upto 12 days. It shows 50% of the original tensile strength after 5 days and all of its tensile strength is lost after 14 days. Its absorption is associated with minimal tissue reaction facilitating improved cosmetis and reduction of postoperative pain. The absorption is essentially complete within 35-42 days.

Uses: Ideal for intra-oral use.

POLYGLECAPRONE 25 (MONOCRYL)

It is a monofilament, synthetic, absorbable suture.

Composition. It is a co-polymer of 75% glycolide and 25% caprolactone.

Colour: Golden.

Wound strength: It has a high initial tensile strength, which is double that of chromic catgut when placed in tissue. After 7 days post implantation approximately 50-60% of the original tensile strength remains. At the 14th postimplantation day, approximately 20-30% of the original strength remains, with wound support continuing upto 21 days.

Absorption: It is broken down by hydrolysis. The time required for absorption to be complete and 90-120 days postimplantation.

Advantages: High tensile strength.

  • More predictable wound strength and absorption characteristics.
  • Absorption is by hydrolysis, so it is not affect by infection.
  • Relatively inert.
  • Smooth surface so glides through the tissue with minimal effort.
  • Monofilament sutures reduces the chance of infection.
  • It is virtually memory free, so it can be controlled by a surgeon when suturing or ligating.

Disadvantages: Cost.

Indications:          Subcutaneous closure

Subcuticular closure

Available sizes: 5-0 to 1-0.

POLYDIOXANONE SUTURE (PDS):

It is a synthetic, absorbable suture material. Total absorption takes 240 days. Mechanism of absorption is same as that of vicryl.

Tensile strength: 70% tensile strength remains at 20 days, at 40 days and 20% at 60 days.

COTTON THREAD: It is a natural, non-absorbable suture material of vegetable origin. It is a twisted polyfilament available in reels in an unsterile form.

Sterilization: long pieces of thread are wound around a rubber tube and autoclaved.

Sizes: 2, 8, 10, 20, 40, 60 and 80: No. 2 is the thickest and 80 the thinnest.

Advantages: Cheapest and freely available; Secure knotting and easily handled.

Disadvantages: Absorbs fluids by capillary action, so more chances of infection.

  • Tissue reaction is more.
  • Frays easily and has low tensile strength.

LINEN: It is a natural, non-absorbable, polyfilament suture material of vegetable origin made from jute fibres. Though costlier, it is preferable to cotton.

Colour: Natural linen colour. Pack is pink colour.

Size: Thickest No. 20; thinnest No. 80.

Advantages: It is easily handled : Knots slide down smoothly and tie securely.

SILK: Natural, non-adsorbable, polyfilament suture material, obtained from the cocoon of silkworm. It loses its tensile strength in about a year and is completely removed from the operative site in two years. So, its actually an absorbable material.

Size: No. 2 thickest, and No. 80 thinnest.

Advantages:

  • It does not soak up fluids and never becomes limp or brittle.
  • It ties down smoothly and securely and its natural elasticity gives it an extensibility that signals when optimum knot replacement has been achieved.

Disadvantages : Stitch granuloma.

Infection rate is high as compared to synthetic materials.

Availability : In sterile foil overwrap pack as eyeless needled sutures. As sutupac-precut lengths of sterile sutures, in a pack of 2 & 6 pieces of suture material, without needle. On reels – nonsterile.

Colour : Black.

Types: According to preparation.

  • Perma hand surgical silk.
  • Virgin silk suture which is prepared from the glands of silk worm before their pupae stage.

According to fibre pattern:

Uses: To ligate blood vessels and pedicles.

  • To suture nerve.
  • To suture grafts in vascular surgery (atraumatic silk).
  • To suture tendons.
  • Skin suture.
  • For fixing skin grafts.
  • Suturing of wound over face.

NYLON: It is a synthetic, non-absorbable suture. It may swell up in tissues and lose some of its tensile strength after a year. Its thickness varies from 1N to 8N.

Advantages:

  • Less irritant.
  • High tensile strength, which is retained for a long period. Its tensile strength is expressed in terms of weight in pounds it can suspend. E.g., 1 pound, 6 pounds etc.

Disadvantages:

  • Knot is slippery, so 5-7 knots should be applied.
  • Infection due to crevices in braided nylon.
  • Too smooth and stiff knots likely to slip.

PROLENE: It is made up of a polymer of propylene. It is a synthetic, non-absorbable suture.

Advantages:

  • It is as inert as steel and resists breaks by infection.
  • Monofilament, so less chances of infection.
  • High degree of smoothness, so it requires much less force to draw through the tissue.
  • Its sky blue colour has high visibility in tissues.
  • It is pliable, so it ties securely and can be easily handled.
  • Knot security – plastic deformity enables the knot to flatten out and lock against itself.
  • Least thrombogenic, so an important factor in vascular surgery.
  • It will retain its tensile strength for years.
  • It is unwetted by blood, unweakened by tissue enzymes and offers prolonged tensile strength, even in infected areas.
  • More elastic.

Availability : In pre-sterilized foil overwrap pack as eyeless needled sutures.

Size: 7-0 to 10-0.

Length : 70 cms.

Uses: Plastic surgery.

Vascular surgery for anastomosis between vessels.

Sterilization: Available pre-sterilized; sterilized in ethicon fluid when it is to be re-used.

Stainless steel wire: It is made up of stainless steel. It excites very little tissue reaction.

Disadvantages: Cutaneous discomfort, knots are not firm and may break.

Sizes : 25 to 40 wire gauge.

Sterilization : Autoclaving.

POLYAMIDE (ETHICON)

It is a synthetic, non-absorbable suture. It is monofilament polyamide.

Colour: black.

Advantages:

  • Minimal tissue reaction.
  • Remarkably smooth, so preferred for subcuticular stiches.
  • High degree of elasticity with secure knot tying extremely strong.

Size 10-0 to 1-0.

Length:       10-0 to 8-0 ; 25 cms and 38 cms.

6-0 to 1-0 ; 70 cms.

It is available in sterile foil packing as eyeless needled sutures.

10-0 to 8-0 are used in microsurgery

6-0 to 3-0 are used in plastic surgery.

Polyamide is also available as braided polyfilament.

SUTUPACK: It is available as two or more pieces of suture material without a needle. Two types are available – silk and nylon.


Expanded PTFE (Gortex):

It is a non-absorbable, monofilament suture. Expands causes a porous micro-strucutre which is more than 50% air by volume.

Advantages:

  • Inert – minimal tissue reaction.
  • Does not degrade in the presence of infection.
  • Fibroblasts and leukocytes infiltrate into internodal spaces, thus re-inforcing the strength.

NEWER NON-ABSORBABLE SYNTHETIC SUTURE MATERIAL

Dacron

PTFE (Gortex)

Mersidene (Orange)

Maxon

Marlex

Ethibond

Polyglyconate (green)

Polyethylene

Polyester

PRINCIPLES OF SUTURE SELECTION

The selection of a suture material by a surgeon must be based on a sound knowledge of the 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.

  • When a wound has reached maximal strength, sutures are no longer needed. Tissues that heal slowly such as skin, fascia and tendons should usually be closed with non-absorbable sutures. Tissues that heal rapidly such as peritoneum, liver, small intestines, muscles, stomach, colon and baldder may be closed with absorbable sutures.
  • Multifilament sutures should be avoided in contaminated wounds as bacteria can linger within them and may convert it into an infected one.
  • Where cosmetic results are important, close and prolonged apposition of wounds and avoidance of irritants will produce the best results. So, the smallest inert monofilament suture materials such as polyamide or prolene should be used. Skin sutures should be avoided and subcuticular closure should be performed wherever possible.
  • Intra-orally, multifilament braided materials such as black silk, or absorbable synthetic materials such as polyglycolic acid and polyclactin, are flexible and preferable for use. Of these, absorbable sutures are more preferable as they spare the patient the discomfort of having the sutures removed and an inconvenience of an additional visit to the clinic and are especially important when dealing with children. The optimum time for spontaneous suture loss intra-orally is 5-14 days and an ideal materials which satisfies this criteria more or less is vicryl rapide.


NEEDLES:

Proper suturing begins with an understanding of the physical and biologic properties of both the needle and suture material.

The surgical needles are sharp, pointed instruments used for puncturing the tissue for guiding the thread or wire to suture or pass a ligature around the vessels. They are available in a wide range of types, shapes, lengths and thickness.

Needles are either made of stainless steel or carbon steel.

 

ANATOMY OF SURGICAL NEEDLES:

Classification of Surgical Needles:

  1. According to its eye:
  1. Eyeless needles.
  2. Needles with eye.
    1. According to shape:
  3. Straight needles.
  4. Curved needles.
    1. According to cutting edge:
  5. Round body needles.
  6. Cutting needles
    1. Conventional cutting needles.
    2. Reverse cutting needles.

 

  1. According to its tip.
  1. Triangular tipped needles.
  2. Round tipped needles.
  • Blunt point needles.
    1. Others:
  • Spatula needles.
  • Micropoint needles.

EYELESS NEEDLES:

One strand of suture material is attached to the swage of a needle during manufacturing.

It has the following advantages.

  1. Causes minimal tissue trauma as only a single swaged suture strand is drawn through the tissue.
  2. Each patient has the benefit of a new sharp needle. Reusable needles are potentially dull, blurred or tarnished.
  3. these needles do not unthread and can be easily recovered it accidentally dropped.
  4. Allows faster, more efficient surgery.

NEEDLES WITH EYE

The only advantage is that as it can be re-used, it is cheaper.

Straight needles: Available both as eyeless and with eye and round body and blunt tip.

  • Particularly used to suture skin and fascia.
  • Intra-orally (Oral & Maxillofacial surgery), used for the passage of circum-zygomatic and circummandibular wires.

 

 

 

CURVED NEEDLES: Available as eyeless and with eye and round body and cutting needle.

Needles traverses the tissue with circular movement and facilitates working in depth.

The more confined the operative site the greater the curvature required.

Manufactured with varying curvatures – 1/8, ¼, ½, 3/8 and 5/8.

ROUND BODY NEEDLES:

They are designed to separate tissue fibres rather than cut them and are used for soft tissues like muscle and fascia, or in situations where easy splitting of tissue fibres is possible. After the passage of needle, the tissue closes tightly and the suture material, thereby forming a leak proof suture line, which is particularly vital in intestinal and cardiovascular surgery.

MAYO’S NEEDLE: It is a strong round body needle with a round tip used to penetrate periosteum.

CONVENTIONAL CUTTING NEEDLE: The point of this needle is triangular in cross-section with the apex cutting edge on the inside of the needle curvature. It is used for keratinized mucosa, skin or subcuticular layers where the tissue is difficult to penetrate.

REVERSE CUTTING NEEDLE: The body of this needle is triangular in cross-section with the apex cutting edge on the outside of the needle curvature. This improves the strength of the needle and particularly increases resistance to bending.

TROCAR POINT NEEDLE: This needle has a strong cutting head, which merges into a robust round body. The design of the cutting head is such that it ensures powerful penetration even when deep in the dense tissue.


PRINCIPLES OF SUTURING

  1. The needle holder should grasp the needle at approximately 1/4 of the distance from the point.
  2. The needle should enter the tissue perpendicular to the surface. If the needle pierces the tissue obliquely, a tear may develop.
  3. The needle should be passed through the tissue following the curve of the needle.
  4. The suture should be placed at an equal distance from the incision on both the sides and at an equal depth. This principle can be modified in cases where the tissue edges are at different levels; then passage of the suture closer to the edge of the lower and farther from the edge of the higher side will tend to approximate the levels. Another method involves passage of the suture at an equal distance form the wound margins on both sides, but deeper into the tissues on the lower side and more superficially on the higher side.
  5. The needle should pass from the free tissue to the fixed side.
  6. If one tissue side is thinner than the other the needle should pass from the thinner tissue to the thicker one.
  7. If one tissue plane is deeper than the other, then the needle should pass from the deeper to the superficial side.
  8. The distance that the needle is passed into the tissue should be greater than the distance from the tissue edge.
  9. The tissues should not be closed under tension, since they will tear or necrose around the suture. If tension is present the tissues should be undermined to relieve it.
  10. The suture should be tied so that the tissue is merely approximated and the edges are everted.
  11. The knot should not be placed over the incision line.
  12. Sutures should be placed approximately 3-4mm apart. Closer spaced sutures are indicated in areas of tension.
  13. If “dog ear” occurs at the end of incisions, it should be eliminated.

“Dog ear” elimination:

Excess tissue is undermined and an incision is made at approximately 30 degrees to the parent incision directed towards the undermined side. The extra tissue is pulled over the incision and the appropriate amount is excised. Closure is then achieved in normal manner Another method includes excising the excess tissue with an elliptical incision and then achieving closure in the normal manner.

KNOT TYING:

The surgeon may use either the instrument tie or one or two hand tie. The instrument tie is more convenient in closed areas such as mouth, but can be used in open areas as well. Therefore adequate knowledge of this technique is recommended.

SQUARE KNOT: The basic knot is the square knot and requires at least three ties for surface knots. It is formed by wrapping ties around the needle holder once in opposite directions between ties.

SURGEON’S KNOT: Because of the double throw, the surgeon’s knot offers the advantage of reducing slippage of the first tie, while the second tie is put in place. This is particularly useful in confined or difficult to reach places where the first tie would ordinarily be loosened in the process of producing the second tie. A third tie squared on the surgeon’s knot is usually made for security. This method is modified for use with polyglycolic acid and synthetic sutures.

GRANNY KNOT: This knot involves a tie in one direction followed by a single tie in the same direction as the first. A third tie is then squared on the second to hold the knot permanently.

SUTURE METHODS

Some of the commonly used suturing types:

  1. Interrupted methods.
  2. Continuous suture.
  3. Locking continuous suture.
  4. Mattress suture.
  5. Figure of 8 suture.
  6. Subcuticular suture.
  7. Tension suture.
  1. Interrupted suture:

The interrupted suture is the most commonly used and it is preferred in areas of tension over continuous sutures.

Advantages:

  1. It is strong and successive sutures can be placed in a manner to fit the indirect requirements of the situation.
  2. Each suture is independent of the next and loosening of one suture will not cause loosening the others.
  • A degree of eversion of the incision can be produced by ensuring that the depth of the bite is greater than the distance from the suture of the wound edge, should the wound become infected, removal of a few selected suture may be satisfactory treatment..


  1. CONTINUOUS SUTURE:
    • The continuous suture provides a rapid technique for closure.
    • Provides even distribution of tension over the entire suture line.
    • Provides a more watertight closure, which is especially important in intra-oral bone grafting.
    • It should not be used in areas of existing tension.

Method: A simple interrupted suture is placed and needle is then inserted in continuous fashion. The suture passes perpendicular to incision line underneath tissue and diagonally on surface and is ended by tying to last untightened loop of suture.

LOCKING CONTINUOUS SUTURE

This technique offers two advantages over the simple continuous technique:

  1. The suture will align itself perpendicularly to the incision.
  2. The locking feature prevents continuous tightening of the suture as wound closure progresses.

Here, care should be exercised not to tighten the individual lock excessively, since this can produce tissue necrosis.

Also, the locking feature may prevent adjustment of tension over the suture line as tissue swelling occurs.

Method: Suture is passed perpendicular to incisor line and degree of locking is provided by withdrawing suture through its own loop. The suture technique is begun and ended identically to continuous technique.


MATTRESS SUTURE :

Mattress sutures are of two types –

Vertical & Horizontal.

Techniques:

Vertical : needle is passed close to incision line on both sides and then engages tissue deep to first pass when returning towards the original side.

Horizontal: Suture passes perpendicular to incision line underneath tissue and parallel to it on the surface and then again perpendicular to incision line underneath tissue to be knotted on that side.

A mattress suture is used to provide more tissue eversion and is used in areas when wound contraction could cause dehiscence and broad soar formation. The vertical mattress suture offers the advantage of running parallel to the blood supply of the edge of the flap and therefore not interfering with healing.

The interrupted horizontal mattress suture produces broad contact of the wound margins and is useful where such a condition is needed. However, it suffers from the disadvantage of constricting the blood supply to the edges of the incision.

A continuous horizontal mattress suture is often used after intra-oral bone grafting, as the eversion and continuity provide a very watertight closure.


FIGURE OF EIGHT: The figure of 8 suture is used over extraction sites where it provides some protection to the socket as well as adaptation of the gingival papillae round the adjacent teeth.

SUBCUTICULAR SUTURE:

  • An absorbable 4-0 suture material is generally used for closure of the subcuticular layer.
  • If individual subcuticular sutures are placed, they should be buried with the knot inverted.
  • A continuous subcuticular suture can be used with no knots by having the ends exist a short distance from the wound and taping to the skin.
  • In this technique non-absorbable sutures are usually used.
  • Free passage of the suture along the incision to facilitate subsequent removal is ensured by pulling the ends after placement.
  • A continuous subcuticular suture may be left for 7-10 days and removed by pulling in one direction.

TENSION SUTURE: This type of suture is used to prevent wound dehiscence. A suture materials of good strength like non-absorbable nylon or prolene is used with a plastic tubing to reduce the tension exerted by the sutures on the tissues.

SUTURE REMOVAL: When sutures are removed, suture should be grasped with an instrument elevated above the epithelial surface.

A scissors should be used to transect side of the loop as close to the epithelial surface as possible. In this way a minimal amount of the portion of the suture that was exposed to the outside environment and has become laden  with debris and bacteria will be dragged through the tissue.

OTHER SUPPLEMENTS / ADJUNCTS TO WOUND CLOSURE

  1. Skin staples: Skin staples are particularly used for long incisions as a time saver or to position a skin closure or flap temporarily before suturing. Grasping the wound edges delicately with forceps to evert the tissue is helpful when placing the staple to prevent inverted skin edges.

Staples must be removed early to prevent inverted skin marks and are therefore best used in hair bearing scalp.

  1. Skin tapes : Skin tapes can effectively approximate the wound edges, although buried sutures are often required in addition, to approximate deeper layers, relive tension, and prevent inversion of the wound edges. As skin sutures are ideally removed within 5 days. If adequate intradermal suturing has been performed, this guideline can be followed in any area of the body.
  2. Tissue adhesives.

Cyanoacrylates, the tissue adhesive component of many commercially available glues has been used by the medical profession for various purposes, including tissue adhesion, embolization, hemostasis, osteosynthesis and as wound dressing material.

Cyanoacrylates are quick-setting, biodegradable, polymeric tissue adhesives that have become useful tissue bonding agents.

They form a strong, durable bond with most human tissues, particularly those that contain a large amount of protein such as skin and tendon.

The cyanoacrylates tissue adhesives polymerize by an exothermic reaction in the presence of water and hydroxyl groups on the wound surface and thus are effective on moist surfaces.


ADVANTAGES OF CYANOACRYLATE TISSUE ADHESIVE INCLUDE:

  1. Effective and immediate hemostasis.
  2. Bacteriostatic properties.
  3. Rapid adhesion of hard and soft tissues.
  4. Significantly less pain and oedema.
  5. Better aesthetics when compared to sutures.

Disadvantages:

  1. Low tensile strength.
  2. After polymerization, the tissue adhesive is brittle and can fragment if flexed over a joint crease.

TISSUE REACTION TO SUTURES:

The initial body response to sutures is almost identical in the first 4 to 7 days, regardless of the suture material. The damage done to the tissue by the needle evokes a significant inflammatory response even without the presence of suture material. After 4 to 7 days the response is more related to the type of suture material.

If the suture material leads to mucosal or skin surfaces, epithelial cells will begin tracking down the suture pathway at 5 to 7 days. The longer the suture remains the deeper the epithelial invasion of the underlying tissue. When such sutures are removed an epithelial tract remains. These cells may eventually disappear or remain to form keratin and epithelial inclusion cysts. The epithelial pathway may also cause the site of the sutures to be visible and the typical “railroad track” scar results.

The development of surgical infections is greatly enhanced by the presence of a suture in a contaminated wound. The use of monofilament sutures rather than braided sutures reduces the potential for infection as the multifilament sutures provide a haven for bacteria, which can penetrate the interstices of the suture that are too small to allow granulocytes and macrophages. As a general rule, sutures should not be used in the presence of infections and should be removed if an infection becomes evident.

All sutures passing through the mucous membrane or skin provide a “wick” down through which bacteria can gain access to the underlying tissues and may cause inflammation possibly leading to granuloma formation or a stitch abscess. Because of this and the downward growth of the epithelial tissue, the sutures should be removed as early as possible consistent with adequate healing. Generally, sutures should be removed after 3 to 5 days on the skin of the head and neck, 5 to 7 days intra-orally, 5 to 10 days in other sites, and longer for areas subjected to considerable stress, such as over joints or the iliac crest, or in areas of slower healing such as the palms or soles. In cancer patients, the sutures should be removed on the 14th day.

At the 5th to the 7th day when sutures are most often removed, there is relatively little tensile strength of the wound and that which is present is due to adhesiveness of cells, blood vessels, globular proteins, and fibrin not to formation of collagen. At least 5 to 42 days are required for significant collagen synthesis to occur. Therefore, cutaneous wounds should be supported with sterile tape following suture removal.


SUMMARY & CONCLUSION

Choice of appropriate suture for a given wound should be based upon principles of wound care. In wound closure, the surgical technique is far more important than the sutures used but a good scientific knowledge of different sutures and needles and how they perform, will aid the surgeon to achieve optimum wound healing. Since suture technology has kept pace with advances in surgical techniques, it is imperative on the part of the surgeon not only to be fully aware of them but also to keep them in their surgical armamentarium.


REFERENCES

  1. Oral & Maxillofacial Surgery. Vol. I : By Daniel M. Laskin.
  2. General Surgical Operations: By R.M. Kirk.
  3. Grabb & Smiths : Plastic Surgery.
  4. Plastic Surgery : Mc Carthy.
  5. Textbook of Surgery : Sabiston.
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Author:

I am a practicing maxillofacial surgeon working in India.

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