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Suturing - Materials and Techniques

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Suturing is a technique used to close opened wounds, secure them, and position the surgical flaps. This article discusses the techniques and materials used.

Written by

Dr. Sowmiya D

Medically reviewed by

Dr. Sneha Kannan

Published At April 20, 2022
Reviewed AtFebruary 12, 2024

What Is a Suture?

Closing the wounds with a needle and thread is age-old. At present, we have established several techniques to perform this procedure. A suture is an artificial material or thread used to ligate or approximate the wound tissues until they heal. This provides support for the tissue margin and reduces postoperative pain.

Why Do We Need a Suture?

An adequately placed suture is required for the following reasons,

  • To approximate the wound edges.

  • To provide adequate tension of wound closure without dead space to enable adequate blood flow to the wound, which promotes healing.

  • To ensure hemostasis (blood clots),.

  • To provide support for the tissues until they heal.

  • To reduce postoperative pain.

  • To prevent bone exposure.

  • To prevent infection of the surgical site.

What Are the Requirements of Suture Material, and How Do We Choose Them?

Suture materials are selected based on the physical and biological characteristics of the suture material, the healing properties of the tissue to be approximated, and the nature of the wound.

  • It should have the following requirements,

  • It should be sterile.

  • It should have enough tensile strength to hold the wound securely throughout the healing period.

  • It should be easy to handle and limit bacterial adhesion.

  • It should have a uniform diameter.

  • It should be biologically inactive.

What Are the Types of Suture Materials?

Sutures are classified based on the following criteria:

  • According to Absorbability- it is either absorbable or nonabsorbable.

  • According to the Source- Natural or synthetic.

  • According to Structure- Monofilament or multifilament.

  • According to Tissue Reaction- Reactive or non-reactive.

  • According to Handling- Easy or difficult to handle.

Natural Absorbable Sutures- They are monofilaments of highly purified collagen. They have mild to moderate strength. Also, they have a mild inflammatory reaction and should be avoided in some instances with highly acidic environments like Nervosa bulosa, etc.

They are available in two types-

Plain Gut - They have a resorption rate of 3 to 5 days.

The Chromic Gut- It has a longer resorption rate of 7 days to 10 days.

Synthetic Absorbable Sutures- They are braided filaments of polyglycolic acid. They inhibit bacterial growth and resorb within 21 to 28 days.

They are available in two types-

  • Dexon Vicryl

  • Vicryl.

Non-Absorbable Sutures- They are resistant to resorption and are available as,

Natural nonabsorbable sutures- for example, cotton and silk. They have poor strength but promote bacterial growth and severe inflammatory reactions.

Synthetic nonabsorbable suture- for example- Nylon, polyester, etc. They can be braided or unbraided and monofilaments or multifilaments.

What Are the General Principles of Suturing?

Do not suture very small pieces of tissue, as the suture tears through the wound edges. It should be placed at least 2 - 3 mm from the wound edge. The sutures should always be inserted through the most mobile tissue flap first. If one tissue side is thinner than the other, the needle should pass from the delicate and thin tissue to the thicker one. When inserting, the needle should first enter the tissue at right angles. Passing through the facial and lingual papillae in one pass is not advisable. Always use sharp needle points to avoid forcing through the tissues. Suture needles are grasped in the center and only by a needle holder. The needle is inserted and pulled through the tissue in line with the circle. The suture is secured tight enough without restricting the blood supply. The knot should not be placed over the incision line. Sutures should be placed 3 mm - 4 mm apart.

How to Select Suture Selection?

  • Biocompatible suture materials that cause little tissue reactivity and have enough strength throughout the crucial healing phase are ideal. These materials fall into two categories: absorbable and nonabsorbable, or braided multifilament and monofilament.

  • Wound healing and surgical results are influenced by needle and thread properties. In implant procedures, for example, the silk sutures were tested against Teflon (polytetrafluoroethylene).

  • Less intraoperative management and patient pain were seen with silk sutures. It was also demonstrated that the latter had reduced plaque buildup; no statistically significant difference existed.

  • The dentistry market currently offers a wide variety of suturing materials. The choice of suture material for implant or periodontal surgery has yet to be thoroughly studied and is frequently dependent on personal preferences rather than scientific research.

What Are the Different Techniques in Suturing?

  • Simple loop modification of interrupted suture technique.

  • Continuous non-interlocking suture technique.

  • Continuous locking suture technique.

  • Vertical mattress suture technique.

  • Horizontal mattress suture technique.

  • Continuous horizontal mattress suture technique.

  • Modification of interrupted suture technique.

  • Cross suture technique.

  • Periosteal suturing technique.

  • Coronally repositioned mattress suture technique.

  • Vertical sling mattress suture technique.

  • Single interrupted sling suture technique.

  • Continuous independent sling suture technique.

  • Independent sling suture technique.

  • Sling suture around the single tooth.

Here are some of the most commonly used suturing techniques discussed in detail:

Interrupted Simple Suture:

This is the most commonly used suture, inserted through one side of the wound and tied with a surgeon’s knot. These are used in areas of stress and are easy to clean.

Simple Continuous or Running Suture:

It is a simple, interrupted suture placed continuously. It distributes the tension uniformly, but if cut open at one point, the suture slackens along the whole length.

Continuous Locking or Blanket Suture:

It is similar to a continuous suture, but locking is provided by withdrawing the suture through its loop. It is used in long edentulous areas, tuberosity, or retromolar areas.

Vertical Mattress Sutures:

It is a variation of simple interrupted sutures used in wounds under tension. They provide excellent wound support and decrease dead space.

Horizontal Mattress Sutures:

They are useful in wounds that require distributing the tension across larger wounds, but they strangle the blood supply and cause the death of tissues in the end.

Periosteal Suturing Technique:

This technique involves penetrating the periodontal tissues and periosteum into the bone. The aim is to regenerate the lost alveolar structure for prosthetic purposes.

Sling Suture About Single Tooth:

This procedure is used mainly for root coverage, gingiva esthetics, etc.

Figure 8 Modification of the Interrupted Suture:

This technique is used to extract socket closure and adapt the gingival papilla around the tooth.

Conclusion

Considering the requirements of modern surgery, many suturing techniques and methods have been developed. A good surgeon must have proper knowledge about the suture, needle, instruments, and technique. The difference in tissue reaction and bacterial adhesion should always be considered when selecting the suture material. Proper handling of the soft tissues and appropriate suturing techniques can achieve the desired effects of tissue healing.

Frequently Asked Questions

1.

What Materials Are Used in the Manufacture of Sutures?

There are two types of sutures, namely absorbable and non-absorbable. Absorbable sutures are made of fibers that line the intestines of animals or artificially manufactured polymers that get easily dissolved. Examples include catgut, polydioxanone, poliglecaprone, and polyglactin sutures. Non-absorbable sutures are ideal for soft tissue repair and are made from silk, cotton, linen, nylon, polypropylene, and polyester.  

2.

What Are the Types of Suturing Materials?

There are two types of sutures, namely absorbable and non-absorbable. Absorbable sutures get digested by the body's enzymes, while the physician must remove non-absorbable sutures. Sutures can also be monofilaments (single thread) or braided. Silk, cotton, linen, and catgut are natural, while nylon, polyester, polypropylene, polydioxanone, and poliglecaprone are artificial (synthetic) sutures.

3.

What Is the Simple and Common Suturing Technique?

The simple interrupted suture technique is the most simple and common suturing technique. It is performed by inserting the needle perpendicular to the outermost layer of the skin, called the epidermis. The perpendicular insertion of the needle aids in taking a wider bite of the deeper tissues, which helps in quick wound healing and results in a thinner scar. The stitch should be wide or broad at the base than the top layer. The suture is finally secured by a knot. 

4.

Which Is the Ideal Suture Material?

There is no ideal suture material, and the suture must be selected appropriately for a particular condition. An ideal suture material should be firm, cheap, have minimal friction, have a predictable behavior in the body, tie secure knots, be easy to handle, cause minimal or no inflammatory response, and resist infections. For example, monofilament non-absorbable sutures are ideal for an uncomplicated laceration (a deep cut in the skin).

5.

What Is the Widely Used Suture?

Synthetic non-absorbable monofilament sutures are widely used in skin procedures, including polypropylene, nylon, and polybutester. FiberWire is a strong suture material that is preferred in areas where a large number of throws is feasible. Polypropylene or polydioxanone sutures are ideal for fascia (sheets of connective tissue beneath the skin), and polypropylene sutures are widely preferred in cardiovascular surgery. 

6.

What Instruments Are Needed for Suturing?

A basic suturing kit contains:
- A needle holder.
- Toothed forceps with a hook to hold or grasp the tissue.
- Fine suturing scissors.
- A scalpel.
- An appropriate suturing material.
- A sterilized needle.
Needle holders are used to hold the needles while suturing. Other materials include sterile gloves, saline, povidone-iodine or chlorhexidine solution, sterile drapes, gauze, local anesthetic, dressing materials, and a sharps bin.

7.

What Is the Size of the Sutures to Be Used?

Commonly used sutures are between 3-0 to 6-0. Small sutures of size 5-0 and 6-0 are usually used on the face. Large sutures of size 3-0 and 4-0 are ideal for areas that do not need aesthetics, like the extremities. Smaller sutures will have a more significant size number. Stronger absorbable sutures will have a greater absorption time. A smaller diameter suture will act against static and dynamic tensional forces on the skin. 

8.

Where Is Vicryl Used?

Vicryl sutures are a type of absorbable braided sutures manufactured from polyglactin 10. Dyed (colored) vicryl is preferred in deeper tissues as it is easily visible and can be followed. These should not be used on the skin surface as they can create a tattooing effect. Vicryl is used for closing skin and soft tissues, suturing ligated blood vessels in sensitive areas or skin creases, abdominal surgery, securing an opening to the skin, and repairing holes in the bladder or gastrointestinal tract. Vicryl is contraindicated on cardiac, nerve, and vascular (blood) tissues.

9.

Which Suture Is Suitable for the Skin?

Synthetic non-absorbable monofilament sutures are widely used in skin procedures, including polypropylene, nylon, and polybutester. Polyglactin 910 (Vicryl Rapide) is a synthetic absorbable suture for suturing the skin and mucosa. Monocryl, an absorbable suture, is used to close surgical incisions on the superficial layer of skin, such as those on the eyes, ears, face, neck, and abdomen.

10.

What Thread Is Preferred for Sutures?

Sutures, commonly known as stitches, are sterile (completely clean and free from bacteria) surgical threads that repair and heal cuts. Metal staples are alternative methods of sutures. Suture threads are made of special silk, catgut, cotton, linen, or synthetic materials like nylon, polyester, or polypropylene. Sutures are widely used to close incisions following surgery. Different sutures are preferred in different conditions.

11.

How Much Should the Distance Between the Sutures Be?

The ideal distance between sutures should be approximately ½ the length of the individual sutures. The spacing should equal the distance from where the needle enters the wound margin. The tension forces on the tissue walls decrease if the distance to the wound edges is closed by ½.

12.

What Is Meant by Suture Length?

The length of the suture used along the wound length depends on the stitch size and the stitch interval. The suture length to wound length ratio is calculated by dividing the length of the suture material by the length of the incision (10 cm). A suture-to-wound length ratio greater than or equal to 6:1 is recommended for safe midline abdominal closure.

13.

How to Select Suture Size?

Sutures of the smallest size should be chosen considering the tissue's natural strength. Smaller sutures will have a more significant size number. Large-sized sutures will have a smaller diameter. For instance, a 7-0 suture will be smaller than a 4-0 suture. Commonly used sutures are between 3-0 to 6-0. Stronger absorbable sutures will have a greater absorption time. A smaller diameter suture will act against static and dynamic tensional forces on the skin. 

14.

How Many Knots Are Needed for a Suture?

At least three throws would suffice to secure the knot, but some may need more. Five throws can hold almost all types of sutures securely. Commonly used knots are the surgeon's, square, granny, and sliding-half hitch. A study showed that Vicryl showed excellent knot security while silk had the least. Moreover, knot security depends on tying technique, suture material, and the number of throws but remains unaffected by suture size. 
Source Article IclonSourcesSource Article Arrow
Dr. Sowmiya D
Dr. Sowmiya D

Dentistry

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