A wide variety of suture materials are available, all with variable handling characteristics, tissue reactivity, absorption characteristics, and costs. While much attention is paid to suture material, the needle may be as or more important than the suture material itself in promoting an ideal surgical outcome. Needles vary by manufacturer and even by suture material, and utilizing the most appropriate needle for the task is critical. Even the most accomplished surgeon will perform in a less-than-ideal fashion if their instruments or needle choices are flawed.
Most needles used for skin and soft tissue reconstruction are 3/8 circle in diameter, and most needles used for skin and soft tissue reconstructions are reverse cutting in nature (Figure 3-1). There are, however, important exceptions to this rule. For example, a semicircular P-2 needle may be used for narrow closures, such as those sometimes encountered on the nose, and a cutting needle, with the sharp edge on the inside of the curve, may be useful for nasal reconstruction where the thin atrophic dermis may be cut by the superficially coursing outside of the needle.
The two largest manufacturers of suture material used in cutaneous surgery are Ethicon and Covidien. While suture size is governed by USP guidelines (the larger the number of zeros, the smaller the suture), needle size and configuration is largely proprietary. Thus, the surgeon must be comfortable understanding the various needle sizes and configurations of the various manufacturers. Suture material packaging does include a cross-sectional image of the needle, permitting some comparison between companies. Of note, Covidien does not (except on its website) refer to any of its needles as reverse cutting; instead, they label cutting needles as conventional cutting and reverse cutting needles as cutting (Table 3-1). These distinctions are important when choosing suture, though many suture type and needle combinations are only available with a finite number of permutations. Since cutting and reverse cutting needles have a triangular tip, the orientation of the cutting end is indicated by whether the triangle on the box is pointing up (cutting) or down (reverse cutting).
TABLE 3-1COMPARISON OF FREQUENTLY USED REVERSE CUTTING NEEDLES FROM ETHICON AND COVIDIEN ||Download (.pdf) TABLE 3-1 COMPARISON OF FREQUENTLY USED REVERSE CUTTING NEEDLES FROM ETHICON AND COVIDIEN
|Ethicon ||Covidien |
|P-1 ||P-10 |
|P-3 ||P-13 |
|PS-1 ||P-14 |
|PS-2 ||P-12 |
|CP-2 ||GS-10 |
|FS-1 ||C-14 |
|FS-2 ||C-13 |
|P-2 ||P-21 |
The material used to make the needles themselves also varies considerably between manufacturers, as proprietary alloys are used to maximize strength and durability. While Ethicon and Covidien products are used most often in skin and soft tissue reconstruction, many other reputable companies manufacture suture material, and individual preferences may vary widely (Table 3-2).
TABLE 3-2COMPARISON OF FREQUENTLY USED SUTURE MATERIALS FROM ETHICON AND COVIDIEN ||Download (.pdf) TABLE 3-2 COMPARISON OF FREQUENTLY USED SUTURE MATERIALS FROM ETHICON AND COVIDIEN
|Ethicon ||Covidien ||Application |
|Vicryl ||Polysorb ||Standard for buried sutures |
|VicrylRapide ||Velosorb Fast ||Alternative to fast-absorbing gut; excellent for skin grafts or when suture removal is not an option |
|Monocryl ||Biosyn ||Monofilament alternative for buried sutures; support is lost faster than Vicryl/Polysorb |
|PDS I/II ||Maxon ||Monofilament alternative for buried sutures; support lasts longer than Vicryl/Polysorb |
|Prolene ||Surgipro I/II ||Smooth monofilament nonabsorbable suture; excellent choice for running subcuticular sutures if suture removal is planned |
|Ethilon ||Monosof ||Standard nonabsorbable monofilament nylon suture for epidermal approximation |
Any monofilament suture, including absorbable sutures, may be used for transepidermal suture placement. Thus, utilizing a monofilament absorbable suture may permit the use of a single suture pack for both buried and epidermal sutures.
Many suture characteristics are commonly discussed, including handling, memory, pliability, knot security, tissue reactivity, and others. There are subtle differences between the handling characteristics of different suture materials, most modern options fall well within the realm of utility, so that while the handling of silk, for example, is clearly superior to the handling of nylon, even nylon handles very well. Similarly, certain materials, such as catgut, may be highly reactive, though the more frequently used formulations, such as chromic gut and fast-absorbing gut, do not lead to enough inflammation to make a marked clinical difference in most situations. For the most part, monofilament sutures lead to less tissue drag, and therefore are useful with running techniques, while braided sutures provide excellent handling and knot security, and are therefore useful for interrupted buried sutures. With improvements in materials, the distinction between outcomes now likely relates more to suturing technique than to choice in suture materials.