Chapter 16: Suture Closure Materials and Techniques

INTRODUCTION

Suturing is one of the foundational skills of dermatologic surgery.¹ Dermatologic surgeons must familiarize themselves with both the physical properties of suture material, as well as the available suturing techniques in order to ensure the best results for their patients.

BASIC SUTURE PROPERTIES AND TERMINOLOGY

Before he or she can select the proper suture material for a given closure, the dermatologic surgeon must understand the properties that differentiate the various suture materials, and the terminology used to describe these properties.

Configuration and Coating

Configuration refers to whether a suture material has a single strand (monofilament), or multiple braided strands (multifilament).² Monofilament sutures generally exhibit less resistance when being pulled through tissue and have a lower risk of infection.³ However, they exhibit greater memory – the suture’s tendency to retain its packaged shape – and are consequently more difficult to handle than their multifilament counterparts.

Multifilament sutures, on the other hand, are more pliable and handle more easily. The braided nature of multifilament sutures creates natural crevices for bacteria, and higher rates of surgical site infection have been demonstrated relative to monofilament sutures.^4,5

Braided sutures have more surface area than their monofilament counterparts. This increase in surface area increases resistance to being pulled through tissue and allows inflammatory cells better access to the suture material. Thus, multifilament sutures tend to be more reactive and are absorbed more quickly. In an attempt to negate the infection risk associated with multifilament sutures, antibacterial coatings have been added to multifilament sutures. Although triclosan-coated polyglactin 910 (Vicryl PLUS, Ethicon Inc., Summers, NJ) has been shown to decrease postoperative pain in the pediatric surgery population,⁶ no consistent decrease in wound infection rates relative to uncoated suture has been demonstrated.^7–9

Tissue Reactivity

Although all sutures will initiate some degree of host response, the magnitude of this response can vary widely. In general, there are several guidelines which can be reliably followed. First, larger sutures will cause a larger host response, further supporting the general recommendation of using the smallest suture that is reasonable for a given defect. Second, multifilament sutures will elicit a larger inflammatory host response than monofilament due to their larger relative surface area. Third, natural materials such as silk will cause a larger response than their synthetic cousins. Finally, absorbable sutures tend to cause a larger response than nonabsorbable sutures.

Diameter and USP Size

The size of suture is reported by the United States Pharmacopeia (USP) as the diameter of a given suture material necessary to obtain a certain tensile strength. This diameter is then reported as a number of zeroes, with fewer zeroes representing larger diameter. For example, 3-0 Prolene (Ethicon Inc., Somerville, NJ) has a larger diameter than 6-0 ...