SUTURES

&
SUTURING
Dr. Sateessh Bhatele
Oral & Maxillofacial
Surgery
 INTRODUCTION
 Edwin Smith in 16th century BC first used
sutures in operative procedures.
 In 900 AD the great arabian, Rhazes started
used “Kitgut” to suture abdominal wounds.
 In 1902, Claudius established IODINE
sterilization of the sutures.
 Development of Synthetic absorbable
sutures began in 1931 with production of
polyvinyl alcohol
 But one of the earliest Indian surgical text
written by Sushruta described in detail about
sutures, its definition, type, needles and
suture materials.
 They used hair as one of the suture material.
 Today with constant advancement a wide
range of suturing materials are used.
  Many materials were used as ligatures and
sutures through centuries.
 Eg:
i. Horse hair strands
ii. Gold /silver wires
iii. Silk
iv. Linen
v. Cotton
vi. Intestinal tissues of various animals
 DEFINITION
 Suture is a wound closure biomaterial, used
to facilitate the wound healing process by
approximating tissue edges and minimizing
the risks of bleeding, infection and scaring.

 Suturing is the act of sewing or bringing

tissues together and holding them in
apposition until healing has taken place.
 PURPOSE
 The basic purpose of the suture is to hold a
wound together in good apposition until such
time as the natural healing process is
sufficiently well established.
 Goal is to “Approximate not Strangulate”
 SUTURE CLASSIFICATION
1. Absorbable / nonabsorbable
2. Multifilament / monofilament
3. Braided / unbraided
4. Synthetic / natural
5. Metallic/non-metallic
 CLASSIFICATION
I.ABSORBABLE & NON
ABSORBABLE
1.ABSORBABLE: can be digested by body
enzymes or are hydrolyzed by tissue
fluids.
Used for deep tissues, membranes, & subcuticular
skin closure
 They got degraded and eventually
eliminated in one of two ways:
 Via inflammatory reaction utilizing tissue
enzymes
 Examples are:-
 “Catgut”(enzymatic breakdown &
phagocytosis)
 Chromic cat gut
 Vicryl(hydrolysis)
 Monocryl(hydrolysis)
 Dexon(slow hydrolysis)
2.NON ABSORBABLE : can’t be digested by
tissue enzymes and are encapsulated or
walled off.
Used for skin (removed) & some deep
structures (tendons, vessels, nerve repairs –
not removed)
 It is not degraded

 Examples are:-

 Prolene(polymer of propylene)

 Nylon(polyamide polymer)

 Dacron(terephthalate)

 Silk
 Absorbable sutures can be – Natural
Synthetic

 Non absorbable sutures can be – Natural

Synthetic

Metallic
 MONOFILAMENT & MULTIFILAMENT SUTURE
MONOFILAMENT :
 Grossly appears as single
strand of suture material; all
fibers run parallel
 Minimal tissue trauma
 Resists harboring
microorganisms
 Ties smoothly
 Requires more knots than
multifilament suture
 Possesses memory
 Examples are:-
 MULTIFILAMENT SUTURE:
 Fibers are twisted or braided
together
 Greater resistance in tissue
 Provides good handling and
ease of tying
 Fewer knots required
 Examples:-
 Vicryl (braided)
 Chromic (twisted)
 Silk (braided)
 NATURAL & SYNTHETIC SUTURE
NATURAL:
 Biological origin
 Good handling & knotting.
 Economical
 It cause intense inflammatory reaction
 Examples are:-
 “Catgut” – purified collagen fibers from

intestine of healthy sheep or cows

 Chromic – coated “catgut”

 Silk
SYNTHETIC SUTURE:
 Synthetic polymers
Advantages
 Non-Absorbables are inert
 Absorbables resemble natural substances
 Absorption by hydrolysis
 Predictable absorption
 Strength
 It do not cause intense inflammatory reaction
Disadvantages
 Monofilament handling

 Examples:-
 Vicryl

 Monocryl
 Prolene

 Nylon
 A. NATURAL ABSORBABLE SUTURES
CATGUT
 Oldest known natural suture
material
 It is polyfilamentous but
when polished it yields a
monofilamentous
appearance.
 Plain gut tanned with a
solution of chromium salts is
called chromic cat gut
 Chromium increases the
tensile strength and
 Source:
 Purified connective tissue found in intestinal
mucosa of large animals such as sheep/cattle
 Properties:
 Difficult to use
 Poor knot stability
 Robust inflammatory reaction
 Has the lowest tensile strength
 Plain gut retains its tensile strength for 3-5
and chromic gut 5-7 days respectively.
 Completely absorbed by Enzymatic
breakdown & Phagocytosis Plain- 70
days/Chromic- 90 days.
B. SYNTHETIC ABSORBABLE SUTURES
They are polymers

‣They are twice as strong as compared to

natural absorbable sutures & lose their
tensile strength slowly thus helping to hold
tissues together during the critical period of
wound healing.
 POLYGLYCOLIC ACID AND POLYGLACTIN 910

 Polyglycolic acid – polymer of hydroxyacetic

acid
 Polyglactin 910(vicryl) – copolymer of
hydroxyacetic acid and lactic acid in 90:10
ratio.
 Properties:-
• Both are polyfilament and braided.
• Knot tying is difficult.
• Tensile strength maintained for 30 and 20
days respectively.
• Minimal tissue reaction
• Braided
 Resorption:-
 hydrolysis(56-70days)
 WARNING: safety not proved in neural and
cardiovascular tissues.

 Polyglactin coated with bacteriostatic agent

TRICLOSAN is also available as VICRYL PLUS.
 NONABSORBABLE SUTURES
‣ CHARACTERISTICS:
‣ Permanent
‣ Only used when long term support is
required
‣ Removed when used for skin
‣ Tissue reaction generally low (except
silk)
‣ True non-absorbable sutures include
polyester, polyethylene, polypropylene
and steel
 NATURAL & SYNTHETIC NON ABSORBABLE SUTURES
SILK
 Most popular for intraoral
use. Doesn’t soak fluids.
 Natural , inexpensive, braided
which gives it excellent
handling characterstics.
 Source:- silk protein from
silkworm in making cocoon
 Advantages:
 superb handling
 strong knot strength(superior frictional
resistance)
 Disadvantages:-
 great deal of inflammation
 wicking effect(braided)
 Infection rate is higher as compared to other
synthetic materials.
 Contraindicated in cardiovascular surgery.
 NYLON
 Monofilament form more popular than braided .
 Most popular skin suture.
 Least tissue reaction among all sutures.
 Has memory so poor knotting property.
 Not used intraorally because of its stiffness, the large
knot is required and a tendency to tear through non-
keratinized tissue.

COTTON, LINEN, AND METAL

 Neither of these has been widely used.
 DACRON POLYESTER, POLYPROPYLENE
(PROLENE) AND POLYETHYLENE

 BRAIDED SYNTHETIC SUTURE

MATERIAL.
 Greater tensile strength and knot
handling ability among the non
metallic suture materials.
 Polypropylene is used for esthetic
areas (facial skin).
 PURPOSE OF SUTURING
1. To place the tissue layers and wound edges in
passive approximation, assisting in healing.
2. To limit the size of the wound and therefore
reduce the chances of contamination and
infection.
3. To assist in controlling haemorrhage,
especially the most common type of post
extraction hemorrhage – Capillary
haemorrhage. Helps in formation and
maintenance of clot, and therefore less post
operative pain.
4. Prevent bone exposure resulting in delayed
healing and unnecessary resorbtion
5. Permit proper flap position
PRINCIPLES OF SUTURE MATERIAL
SELECTION
1. Rate of healing of tissues:- When a
wound has reached maximal strength ,
sutures are no longer required.
i. The surgeon should select a suture that will
lose it’s tensile strength at about the same
rate that the tissues gain strength.
ii. Tissues that ordinarily heal slowly such as
skin , fascia and tendons should be closed
with non-absorbable sutures.
iii. Tissues that heal rapidly such as muscles,
periosteum may be closed with absorbable
2. Tissue contamination :-

Foreign bodies in potentially

contaminated tissues may convert
contamination to infection.

Monofilament absorbable or non-absorbable

sutures are used in potentially
contaminated wounds.
3. Cosmetic results :-
where cosmetic results are
important , close and prolonged apposition of
wounds and avoidances of irritants will
4.Microsurgical procedures:-
 The tissues most commonly approximated

under microscope are arteries , veins ,

nerves and tendons etc.
 The most commonly suture is 10-0 polyamide

monofilament.
5. Cancer patients:-
 Hypoproteinemia and chemotherapy can

breakdown the wound.

 Synthetic non-absorbable suture are used. If

the patient is to be irradiated in the post

operative period.
 Monofilament polypropylene should not be

used . Instead polyster should be used.

6. Wound repair in patients following
irradiation:-in these patients not only the
normal healing process is delayed but the
tolerance to trauma of irradiated tissue is
markedly reduced.
7.Nutritional status:- when the patient is
under nourished and hypoproteinemic , non-
absorbable suture should be used , as tissues
need to be kept in approximation for longer
period.
8. Suture size:- the size of suture material
should be properly selected, depending on
tensile strength of the tissues to be
approximated and whether or not there will
 REQUISITES FOR SUTURE
MATERIALS
 Adequate strength – depends on the elasticity of
the material, flexible material will have a greater
ability to stretch and bear stress.
 Low tissue irritation and reaction – sutures
made from organic material will evoke a higher
tissue response than synthetic sutures. Tissue
reaction is also directly proportional to the amount
and size of the suture material used.
 Smoothness - minimum tissue drag
 Good handling and knotting properties.
 Sterilization without deterioration in
properties.
 Low capillary action– multifilamentous suture
materials soak up tissue fluid by capillary action
providing a rich medium for proliferation of microbes
and in turn increasing the chances of inflammation
and infection.
 Should be nonallergic, non carcinogenic.
 Should be unfriendly to bacteria
 Predictable performance
 Should be freely available and cost effective

‣ Most of the suture materials available in packages

are sterilized by dry heat and ethylene oxide gas.
SUTURE DIAMETER AND STRENGTH
 Suture materials are numbered according to
their thickness from 1-0 to 10-0.
 Size denotes the diameter of the material
 The greater the number of zeros the thinner
the material.
 The sizes and tensile strength are
standardized by U.S.P regulations

10..9..8..7..6..5..4..3..2..1..0
 Smaller diameter denotes the less tensile
strength of the suture.
 Thicker suture – for deeper layers, wounds
in tension prone areas and for ligation of
blood vessels.
 Thin sutures are used for closing delicate
tissues like conjunctiva and skin incisions of
the face.
 Fascia: 1 - 0
 Skin: 2 - 5
 Arteries: 2 - 8
 Micro surgery 9 - 10
 Corneal closure: 9 – 10
 These are rough guides, it’s really the Surgeon’s
 TISSUE REACTION TO SUTURES
 The initial body response to suture is almost
identical in first 4-7 days regardless of suture
material.
 The damage done to the tissue by the needle
evokes a significant inflammatory response
even without the presence of suture material.
 The early response is a generalised acute
aseptic inflammation, involving primarily
polymorphonuclear leukocytes.
 After a few days, mononuclear cells,
fibroblasts, and histiocytes become evident.
 After 4-7 days the response is related more
to the type of suture material.
 e.g. plain gut elicits an intense response with
macrophages and polymorphonuclear
leukocytes, predominating, while the non
absorbable material show a less intense,
relatively acellular histologic pattern.
 If the suture material leads to mucosal or
skin surface, epithelial cells will begin
tracking down the suture pathway at 5-7
days.
 The longer the suture remains, the
deeper the epithelial invasion of the
underlying tissue.
 When the suture is removal, an
epithelial tract remains.
 These cells may eventually disappear
or remain to form keratin and
epithelial inclusion cysts. The cause
the site the suture to be visible and
the typical “railroad track” scar
results
 COMPLICATIONS OF SUTURES
There are 3 main complications:-
- Haemorrhage
- Leakage
- Stenosis
HAEMORRHAGE:
 May occur from the suture line.

 It may be immediate or late or delayed.

LEAKAGE:
 Esophageal and colonic anastomosis are
most prone to leak.
 The outcome depends on the size of the leak
and its anatomical site.
STENOSIS:
 Stenosis can be caused by excessive
inversion especially with two layered
anastomosis.
 An inadequate string in the first place /
ischaemia can also lead to subsequent
stenosis.
 NEEDLE
 DEFINITION:
 A small, slender implement used for sewing

or surgical suturing, made usually of polished

steel and which may or may not be having
an eye at one end through which a thread is
passed and held.
 A needle is generally a thin, cylindrical

object, often with a sharp point on the end.

Made of either stainless steel or carbon steel.
 DESIRABLE NEEDLE
CHARACTERISTICS
 Made of high quality stainless steel
 As slim as possible
 Stable grasp in needle holder
 Able to carry suture material through tissue
with minimum trauma.
 Sharp and Rigid
 Sterile and corrosion resistant.
Classification of Needles:
1. Based on curvature

2. Based on attachment

3. Based on needle point geometry

 1 . BASED ON CURVATURE
 Needle curvature is selected according to site
accessibility.
 Two basic types:
 Straight
 Curved.
 2. DEPENDING ON ATTACHMENT
1. SWAGED OR
ATRAUMATIC:
 suture is pre inserted into

the needle
ADVANTAGES:
‣ Less trauma to the tissues.
‣ Each patient has the benefit of a new, sharp, sterile
needle.
‣ No chances of accidental unthreading of needle &
losing it while suturing.
‣ Faster & more efficient procedure.

‣ Needles are made up of high quality steel.

‣ True-tempering process gives uniform strength.
‣ Nurse working hours are saved no need of
ordering ,cleaning, sterilising & threading the eyed
needles.
DIS-ADVANTAGES:
 Costly

 Single use
2. EYED OR TRAUMATIC:

 In this type of needles the suture is

passed through the eye since the
eye is larger than the diameter of
the suture
ADVANTAGES:
 Reusable
 Cost effective

DIS-ADVANTAGES:
 Difficulty while suturing
 Chances of tissue tear while

suturing
 Chances of accidental unthreading

of needle & losing it while suturing.

3. BASED ON NEEDLE POINT GEOMETRY
 Conventional cutting needle.
 Micropoint reverse cutting needle.
 Tapercut surgical needle.
 Taper
 Blunt
 Reverse cutting
 Side cutting spatulated
 TYPES OF NEEDLES
CUTTING NEEDLES
 They have atleast two opposing edges.
 They are shaped to cut through tough ,
difficult to penetrate tissue.
 They are ideal for skin suturing
 CONVENTIONAL CUTTING NEEDLE
 In addition to the two cutting edges they
have a third cutting edge on the inside
concave curvature of the needle
 The needle may be prone to cut out of tissue
because the inside cutting edge cuts towards
the edge of the incision / wound.
 REVERSE CUTTING NEEDLES
 The reverse cutting needles are as sharp as
the conventional needles, but its design is
distinctively different from the conventional
by having the third cutting edge on the outer
convex curvature of the needle
 Danger of tissue cut out is greatly reduced.
 SIDE CUTTING NEEDLES
 Also referred as spatula needles
 They futures a unique desigh which is flat on
both the top and bottom eliminating the
undesirable tissue cut outs like other cutting
needles
 TAPER POINT NEEDLES(ROUND NEEDLES)
 They pierce and spread tissue with out
cutting it
 The needle point taper to a sharp tip ,then
the needle body then flattens to an oval or
rectangular shape.
 BLUNT POINT NEEDLES
 They literally dissect friable tissue rather
than cutting it they have a taper body with a
rounded blunt point that will not cut through
tissue they may be used for suturing the liver
and kidney
 •Suited to soft tissue
Taper-Point •Dilates rather than cuts

•Very sharp
Reverse cutting •Ideal for skin
•Cuts rather than dilates
•Very sharp
Conventional •Cuts rather than dilates
Cutting •Creates weakness allowing suture tearout
•Ideal in tough or calcified tissues
Taper-cutting •Mainly used in Cardiac & Vascular
procedures.

•Also known as “Protect Point”

Blunt •Mainly used to prevent needle stick
injuries i.e. for abdominal wall closure.
Premium point •Ophthalmic Surgery
spatula
•Ophthalmic Surgery
Spatula

½ The Penetration force

DermaX* •Superior Cosmetic Effect
 PARTS OF NEEDLE

Needle comprises of 3 parts:

1- Needle eye
2- Needle body
3- Needle point
ANATOMY OF A SURGICAL NEEDLE
 NEEDLE BODY
‣ The body or the shaft section is usually
referred to as needle grasping area.
‣ It may be round, oval, side flattened,
rectangular, triangular or trapezoidal.
‣ The longitudinal shape of the body may be
straight, half curved, curved
(1/4th,1/2,3/8th)or compound curved.
‣ 1/2 circle curved needles are the most
commonly used needles in oral surgical
procedures.
 NEEDLE POINT
 Needle Point : Penetration of a needle is dependant on
the point. Each specific point is designed and produced to
the required degree of sharpness to penetrate smoothly the
types of tissues to be sutured.
 The tip can be cutting or blunt.
 Cutting needles are ideal for suturing keratinized
tissues like the skin, palatal mucosa, buccal &
alveolar mucosa.
 Cutting edges can be conventional , reverse or side
cutting.
 They are triangular cross-section.
 Round/Tapered needles are used for suturing soft &
non keratinized tissues like muscle , fascia & neural
sheath.
 PRINCIPLES OF SUTURING

1. The needle holder should

grasp the needle approx.
¾ the distance from the
point.
2. The needle should enter
the tissue perpendicular to
the surface.
3. The needle should pass
through the tissue
following the curve of the
needle.
 PRINCIPLES OF SUTURING…
4. The suture should be placed at
an equal distance (2-3 mm) from
the incision on both sides and at
an equal depth.
5. If one tissue side is free, the
needle should pass from the free
to the fixed side.
6. If one tissue side is thinner, the
needle should pass from the
thinner to the thicker side.
7. If one tissue plane is deeper than
the other, the needle should pass
from the deeper to the more
 PRINCIPLES OF SUTURING…
8. The distance that the needle is passed into the
tissue should be greater than the distance from
the tissue edge.
9. Tissues should not be closed under tension.
10. The Suture should be tied so the tissue is merely
approximate, not blanched.
 PRINCIPLES OF SUTURING…
11. The knot should not be placed over
the
incision line.

12. Sutures should be placed approx. 3 to

4mm apart.
Closer placement:
 Areas of underlying muscular
activity
 Areas of increased tension

13. Avoide formation of “Dog ear”.

 TYPES OF KNOTS
1. Instrument tie
2. One- or two- hand tie

 Square knot – two ties are given, the

second throw being opposite to first
throw.

 Surgeon’s knot – because of the double

throw in the first tie, this prevents
slippage of 1st tie while 2nd tie is put in
placed (opposite to 1st tie).

 Granny knot – this knot resembles a tie in

one direction, followed by single tie in
the same direction as the first however; a
third tie squared on the second must be
made to hold the knot permanently.
 SUTURING TECHNIQUES
a) Continuous suture
b) Interrupted suture

c) Continuous locking
d) Mattress sutures

1. Horizontal mattress suture

2. Vertical mattress suture
E. Figure of 8 suture
F. Subcuticular sutures
 INTERRUPTED SUTURE
 Suture is passed through both the edges at an
equal depth and distance from the incision
and the knot is tied.

 Most commonly used suture.

Advantages:
 It is strong, and can be used in areas of stress.

 Successive sutures can be placed according to

individual requirement.
 Each suture is independent and the loosening
of one suture will not produce loosening of
the other.
 A degree of eversion can be produced.
 If the wound becomes infected or there is an
hematoma formation, removal of a few
sutures may offer a satisfactory treatment.
Interrupted suture
 CONTINUOUS SUTURE
 Initially a simple interrupted
suture is placed and the needle
is then reinserted in a
continuous fashion such that the
suture passes perpendicular to
the incision line below and
obliquely above.
ADVANTAGES:
 Rapid technique.
 Distributes the tension uniformly
over the suture line.
 Offers a more water tight
closure.
 Continuous suture is used in cases of intraoral bone
grafting.
 Should be avoided in cases of existing tension.
Disadvantages:
 Tissue necrosis
 If one suture is torn away the the whole suture

becomes loose
 CONTINUOUS LOCKING
 Similar to continuous
suture, but locking is
provided by withdrawing
the suture through its
own loop.
 Locking prevents
excessive tightening of
the suture as the wound
closure progresses.
 Suture will align itself
perpendicular to the
incision
 MATTRESS SUTURES
Main purpose of mattress suture
is to provide more eversion
than SI.
1. HORIZONTAL MATTRESS
SUTURE:
 The needle is passed from

one edge of the incision to

another and again from the
latter edge to the first edge
and a knot is tied.
 Distance and depth of needle
penetration is same.

VERTICAL MATTRESS SUTURE:
 Similar to horizontal mattress, except that, all factors

remaining constant, the depth of penetration varies,

i.e. when the needle is brought back from the second
flap to the first, the depth of penetration is more
superficial.
 Used for closing deep wounds.
 FIGURE OF 8
 Used for extraction socket
closure
 For adaptation of the gingival
papilla around the tooth.
 SUBCUTICULAR SUTURES
 Used when cosmetic results are required as
this suture holds skin edges in close
approximation.
 Continuous short lateral stitches are taken
beneath the epithelial layers of the skin.
 MECHANICAL WOUND CLOSURE
DEVICES
LIGATING CLIPS:
 Can be resorbable or
nonresorbable.
 Made from stainless steel,
tantalum or titanium or p -
dioxanone.
 Designed for ligation of
tubular structures.
 SURGICAL STAPLES:
 Used for skin closure and closure
of the abdominal layers.
 Made of stainless steel.
 Cause minimal tissue reaction.
 Contraindicated when it is not
possible to maintain at least
5mm distance from the stapled
skin to the underlying bone and
blood vessels.
 TISSUE ADHESIVES:
 After tight closure of the
subcutaneous tissue, the
skin layers can be closed
with the help of tissue
adhesives.
 N-butyl cyanoacrylate.
 On tissue contact
polymerizes into a hard
substance that keeps the
wound margins together.
 POST OPERATIVE CARE
1. EDEMA CONTROL – postoperative edema
develops due to so many factors. They are:
 Too tight suturing
 Suturing under tension
 Dead space not obliterated
 Rotating instrument used without sufficient
coolent
 Forceful retraction during surgery
 Marginal trauma
 It can be minimized by advising pt. to have
intermittent cold ice-packs on external area of
surgery at least for 1-2 days.
 Anti-inflammatory drugs are also useful to
2. INFECTION CONTROL: sterilisation of instruments
and adoption of strict aseptic techniques go a long
way in establishing control of infection.
Preoperative antiseptic application and prophylactic
or therapeutic antibiotic therapy is useful.
3. NUTRITION: high protein, high calorie diet with
adequate vitamins.
 SUTURE REMOVAL
 Intra oral : 5-7 days
 Other sites : 5-10 days

 Suture should be removed as early as possible consistent

with adequate healing.
 Knot is held by the forceps and lifted up. One of the
suture is cut-off close to the tissues and the knot is
pulled in such a way that the wound margins are brought
nearer to each other. If the suture is pulled in the
opposite direction the wound will be gaped. If the suture
is cut midway, the contaminated external loop is pulled
through the wound that predisposes to wound infection.
THANK