GOOD

MORNING
 SUTURE MATERIALS
&
SUTURING TECHNIQUES

COMPILED BY: NUZHAT NOOR AYESHA

Introduction
CONTENTS
History
Definition
Goals of suturing
Suture materials
- Introduction
- Requisites of ideal suture
- Classification
- Selection of suture material
- Absorption of suture material
- Biological response of body to suture.
Suture armamentarium- needles, needle holder, scissor
Principles of suturing
Suturing Techniques
Knots
Suture Removal
Other methods of wound closure
 INTRODUCTION
• Suture means to ‘sew’ or ‘seam’. In
surgery suture is the act of sewing
or bringing tissue together and
holding them in apposition until
healing has taken place.

• A suture is a strand of material used

to ligate blood vessels and to
approximate tissues together.
HISTORY
 HISTORY
History of the Surgical Suture  “I dress the wound,
God heals it.“
Ambroise Pare, surgeon
16th century
• The act of sewing is probably older then
Homo sapiens, because Neanderthal man
wore some sort of clothing.
 HISTORY

 Perhaps the world’s oldest suture was placed by an

embalmer on the body of a twenty first dynasty mummy
about 1100 B.C.
• A south American method of wound
closure used large black ants which bite
the wound edges together and the ants
body is then twisted off leaving the head
in place.

• East African tribes ligated blood vessels

with tendons and closed wounds with
acacia throns
• The first detailed
description of a wound
suture and suture
materials used in it is by
the Indian physician
Sushruta, written in 500
BC.
 Galen, the physician to
Roman gladiators in the
second century A.D. used
silk for hemostasis.

Andreas Vesalius first

advocated the suture of all
fresh wounds as well as
severed tendon and nerves.
• Joseph Lister (1827-1912)
discovered that bacteria
present in suture strands
cause wound infection. He
disinfected sutures with
carbolic acid. He made
sterile sutures possible to
bury it in clean wounds
without infection.
• Sometime around 30 A.D., a
medical encyclopedia was written
by a Roman named Aurelius
Cornelius Celsus. His work, De Re
Medicina, tells the reader that
sutures should be “soft, and not
over twisted, so that they may be
more easy on the part.” He is
also credited with first
substantiated mention of ligating
by recommending it as a
secondary means of stopping a
hemorrhage.
• Rhazes of Arabia was credited in
900 A.D. with first employing ‘kit
gut’ to suture abdominal wounds.
The Arabic word ‘kit’ means a
dancing master’s fiddle, the
musical strings of which ‘kit
string’ were made up of sheep
intestines. Over the years ‘kit’
was confused with kitten or cat,
and the misuse of the term was
propagated.
DEFINITIONS

• DEFINITION: suture material is an artificial

fibre used to keep wound together until they hold
sufficiently well by themselves by natural fibre
(collagen) which is synthesized and woven into a
stronger scar

• Suture is a Stitch/Series of Stiches made to

secure apposition of the edges of a
Surgical/Traumatic wound (Wilkins)

• Any Strand of Material utilised to ligate blood

vessels or approximate Tissues (Silverstein L.H
1999)
 GOALS OF SUTURING
Suturing is performed to
 Provide adequate tension
 Maintain hemostasis
 Provide support for tissue
margins
 Reduce post-op pain
 Prevent bone exposure
 Permit proper flap position
 SUTURE
MATERIALS
• The basic purpose of a suture is to hold
severed tissues in close approximation
until the healing process provides the
wound with sufficient strength to
withstand stress without the need for
mechanical support.

• Since wounds do not gain strength until

4-6 days after injury, the tissues are
approximated till then by sutures.
 The amount of tension or pull the
suture can withstand before
breaking is important.
Tensile St α diameter of suture

 If the diameter of suture is

doubled, T.S is quadrupled.
Suture material should be atleast as
strong as the tissues in which they
are used. By the end of 2nd week,
when most skin sutures are removed,
the wound would have attained 3%-
7% of final Tensile St.
3rd week – 20% of T.S
4th week – 50% of T.S

Wounds will never regain more than

80% of Tensile St. of intact skin
REQUISITES OF AN IDEAL SUTURE

• Tensile st: adequate material strength

will prevent suture breakdown & use of
proper knots for the material used will
prevent untying or knot slippage.

• Tissue biocompatibility: sutures made

from organic material will evoke a higher
tissue response than synthetic sutures.
tissue reaction α amount & size of
suture material.
• Low capillarity: multifilament type soak
up tissue fluid by capillary action
providing a rich medium for microbes
increasing chances of inflammation &
infection.
• Good handling & knotting properties:
ease of tying & a thread type that
permits minimal knot slippage also
influence thread selection.
• Sterilization without deterioration of
properties: most sutures available in
packages are sterilized by dry heat &
ethylene oxide gas.
• Non allergic, non electrolytic and non
carcinogènic

• Its use should be possible in any

operation.

• Low cost

• It should not fray, should slide through

tissues readily & knot should not slip after
tying.
• It should be readily visualized , should not
shrink & should not be extruded from the
wound.

• On break down ,it should not release toxic

agents.

• It should disappear without excessive

reaction once its task is completed.
 CLASSIFICATION OF SUTURE
MATERIALS

According to source:
1. Natural
2. Synthetic
3. Metallic
According to structure 1. Monofilament
2. Multifilament
According to fate:
1. Absorbable (undergo degradation and
lose T.S. < 60 days)
2. Non absorbable ( maintain T.S > 60
days)

According to coating: 1. Coated

2. Uncoated
 NATURAL
Absorbable Non Absorbable

Catgut Silk
Silk worm gut
Chromic catgut
Linen
Collagen Cotton
Fascia lata Ramie
kangaroo tendon Horse hair
Beef tendon
Cargile membrane
 SYNTHETIC
 Absorbable  Non Absorbable

 Polyglycolic Acid  Nylon/ polyamide

 Polyglactic Acid  PolyPropylene
 Polyglactin 910(Vicryl)  Polyesters
 Polydioxanone(PDS)  Polyethelene
 Polyglecaprone 25  Polybutester
 Polyvinylidene fluoride /
PVDF Sutures
 Monofilament

Multifilament
 MONOFILAMENT
Advantages Disadvantages
• Smooth surface • Handling and
• Less tissue trauma knotting
• No bacterial • Stretch
harbours • Any nick or crimp in
• No capillarity the material leads
to breakage.
 MONOFILAMENT

 Absorbable  Non Absorbable

 Surgical Gut- Plain,  Polypropylene

Chromic  Polyester
 Polydiaxanone  Nylon/polyamide
 Polyglactin 910  Polyvinylidene fluoride /
PVDF Sutures
 MULTI FILAMENT
Advantages Disadvantages
• Strength • Bacterial harbours
• Soft and pliable • Capillary action
• Good handling • Tissue trauma
• Good knotting
 MULTIFILAMENT

 Absorbable  Non Absorbable

 Polyglactin 910  Silk

 Polyglycolic Acid  Cotton
 Linen
 MONOFILAMENT  MULTIFILAMENT

 Handling Difficult  Handling easy

 Smooth & strong  Low Strength

 No Wicking  Wicking is a Problem

 Thinner  Thicker
Metallic

SS
Tantalum
Gold
Silver
Aluminium
Non absorbable sutures are categorized
by the United States Pharmacopeia
(USP) as
Class I - Silk or synthetic fibers of
monofilaments with twisted or braided
construction
Class II - Cotton or linen fibers, coated
natural or synthetic fibers in which the
coating does not contribute to T.S
Class III - Metal wire of monofilament or
multifilament construction.
 SELECTION OF SUTURE
MATERIAL

A variety of suture materials and suture/needle

combinations is available. The choice of suture
for a particular procedure is based on the known
physical and biologic characteristics of the
suture material and the healing properties of the
sutured tissues.
 Principles of suture selection

The selection of suture material by a

surgeon must be based on a sound
knowledge of
• 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.
1. Rate of healing of tissues:

• When a wound has reached maximal strength,

sutures are no longer needed.

• Tissues that ordinarily heal slowly such as skin,

fascia and tendons should usually closed with non –
absorbable sutures.

• Tissues that heal rapidly such as peritoneum, liver,

small intestine, muscles, stomach ,colon and
bladder may be closed with absorbable sutures.

• Suture should be stronger than the sutured

tissues, and it is unwise to implant more material
than necessary.
2.Tissue contamination:
• Avoid multifilament sutures as
bacteria can linger with them and
may convert a contaminated wound
into an infected one.

• Use monofilament absorbable or

non- absorbable sutures in
potentially contaminated tissues.
Monofilament polypropylene is
ideal
3. cosmetic results :
• Where cosmetic results are important,
close and prolonged apposition of
wounds and avoidance of irritants will
produce the best results. Therefore use
a smallest, inert monofilament suture
materials such as poly amide and
polypropylene.
• Avoid skin sutures and close
subcuticularly whenever possible
• Under certain circumstances, to secure
close apposition of skin edges , skin
closure tape may be used
4. cardiovascular surgery:
• Monofilament polypropylene, polyester,
coated and un coated and braided surgical
silk are recommended.

• Monofilament polypropylene being smooth,

possess high TS is the material of choice
for vascular anastomosis. This material
does not encourage any thrombus formation.

• Polyester is preferred for suturing artificial

heart valves, myocardium and vascular
prosthesis.
5. Microsurgical procedure:
• Most commonly used suture is 10-0 poly amide
monofilament

6.wound repair in patients following irradiation

• In this group of patients ,not only the normal
healing process is delayed but the tolerance to the
trauma of irradiated tissue is markedly reduced .
So
• Extremely careful and gentle surgical
technique
 Avoid tension sutures and mattress
sutures as they further increase the degree of
ischemia.
 Closure in layers
 Avoid continuous and constant
pressure on irradiated tissues.
 Fascial layer –non-absorbable
sutures, polypropylene is ideal
The selection of suture material is based on

The condition of the wound,

The tissues to be repaired,
The tensile strength of the suture
material
Knot-holding characteristics of the suture
material and
The reaction of surrounding tissues to the
suture materials.
ABSORPTION OF SUTURE MATERIALS

Degraded either by enzymatic process as in gut

sutures, or by hydrolysis, as in many of the
synthetic materials like glycolic acid,
ployglactin910 or polydioxanone.
Non absorbable sutures are walled off or
encapsulated.
 In infected tissues or in a patient who is febrile or
protein deficient, suture breakdown may be
accelerated.
 If the loss of TS outpaces the healing phase,
failure of the wound results.
 Absorbable sutures must be placed well into the
dermis.
BIOLOGIC RESPONSE OF BODY
TO
SUTURE MATERIALS
 BIOLOGIC RESPONSE OF BODY TO
SUTURE MATERIALS
• The initial body response to sutures is almost
identical in the first 4-7 days, regardless of the
suture material.

• The early response is a generalized acute aseptic

inflammation, involving primarily polymorphonuclear
leukocytes.

• After few days mononuclear cells, fibroblasts &

histiocytes become evident.

• Capillary formation occurs at the end of this initial

phase.
• Natural Absorbable – Proteolytic
degradation. Intense tissue response

• Synthetic Absorbable – Hydrolysis. Less

Intense

• Non Absorbable – Encapsulation. Acellular

Response
 RAILROAD SCAR

 Sutures passing through mucous membrane or

skin provide a ‘wick’ or pathway through which
bacteria track down, and bacteria gain access
to underlying tissues.
 The longer the suture remains, the deeper the
epithelial invasion of the underlying tissue.
When suture removed, epithelial tract remains.
 These cells may eventually disappear or remain
to form keratin and epithelial inclusion cysts.
The epithelial pathway result in typical
‘railroad scar’ formation.
ABSORBABLE -NATURAL
Gut / cat gut
Oldest known absorbable suture.
Galen referred to gut suture as early as 175
A.D.
Derived from sheep intestinal sub mucosa or
bovine intestinal serosa.
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.
• Catgut should not be boiled or autoclaved as heat
destroys its tensile strength.

• Catgut is sterilized during preparation and kept in a

preservative solution (isopropyl 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 .

• Absorption :40-60 days

• When placed intra orally sutures are digested in 3-

5days.
• 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

• Absorbtion: Catgut is absorbed by

proteolytic digestive enzymes released
from inflammatory cells collected around
the catgut. So, in the presence of
infection catgut is rapidly absorbed.
CHROMIC CATGUT
Coated with thin layer of chromium salt
solution to minimize tissue reaction,
increase TS, slow the absorption rate,
better knot security, and ease of
handling.
TS – 10-14 days
Absorbed in 90 days
Uses:Opthalmic surgery (6-0)
Oral surgery
Suture subcutaneous tissues
As it is an organic material and
susceptible to enzymatic degradation,
packed in isopropyl alcohol as a
preservative. Also condition or soften
it.

Suture absorbs alcohol and swells. It is

combustible and is also irritating to
tissues. It is removed by a quick rise
in saline prior to use.
 COLLAGEN SUTURE
 Natural, absorbable, monofilament
 Obtained by homogenous dispersion of
pure collagen fibrils from the flexor
tendons of cattle.
 Absorption – 56 days
 TS - < 10% after 10 days.
 Used in opthalmic surgery
 Disadvantage of premature absorption.
 SYNTHETIC ABSORBABLE

POLYGLACTIN 910 (VICRYL) Polyglactic

acid

 Coated and uncoated

 Synthetic suture
 Monofilament/multifilament
 Lactide has hydrophobic qualities→delaying loss of
TS
 TS - 14 – 21 days.
 Absorption – 56-70 days.
 Minimal tissue reactivity and can be used in
infected tissues
 Available in purple and undyed. Undyed used on
face.
 Coated with polyglactin 370 and calcium stearate
which allows easy passage through tissues as well
as easier knot placement.
 On skin wounds, associated with delayed
absorption as well as increased inflammation.
 VICRYL –RAPIDE
• It is braided synthetic absorbable suture material.
• Colour: White.

• 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 cosmetics and reduction of
postoperative pain.
• The absorption is essentially complete
within 35-42 days.

• Uses: Low tensile strength and Rapid

absorption rate --Ideal for intra-oral
use (dental surgeries).
VICRYL plus ANTIBACTERIAL
SUTURE

• Handles and
performs same as
normal vicryl.
• In vitro studies
shown that triclosan
on VICRYL plus
creates a zone of
inhibition around
the suture.
GLYCOLIC ACID HOMOPOLYMER
(DEXON) POLYGLYCOLIC ACID

 Polymer of glycolic acid with greater knot pull

and TS than gut.
 Synthetic, absorbable, braided
 Absorption- hydrolysis, which results in
minimal tissue reactivity.
 Braided and so catches on itself, and knot
tying and passage through tissues difficult.
 Does not tolerate wound infection and not
percutaneous suture.
GLYCOLIC ACID (MAXON) POLYGLYCONATE
-Synthetic, absorbable, monofilament.
-Polyglycolic acid and trimethylene carbonate
-TS – 14-21 days (>Dexon)
Absorption – Hydrolysis in 180 days
In vitro studies by Edlich and co-workers (1973)
have suggested that the degradation products of
polyglycolic acid and nylon sutures - glycolic acid,
1,6-hexane diamine and adipic acid are
antibacterial agents.
POLYDIOXANONE (PDS II)

 Synthetic,absorbable,monofilament.

 Polyester derivative poly P dioxanone.

 TS -14-42 days

 Absorption – Hydrolysis in 6 months.

 Passes through tissues easily.

 Significant memory – compromises the
ease of knot-tying and knot security.

 Minimal tissue reaction

 For wounds under tension and

contaminated wounds.

 May extrude through the wound over

time. So used only in tissues deeper
than subcuticular layer. Or if in face 6-
0 used.
 NON ABSORBABLE SUTURES
• Natural – silk, silk worm gut, cotton ,
ramie,linen
• Synthetic-polyester, polyamide, poly
propylene, polybutester,polyethelene
• Metals : SS
Tantalum
platinum
silver wires
gold
aluminium
NATURAL NON-ABSORBABLE

SURGICAL SILK
-Braided or twisted
-Made from the filament spun by silkworm larva
to form its cocoon. Each filament is
processed to remove the natural waxes and
sericin gum. After braiding, the strands are
dyed, stretched and impregnated with a
mixture of waxes and silicone. Dry silk suture
is stronger than wet silk suture.
Advantage:
 Ease of handling – more for braided
 Good knot security
 made non capillary in order to withstand action
of body fluids & moisture.(wax or silicon coated)
 Cost effective

Contraindications:
Should not be used in presence of infection
Uses:
Plastic surgery, ophthalmic and general
surgeries, ligating body tissues.

Although characterized as non-absorbable,

studies show that it loses most of their
TS after 1 yr. and cannot be detected
in tissues after 2 yrs.
SURGICAL COTTON

 Natural, multifilament, non absorbable

 From stable Egyptian cotton fibers
 good knot security
 Not good in presence of contaminated
wounds or infection
 Rarely used nowadays
Uses:
Most body tissues for ligating and
suturing
 LINEN

 Natural, multifilament, non absorbable

 Made from stable flax fibers
 Poor TS and so not for suturing under
tension
Uses:
Ligation of superficial vessels
Mucosal suturing without stress
SYNTHETIC NON-ABSORBABLE

POLYPROPYLENE (PROLENE)
-Polymer of propylene.
-Inert and TS for 2 yrs
-Holds knots better than other synthetic
sutures.

Advantages
-Minimal suture reaction and so used in infected
and contaminated wounds.
-Do not adhere to tissues and is flexible. So
used for ‘pull-out’ type of sutures.
Uses:
General, plastic, cardiovascular surgery, skin
closure, ophthalmology.
 NYLON – BRAIDED (SURGILON, NURILON)
 Synthetic, non absorbable
 Inert polyamide polymer
 Braided and sealed with silicon coating
 Look, handle and feel like silk, but
more stronger
 Multifilament nylon is weaker and less
secure when knotted, offering little
advantage over monofilament nylon.
NYLON MONOFILAMENT (DERMALON,
ETHILON)
 Uncoated, but inert and non irritating to
the tissues.
 High TS and low tissue reactivity
 Some memory and return to original
linear shape over time. Because of this
more throws (4 throws) indicated.
 Moistened nylon monofilament are more
easily handled and are packaged wet.
Uses:
Skin closure, retention, plastic, ophthalmic
and microsurgery.
 POLYESTER – BRAIDED
Tycron, Mersilene -Uncoated
Dacron, Ethibond - Coated (with polybutilate)
 Multifilament fibers of polyester
 Excellent TS which is maintained indefinitely
 Uncoated is rougher and stiffer than coated form
 Coated provides -low infection rate
-secure knotting
-smooth removal
-low reactivity
-easy passage through
tissues
 More expensive
 In deeper layers, may last indefinitely.
 GOR-TEX
 Nonabsorbable,synthetic,Monofilament
 From,expanded polytetrafluoroethylene
(ePTFE)
 Extremely low tissue reaction, good knot
tensile strenghtand ease of handling.
Uses
All type of soft tissue approximation and
cardiovascular surgeries.
 MONOCRYL
 Absorbable, synthetic, monofilament
 Poliglecaprone 25; copolymer of glycolide
and caprolactone
 Hydrolysis 90-120 days
 Tissue reaction – minimal
 Good knot strength
 Used for soft tissue closure
 Most pliable material ever made
 POLYBUTESTER (NOVOFIL)

-New, monofilament, nonabsorbable, synthetic

-Made of polyglycol trephthate and polybutylene

terephthalate and is considered as a modified
polyester suture.

-No significant memory compared to polypropylene and

nylon. Easier to manipulate and greater knot security.

-Unique feature is their ability to elongate or stretch

with increasing wound edema. When edema subsides,
suture resumes original shape; so it is an ideal suture
for lacerations secondary to blunt trauma.
-TS high and lasts longer
-Minimal tissue reactivity.
-Popularity in cutaneous surgery is gradually
increasing.
SURGICAL STEEL

 Natural, monofilament/multifilament, non

absorbable
 Alloy of iron, nickel and chromium
 Good TS even in infection
 Difficult to handle and tendency to cut
through tissues. Very hard to tie, and knot
ends require special handling.
 Potential to corrode or break at points
of twisting, bending or knotting.

 Not to be used with a prosthesis of

another alloy.

 Used in abdominal wall and skin closure,

sternal closure, retention, tendon
repair, orthopedic and neurosurgery.

 OMFS- for suspension of splints or arch

bars and not as suture material.
 Major Disadvantages

1.Linear artifacts caused by substances with

high atomic number on CT images

2.Possible movement of metal suture during

MRI

3.Patch test for nickel sensitivity should be

done.
 Packaging………
PRODUCT CODE
METRIC GUAGE IMPERIAL GUAGE

NEEDLE SIZE &

CURVATURE

NEEDLE TYPE

NEEDLE TIP

NEEDLE PROFILE

STERILIZED
DO NOT REUSE
EXPIRY DATE BATCH NO
ETHELENE OXIDE
SEE INSTRUCTIONS FOR USE
 SUTURE SIZES
• Largest size 1 to extremely fine 11-0.
Increasing number of zeroes correlates with
decreasing suture diameter and strength.

• Thicker sutures are used for approximation of

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. Size is chosen to correlate with the
tensile strength of the tissue being sutured.
3-0 or 4-0 OMFS, muscle, deep skin
5-0 or 6-0 facial skin closure
9-0 or 10-0 microsurgery
 SUTURE NEEDLES
Surgical needles are designed to lead
suture material through tissue with
minimal injury. Needles can be
- straight (GIT) or curved
- swaged or eyed
Made up of either SS or carbon steel.

Needle is selected according to:

-type of tissue to be sutured
-tissue’s accessibility
-diameter of suture material.
Made up of either SS or carbon steel.

CLASSIFICATION OF SURGICAL NEEDLES

1.According to eye -eye less needles
-needles with eye
2.According to shape -straight needles
. -curved needles
3.According to cutting edge
a) round body
b) cutting -conventional

-reverse cutting
• 4.According to its tip -triangular tip
-round tip
-blunt tip
• 5.Others -spatula needles
-micro point needles
-cuticular needles
-plastic needles
 Ideal Properties Of Needles
• High quality stainless steel

• Smallest diameter possible

• Capable of implanting sutures with minimal trauma

to tissues.

• Stable in the needle holder

• Should be sharp.

• Sterile and corrosion resistant.

Anatomy of a Needle
 Term Definition

Chord The linear distance between eye and

tip.

Length of needle The distance between eye and tip

following the curvature

Radius The distance of the body of the

needle from the centre of the circle

Diameter Gauge or thickness of the metal wire

out of which the needle is made.
 COMPONENTS OF SURGICAL
NEEDLE CLOSED
1. The eye
2. The body; and
3.The point SWAGED
The eye can be - closed
- swaged
- chanelled/drilled
Shape of the eye may be - round
CHANELLED
- oblong; or
- square

Open French-eye needle is easy to load with

varying caliber, but has additional bulk.
Eyed require threading prior to Suture loop inserted through eye
use, results in pulling a double
strand through tissue. Tying the
suture to the eye increases bulk
of suture material drawn through Loop placed over tip
tissues. So they are also called
‘traumatic needles’.

Most suture materials and Loop drawn back

needles are difficult to sterilize.
Needles are also difficult to
clean after use and become blunt
Suture tied on eyed needle
and workhardened so that they
snap.
 SWAGED NEEDLE

• Swaged needles do not require threading and

permit a single strand of suture material to be
drawn.
• Suture attached to needle via a hole drilled
through the end of the needle, and the end is
swaged during manufacturing.
• It is atraumatic and
act as a single unit.
• Prepacked and presterilized
by gamma radiation.
Needle attached to suture
Favourable for I/O use but expensive
Less tissue damage
New needle each time
 THE BODY
• Body is the widest portion of the needle
• It is known as grasping area.

-Most commonly used are 3/8 circle. They can be

easily manipulated in large and superficial wounds
and require only less wrist movement.

-1/2 circle used for suturing tissues in small

wounds, and body cavities and orifices. Require
less space, but more supination and pronation of
wrist required.
-5/8 used in oral cavity.
Tapered

Cutting

Reverse cutting
RADIUS OF CURVATURE OF THE CLINICAL USE
BODY(NEEDLE)
Straight Needle Needle of choice for the skin
Limited use in oral surgery
May be used in surgery of the
nose, pharynx, tendons

¼ circle Needle of choice for microsurgery

associated with very fine sutures;
ophthalmology

3/8 circle Oral surgery, flap surgery, wound

closure after placement of
osseointegrated implants and GTR
procedures
May be used in all surgical wounds

Needle of choice in oral surgery

½ circle Wide range of uses in many
surgical wounds

5/8 circle Wounds of the urogenital tract

 THE POINT
Point runs from tip to the max. cross sectional
area of the body.

• Can be -triangular tip/cutting

-round tip
-blunt tip

• Cutting needles are Ideal for suturing keratinized

tissues like skin, palatal mucosa, subcuticular
layers and for securing drains.

• Round/tapered needles used for closing

mesenchymal layers such as muscle or fascia that
are soft and easily penetrable
• The conventional • The reverse cutting
cutting point has two point has two opposing
opposing cutting edges cutting edges and third
and third edge on the cutting edge on the
inside curvature of the outer curvature of the
needle. needle.
• The tapered point is used primarily on soft,
easily penetrated tissues . it leaves small hole
and can be used in vascular surgery as well as
fascial soft tissue surgery.

• The blunt point has a rounded end which does

nt cut through the tissue .it is used in friable
tissue suturing or to the parotid duct or
lacrimal canaliculi.
Cuticular needles Plastic needles

• Sharpened 12 times • Sharpened an additional 24

• Designated as C or FS times
• Designated as P or PS or PC
(CUTICULAR or FOR SKIN)
(PREMIUM or PLASTIC
SURGERY or PRECISION
COSMETIC ).
• Needles in the PC series
are made up of stronger
SS alloy and have flattened
and conventional cutting
edge.
• Curvature of the needle is selected according to
the accessibility. The needle must exit in a
visible spot so that the surgeon is aware of the
position of the point of the needle at all the
times.

• Try to match the needle thickness with suture

diameter .it is not appropriate to use wide thick
needle with small suture material . This will
cause laxity of immediate suture line and allows
bacterial contamination & ingrowth of epithelium
& in vascular surgery it may allow oozing of blood
throught/suture hole.
Placement of a Needle into the Tissue

 Force should always be applied in the

direction that follows the curvature of
the needle.
 Movable to a non-movable tissue.
 Only sharp needles with minimal force.

 Never force the needle through the

tissue.
 Avoid retrieving the needle from the
tissue by the tip.
 Grasp the needle in the body 1/4th to
half of the length from the swaged
area.

 Do not hold the needle by the swaged

area or the eye.

 Avoid excessive tissue bites with small

needles, as it will be difficult to
retrieve them
 NEEDLE HOLDER

• The needle holder is used to handle

the suture needle and thread while
suturing the surgical wound.

• If used properly it enables the

surgeon to perform procedures
correctly and with great precision.
 PARTS OF NEEDLE HOLDER

• Working tip/ jaws

• Hinge device
• Shank/body
• Catch mechanism/ ratchet
• Grip area
 NEEDLE HOLDER

There are different types of needle holders.

The beaks may be short or long, broad or
narrow, slotted or flat, concave or convex,
smooth or serrated. Commonly used have a
locking hand and short beaks and 6’ long
Gilles needle holder (scissors incorporated into
blades)
Kilner needle holder
• Atraumatic needle holder ensures
needle movement and compatibility of
clamping movement. It has textured
tungsten carbide jaw inserts, and its
rounded needle holder jaw edges do not
cause structural damage to
monofilament suture or needle
GILLES NEEDLE HOLDER

Scissors are incorporated into the blades

OLSEN HEGAR NEEDLE HOLDER KILNER NEEDLE HOLDER
 YASARGIL MICRO NEEDLE HOLDER
MAYO HAGER NEEDLE
 Gripping needle holder
The scissor grip
Used in the anterior part of the mouth and in
areas of easy access
The instrument is stabilized with the index finger
Palm grip
• Used in the deeper parts of oral
cavity
 Use appropriate size for
needle
 Grasped 1/4 to ½ distance
from swaged area
 Tips of the jaws should
meet before remaining
portion of jaw
 Needle placed securely
 Do not overclose
 Always directed by
surgeon’s thumb
 Do not use digital pressure
on tissues
PRINCIPLES
OF
SUTURING
 PRINCIPLES OF SUTURING

1.Needle grasped at 1/4th to half the

distance from eye.

2.Needle should enter perpendicular to

tissue surface
3.Needle passed along its curve

4.The bite should be equal on both sides of the

wound margin and the point of the entry of the
needle should be closer to the wound edge than
its point of exit on the deep surface
5.The bite should be about 2-3 mm from the wound
margin of the flap because after wound closure
the edge of the wound softens due to
collagenolysis and the holding power is impaired.
6. Usually the needle to be passed from mobile side to the
fixed side but not always(exception in lingual
mucoperiosteum flap) and from thinner to thicker & from
deeper to superficial flap.

7.The tissues should not be closed under tension , since they

will either tear or necrose around the the suture
8.Tie to approximate; not to blanch

9.Knot must not lie on incision line

10.The distance b/w one suture to another

should be about 3-4 mm apart to prevent
strangulation of the tissue & to allow
escape of the serum or inflammatory
exudate & to get more strength of the
wound.
11.Sutures placed at a greater depth than distance
from the incision to evert wound margins

12.Close deep wounds in layers

13.Avoid retrieving needle by tip

14.Adequate tissue bite to prevent tearing

15.sutures should have correct tension while tying

knot for provision of the slight edema post
operatively, more tensioned sutures cause
ischemia of the edges of the incision
causes tearing of the tissues
may leave suture mark
edges may get overlapped
16.Occasionally extra tissue may be present on
one side of incision and cause DOG EAR to be
formed in the final phase of wound closure.

• Simply extending the length of the incision to

hide the exists will produce an unsatisfactory
result.

• Thus after undermining excess tissue incision

is made at approx. 300 to parent incision
directed towards undermined side. Extra
tissue is pulled over incision and appropriate
amount is excised. Incision is closed in normal
manner.
IMPROPER SUTURING TECHNIQUE
 SUTURING
TECHNIQUES
 1.INTERRUPTED SIMPLE SUTURE

Most commonly used. Inserted singly through side

of the wound and tied with a surgeon’s knot.
Advantages
Strong and can be used in areas of stress
Placed 4-8 mm apart to close large wounds, so that
tension is shared
Each is independent and loosening one will not
produce loosening of the other
Degree of eversion produced
In infection or hematoma, removal of few sutures
Free of interferences b/w each stitch and easy to
clean
2. SIMPLE CONTINUOUS / RUNNING

A simple interrupted
suture placed and needle
reinserted in a continuous
fashion such that the
suturepasses perpendicular
to the incision line below
and obliquely above.
Ended by passing a knot
over the untightened end
of the suture.
Advantages
 Rapid technique and distributes tension
uniformly
 More water tight closure (Shoen, 1975)
 Only 2 knots with associated tags

Disadvantages
If cut at one point, suture slackens along
the whole length of the wound which will
then gape open.
 3.CONTINUOUS LOCKING/BLANKET
Similar to continuous but locking provided by
withdrawing the suture through its own loop.
Indicated in long edentulous areas, tuberosities
or retromolar area.

Advantages
Will avoid multiple knots
Distributes tension uniformly
Water tight closure
Prevents excessive tightening.

Disadvantage :prevents
adjustment of tension over
suture line as tissue swelling
occurs.
 4.VERTICAL MATTRESS

 Specially designed for use in

skin. It passes at 2 levels, one
deep to provide support and
adduction of wound surfaces at a
depth and one superficial to
draw the edges together and
evert them.

 Used for closing deep wounds

 This approximates subcutaneous
and skin edges
Needle passed from one edge to the other and again from
latter edge to the fist and knot tied.
When needle is brought back from second flap to the first,
depth of penetration is more superficial.
Advantages :
• for better adaptation and maximum tissue
approximation

• To get eversion of wound margins slightly

• Where healing is expected to be delayed for any

reason, it is better to give wound added support by
vertical mattress. Used to control soft tissue
hemorrhage.

• Runs parallel to the blood supply of the edge of the

flap and therefore not interfering with healing.

• Uses: abdominal surgeries & closure of skin wounds.

 5.HORIZONTAL MATTRESS
 It everts mucosal or skin margins, bringing
greater areas of raw tissue into contact. So used
for closing bony deficiencies such as oro-antral
fistula or cystic cavities.

 Disadvantage: constricts the blood supply to

edges of incision.
Needle passed from one
edge to the other and
again from the latter to
the first and a knot is tied.

Distance of needle
penetration and depth of
penetration is same for
each entry point, but
horizontal distance of the
points of penetration on
the same side of the flap
differs.
Advantages:
Will evert mucosal or skin margins, bringing greater
areas of raw tissue into contact.

-So used for closing bony deficiencies such as oro-

antral fistula or cystic cavities, extraction socket
wounds.
• Prevents the flap from being inverted into the cavity.

• To control post-operative hemorrhage from gingiva

around the tooth socket to tense the
mucoperiosteum over the underlying bone.
• It does not cut through the tissue ,so used
in case of tissue under tension
(inadequate tissue)
Disadvantages:
• More trouble to insert
• Constricts the blood supply to the incision
if improperly used, cause wound necrosis
and dehiscence
 6. FIGURE OF 8 SUTURE
Used for extraction socket closure and for
adaption of gingival papilla around the tooth
Suturing begun on buccal surface 3-4mm from
the tip of the papilla so as to prevent tearing of
papilla.

Needle first inserted into the

outer surface of the buccal flap
and then the lingual flap.
Needle again inserted in same
fashion at a horizontal distance
and then both ends tied.
 7. SUBCUTICULAR SUTURE
Used to close deep wounds in layers. Knots
will be inverted or buried, so that the knot
does not lie between the skin margin and
cause inflammation or infection.

To bury the knot, first pass of the needle

should be from within the wound and through
the lower portion of the dermal layer. Needle
then passed through the dermal layer and
emerge through subcutaneous tissue and knot
tied
 8.CONTINUOUS SUBCUTICULAR SUTURE

Continuous short
lateral stitches are
taken beneath the
epithelial layer of the
skin. The ends of the
suture come out at each
end of the incision and
are knotted.
Advantages
Excellent cosmetic result
Useful in wounds with strong skin tension,
especially for patients prone to keloid formation.
Anchor suture in wound and, from apex, take
bites below the dermal-epidermal layer
Start next stitch directly opposite the one that
precedes it.
 9.PURSE STRING SUTURE
A circular pattern that draws together
the tissue in the path of the suture when
the ends are brought together and tied.
KNOT TYING
 KNOT TYING

Sutured knot has 3 components

1.Loop created by knot
2.Knot itself which is composed
of a number of tight throws
3.Ears which are the cut ends of
the suture
 KNOT TYING
Principles of knot tying

 Use the simplest knot that will prevent slippage.

 Tying the knot as small as possible and cutting the
ends of the suture as short as reasonable to
minimize foreign body reaction.
 Avoid friction or sawing
 Avoid damage to suture material
 Avoid excessive tension

 Tying sutures too tightly strangulates the tissue

 Maintenance of traction at one end of the
suture after the first loop is thrown, to avoid
loosening of the knot.

 Placing the final throw as horizontally as

possible to keep knot flat

 Limiting extra throws to the knot, as they do

not add strength to a properly tied knot.
 KNOTS
SQUARE KNOT
Formed by wrapping the
suture around the needle
holder once in opposite
directions between the
ties. Atleast 3 ties are
recommended.
Best for gut, silk, cotton
and SS
 SURGEON’S KNOT

Formed by 2 throws on the first tie and one

throw in the opposite direction in the second
tie. Recommended for tying polyester suture
materials such as Vicryl and Mersiline
 GRANNY’S KNOT
A tie in one direction followed by a tie in
the same direction and a third tie in the
opposite direction to square the knot and
hold it permanently.
 SUTURE
REMOVAL
 SUTURE REMOVAL

Skin wounds regain TS slowly. It can be

removed in 3-10 days when the wound
gained 5%-10% of final TS. Skin sutures on
face removed between 3-5 days. Alternate
sutures removed on 3rd day and remaining
sutures after 2 days.
 Intra oral
- Mucoperiosteal closure (without tension)
5-7 days
- Where there is tension on the suture
eg : Oro-antral fistula- 7-10 days
 Back and legs where cosmesis is less important –
10-14 days.
 Continuous subcuticular can be left for 3-4
weeks without formation of suture tracks
 A good guide is that as soon as they begin to get
loose they should be taken out.
 Suture area is first cleaned with normal saline.
 The suture is grasped with non-tooth dissecting forceps
and lifted above the epithelial surface.
 Scissors are then passed through one loop and then
transected close to the surface to avoid dragging
contaminated suture material through tissues.
 The suture is then pulled out towards incision line to
prevent dehiscence.If suture entrapped in a scab,
application of hydrogen peroxide or saline solution is
necessary.
 If pieces of suture left, infection or granuloma formation
can ensue.
• INCORRECT

• CORRECT
• Possible Complication Of Leaving
Suture For Many Days :
1.Sutural abscess.
2.Suture scarring or stitch mark
3.Implanted dermoid cyst
 SCISSORS
Dean’s Scissors
-General purpose scissors
-Used for cutting sutures
-Can also be used to trim mucosal margins.
 SUTURE MARKS

Suture marks are caused by 3 factors

1.Skin sutures left in place longer than 7

days, resulting in epithelialisation of
suture track

2.Tissue necrosis from sutures that were

tied too tightly or became tight due to
tissue edema

3.Use of reactive sutures in the skin.

 Other Methods of Wound
Closure
• Ligating clips
• Skin staples
• Surgical tape
• Surgical adhesives
 Mechanical wound closure
devices

Ligating clips :
• can be resorbable or non resorbable.
• Made up of SS,tantalum or titanium or
pidioxanone.
• Designed for the ligation of tubular
structures.
Surgical staples:
• Used for skin closure .
• Made up of SS.
• They are placed uniformly to span
the incision line.
• They have minimal tissue reaction .
• Can be used for routine skin closure
any where in the body.
 Advantages
• As the clips do not penetrate skin, yet give
apposition, the cosmetic result is excellent.
• Speed and efficacy of stapling is more
compared to sutures.
• Suturing causes more necrosis than stapling in
myocutaneous flaps.

• Most significant advance is the introduction of

absorbable staples (Lactomer).
• Contra indicated when it is not
possible to maintain atleast 5mm
distance from the stapled skin to the
underlying bone and blood vessels.
 SURGICAL TAPE

 Microporous tape is used alone or in conjugation

with skin sutures to decrease tension at the wound
margins.
 The surgical tapes have a backing of viscous rayon
fibers coated with an adhesive copolymer and they
are pervious to sweat but not to blood or purulent
material.
 Comes in 1/8, 1/4, and 1/2 inch wide strips. Skin
margin is prepared with tincture of benzoin to
provide better adhesiveness for tape.
 Used to decrease skin tension on
cheek,forehead,chin.
 Advantages

 Minimizes wound dehiscence and allows earlier

suture removal
 Provides continuous support for the wound and
minimizes scar expansion
 Avoids the ordeal of suture replacement and
removal in children
 Less inflammatory reaction, lower rate of wound
infection, greater TS and better cosmetic results.
 No needle puncture marks and suture canals
 Strangulation and necrosis of tissue are eliminated
 Sterile paper tape is non expensive
 Disadvantage

 Do not evert edges of the wound, and readily loosen

when wet by blood or serum.

 Prior to placement, a thin coat of antibiotic ointment

is placed on wound margin to protect wound from
skin oils and bacteria.

 While removing, to avoid epithelial margin

separation, the ends should be lifted equally towards
the wound margin and then lifted evenly from the
wound.
 Cyanoacrylates

- n-butyl cyanoacrylate is the active ingredient.

Advantages :

 Strong bonding to tissues in presence of moisture

 Biodegradable, bacteriostatic & hemostatic.

 Reduced post operative pain & facilitates healing.

 Good shelf life.

 Produces little or no heat during polymerisation.

 Bonding is by secondary intermolecular forces aided

by mechanical interlocking of irregular forces.

 Quick, atraumatic and cost effective with good
cosmesis
 No injection, suturing and post-op suture removal.

Disadvantages

1.When applied for skin closure, the polymer acts as

barrier, prevents wound apposition, delays healing,
and increases the infection rate.
2.Should not be allowed to come in contact with tissue
under skin as it causes necrosis.
 REFERENCE
• Suturing techniques in oral surgery –Sandro
Siervo
• Atlas of Minor Oral Surgery- Harry Dym
• Laskin vol-1
• Oral & Maxillofacial Surgery Vol 1- W. Harry
Archer
• Textbook of oral & maxillofacial surgery-
Neelima Anil Malik
• Minor Oral Surgery- Goeffrey L.Howe
• Text book of surgery: Sabiston
• Periodontology-Caranza.
THANKTHANK
YOU YOU