presentation includes the various techniques of suturing as well as the suture materials, brief intro on history, periosteal suturing

1. SUTURE MATERIAL &
SUTURING
JOEL D’SILVA
DEPARTMENT OF ORAL & MAXILLOFACIAL SURGERY

2. INTRODUCTION
• Surgical suture (commonly called stitches) is a
medical device used to hold body tissues
together after an injury or surgery.
• A number of different shapes, sizes, and
thread materials as well as different types of
needles have been developed over its millennia
of history.

3. HISTORY

4. • Through many millennia, various suture
materials were used, debated, and remained
largely unchanged.
• Needles were made of bone or metals such as
silver, copper, and aluminium bronze wire.
• Sutures were made of plant materials (flax, hemp
and cotton) or animal material (hair, tendons,
arteries, muscle strips and nerves, silk, catgut)
• African cultures used thorns, and Indians used
ant sutures by coaxing insects to bite wound
edges with their jaws and subsequently twisting
off the insects' body to keep the wound closed
by the clenched jaws.

6. • The earliest reports of surgical suture date
back to 3000 BC in ancient Egypt, and the
oldest known suture is in a mummy from 1100
BC
• A detailed description of a wound suture and
the suture materials used in it is by the Indian
sage and physician Sushruta, written in 500
BC.

7. • Joseph Lister introduced great change in suturing
technique (as in all surgery) when he endorsed
the routine sterilization of all suture threads. He
first attempted sterilization with the 1860s
"carbolic catgut," and chromic catgut followed
two decades later. Sterile catgut was finally
achieved in 1906 with iodine treatment

8. 1- Provide an adequate tension of wound closure
without dead space but loose enough to obviate
tissue ischemia and necrosis.
2- Maintain hemostasis.
3- Permit primary intention healing
4- Reduce postoperative pain

9. 5- Provide support for tissue margins until they
have healed and the support no longer needed
6- Prevent bone exposure resulting in delayed
healing and unnecessary resorption
7- Permit proper flap position

10. QUALITIES OF THE IDEAL
SUTURE MATERIAL
1- Pliability, for ease of handling
2- Knot security
3- Sterilizable
4- Appropriate elasticity
5- Nonreactivity
6- Adequate tensile strength for wound healing

11. QUALITIES OF THE IDEAL
SUTURE MATERIAL
7- Chemical biodegradability as opposed to
foreign body breakdown
Postlethwait (1971), Varma et al. (1974), and Ethicon
(1985)

12. PRINCIPLES OF SUTURING
1- The completed knot must be tight, firm, and
tied so that slippage will not occur
2- To ovoid wicking of bacteria, knot should not
be placed in incision lines
3- Knots should be small and the ends cut short
(2-3mm)
4- Avoid excessive tension to finer gauge
materials as breakage may occur

13. PRINCIPLES OF SUTURING
5- Avoid using a jerking motion, which may break
the suture
6- Avoid crushing or crimping of suture materials
by not using hemostats or needle holders on
them except on the free end for tying
7- Do not tie suture too tightly as tissue necrosis
may occur. Knot tension should not produce
tissue blanching

14. PRINCIPLES OF SUTURING
8- Maintain adequate traction on one end while
tying to ovoid loosing the first loop

15. PRINCIPLES FOR SUTURE
REMOVAL
1- The area should be swabbed with hydrogen
peroxide for removal of encrusted necrotic
debris, blood, and serum from about the
sutures
2- A sharp suture scissors should be used to cut
the loops of individual or continuous sutures
about the teeth

16. PRINCIPLES FOR SUTURE
REMOVAL
3- It is often helpful to use a No. 23 explorer to
help lift the sutures if they are within the sulcus
or in close opposition to the tissue
4- A cotton pliers is used to remove the suture.
The location of the knots should be noted so that
they can be removed first. This will prevent
unnecessary entrapment under the flap

17. Suture should be removed in 7 to 10 days to
prevent epithelialization or wicking about the
suture

18. TECHNIQUE & PRINCIPLES OF
SUTURING
• The technique of suturing begins by selecting
the tissue forceps, needle and needle holder.
• Hold the needle holders in your dominant
hand by placing the thumb and ring finger into
the rings and the index finger on the hinge of
the blades.
• This position permits good control of the
instrument. Scissors should be held in a
similar position.

20. • The needle should be grasped in the holders
on its flattened area approximately one-third
of its length away from the suture material.

21. • To facilitate eversion (turning outwards),
support the wound edge with the tissue forceps
and insert the needle 5 mm from the edge
perpendicular to the skin surface. This creates
good apposition without excessive tension.
• As the wound heals, it causes slight inversion
with contraction; this will result in a flat scar.
Where skin edges curl under during suturing
they tend to invert further, leading to poor
healing and a less satisfactory cosmetic result.

22. • Ensuring that the needle remains at right
angles to the wound, follow the natural curve
of the needle by rotating the wrist and move
through each side of the wound separately. Do
not be tempted to traverse both wound edges
with one bite of the needle

23. • When the needle emerges from the wound,
pull the suture through the tissues until a
short tail remains at the initial skin entry site.
• Then enter the opposite side of the wound at
the same depth as the first bite. Again, follow
the natural curve of the needle by rotating
your wrist so that the needle emerges at the
same distance from the wound edge as the
first bite and at right angles

24. • To tie the suture, keep the needle holders
parallel to the skin and grasp the needle end
of the suture. Then make two clockwise loops
around the needle holder, followed by a single
anti-clockwise throw.

25. • Note that each successive throw is looped
around the forceps in the opposite direction to
the last and that all the knots should be seated
on the same side of the wound. The suture can
then be cut free from the knot, leaving tail
lengths of approximately 5 mm, before
beginning the next insertion.

26. NOTE……
• tie sutures just tight enough for the edges to
meet
• handle the skin edges with toothed forceps only
• if an irregular wound, start with a few initial
strategic sutures to match up the obvious points
• if the edges meet under considerable tension,
consider undermining the skin edges
• if one suture doesn’t look right it can affect the
whole wound/ scar - consider taking it out and
re-doing it

27. POINTS OF NEEDLES
•Cutting
• Cutting edge on
inside of circle
• Skin
• Traumatic

28. POINTS OF NEEDLES
•Reverse Cutting
• Cutting edge on
outside of circle
• Skin
• Less traumatic than
cutting

30. SHAPES OF NEEDLES
• 3/8 circle
• 1/2 circle
• Straight
• Specialty

31. TYPES OF NEEDLES
• Eyed needles
•More Traumatic
•Only thread
through once
•Suture on a reel
•Tends to
unthread itself
easily

32. TYPES OF NEEDLES
•Swaged-on
needles
• Much less traumatic
• More expensive
suture material
• Sterile

33. SURGICAL NEEDLES
•Most of surgical needles are
fabricated from heat treated steel
• The surgical needle has a basic
design composed of three parts
1- The eye which is swaged and
permits the suture and needle to act
as a single unit to decrease trauma

34. SURGICAL NEEDLES
2- The body which is the widest point of the
needle and is also referred to as the grasping
area. The body comes in number of shapes
(round, oval, rectangular, trapezoid, or side
flattened)
3- The point which runs from the tip to the
maximum cross-sectional area of the body.
The point also comes in a number of different
shapes (conventional cutting, reverse cutting,
side cutting, taper cut,taper, blunt

36. PLACEMENT OF NEEDLE IN
TISSUE
1- Force should always be applied in the
direction that follows the curvature of the
needle
2- Suturing should always be from movable to a
non-movable tissue
3- Avoid excessive tissue bites with small
needle as it will be difficult to retrieve them

37. PLACEMENT OF NEEDLE IN
TISSUE
4- Use only sharp needles with minimal force.
Replace dull needles
5- Never force the needle through the tissue
6- Grasp the needle in the body one-quarter to
one-half of the length from the swaged area.
Do not hold the swaged area; this may bend or
break the needle. Do not grasp the point area
as damage or notching may result

38. PLACEMENT OF NEEDLE IN
TISSUE
7- Avoid retrieving the needle from the tissue
by the tip. This will damage or dull the needle
8- Suture should be placed in keratinized tissue
whenever possible
9- An adequate tissue bite is required to
prevent the flap from tearing

39. INSTRUMENTS
adison forcep hemostat metzenbaum scissors suture scissors

40. INSTRUMENTS
Needle holders suture removal scissors
blade handle bandage scissors

41. SUTURE CLASSIFICATION

42. ACCORDING TO THEIR ORIGIN
•organic
•synthetic
•metallic

43. ACCORDING TO THEIR
BEHAVIOR IN TISSUE:
•Absorbable (phagocytized or hydrolyzed)
•Non-absorbable

44. ACCORDING TO THEIR
STRUCTURE
•monofilament
•multifilament

45. ACCORDING TO THE SIZE OF
SUTURE
• It varies from 1-0 being the greatest in the
diameter to 10-0 which are the least in
diameter and difficult to see with the naked
eye.

46. TYPES OF ABSORBABLE SUTURE
MATERIAL
Surgical Gut
• Plain gut loses its strength in 7-10 days and is
completely digested by 60 days. It is seldom
used now due to poor strength and high tissue
reactivity (due to proteolytic enzyme
degradation rather than hydrolysis).
• Chromic gut has been manufactured with
chromium salts to reduce enzyme digestion and
therefore maintains strength for 10-14 days

47. • Fast-absorbing gut is produced by pre-heating
and can be used for attaching skin grafts, or in
areas of low tension where the wound is well
supported by deep sutures, and suture
removal would be difficult. It maintains
strength for 3-5 days

48.  Polyglactin 910 (Vicryl®, Polysorb®)
• A synthetic braided co-polymer which
maintains 75% strength at 2 weeks, and 50% at
3 weeks.
• Absorption is usually complete by 3 months.
• It handles well, has minimal tissue reactivity,
and does not tear tissue. It may occasionally
persist as a small nodule or extrude
(‘spitting’).

49.  Poliglecaprone 25 (Monocryl®)
• Monofilament maintaining 50-60% strength at 7
days with complete absorption by 3 months.
• It offers better handling and knot security than
most other monofilament sutures, with even less
tissue reaction than Vicryl® and is therefore useful
where minimal tissue reaction is essential.

50. Polydioxanone (PDS II®)
• Monofilament polymer with prolonged tensile
strength (70% at 2 weeks, 50% at 4 weeks) and
may persist for more than 6 months.
• Good for high-tension areas or contaminated
wounds, but being a monofilament it has poor
handling and knot security. Its minimal tissue
reaction makes it good for repair of cartilage
where inflammation would lead to significant
discomfort.

51. Polytrimethylene carbonate
(Maxon®)
• A monofilament that combines the prolonged
strength of PDS® and the good handling and
knotting of Vicryl®. 80% strength at 2 weeks,
60% at 4 weeks, and complete absorption by 6
months. Minimal tissue reaction.

52. Glycomer 631 (Biosyn®)
• A monofilament similar to Monocryl® in
characteristics but with prolonged strength
compared to Maxon®.

53. NON-ABSORBABLE
SUTURES

54. Nylon (Ethilon®, Dermalon®, Surgilon®,
Nurolon®, Nylene®)
• Inexpensive monofilament with good tensile
strength, and minimal tissue reactivity.
• Disadvantages are its handling and knot
security, but it remains one of the most
popular non-absorbable sutures in
dermatological surgery. Surgilon® and
Nurolon® handle better but are more
expensive.

55. Polybutester (Novafil®)
• A monofilament with good handling and
excellent elasticity. It responds well to tissue
oedema, and is also suited to subcuticular
running sutures.

56. Polypropylene (Prolene®, Surgilene®,
Surgipro®)
• A monofilament polymer with a very low
coefficient of friction making it the suture of
choice for running subcuticular stitches.
• It has good plasticity but limited elasticity, poor
knot security, and it is relatively expensive.

57. Silk (Dysilk®, Mersilk)
• Braided natural protein with unsurpassed
handling, knot security, and pliability (making
it ideal for mucosal surfaces and intertriginous
areas) but limited by its low tensile strength,
and high coefficient of friction, capillarity, and
tissue reactivity.

58. Polyester (Dacron®, Mersilene®,
Ethibond®)
• Braided multifilament suture with high strength,
good handling, and low tissue reactivity.
• Ethibond is coated and has a low coefficient of
friction.
• Pliability makes these excellent for mucosal surfaces
without the reactivity of silk.

59. ADHESIVES/GLUES
 Simplifies Skin Closure
 No Suture Related Problems
 Noinflammation
 Local Anaesthetic Not Needed
 Used In Facial Lacerations & Children
 Acts As Barrier Against Microbes
 Dermabond(octyl-2-cyanoacrylate)
 Approved By Us Fda

60. TISSUE ADHESIVES
Before Curing After Curing
• Sterilizable
• Easy in preparation
• Viscous liquid or liquid
possible for spray
• Nontoxic
• Rapidly curable under wet
physiological conditions
(pH 7.3, 37°C, 1 atm)
• Reasonable cost
• Strongly bondable to
tissues
• Biostable union until
wound healing
• Tough and pliable
• Resorbable after wound
healing
• Nontoxic
• Nonobstructive to wound
healing or promoting
wound healing

61. NATURAL TISSUE – FIBRIN GLUE
• First reported in 1940
• Mimics blood clot – major component fibrin
network
• Excellent tissue adhesive but insufficient in
amount for larger wounds
• Nontoxic if human protein sources are used to
obtain fibrin

62. SYNTHETIC SYSTEMS:
POLY-ALKYL-2-CYANOACRYLATES
• Discovered in 1951
• “Crazy Glue”
• H2C=C―CO2―R
CN
• R = alkyl group
• CH3 (methyl)
• H3CCH2 (ethyl)
• Release small amount of
formaldehyde when curing
• amount lessens with
length of alkyl chain

63. CHARACTERISTICS OF CURRENTLY
AVAILABLE ADHESIVE SYSTEMS
Fibrin Glue Cyanoacrylate
Handling Excellent Poor
Set time Medium Short
Tissue bonding Poor Good
Pliability Excellent Poor
Toxicity Low Medium
Resorbability Good Poor
Cell infiltration Excellent Poor

64. OTHER EXPERIMENTAL SYSTEMS
• Gelatin-based adhesives
• Mimic coagulation but without fibrin
• Polyurethane (-HNOCO-) based adhesives
• Capped with isocyanate to rapidly gel upon
exposure to water
• More flexible than current cyanoacrylate adhesives
• Collagen-based adhesives

65. FIBRIN BASED TISSUE ADHESIVES
• Achieve Haemostasis
• Seals The Tissues
• Fixate Skin Grafts
• Arrest C.S.F Leak
• TISSEEL & HEMASEEL

66. *Image via Bing
TISSUE ADHESIVES

67. *Image via Bing

68. CYANO ACRYLATE GLUE AVAILABLE IN MARKET
*Image via Bing

69. *Image via Bing
APPLICATION OF TISSUE ADHESIVES

70. *Image via Bing
TISSUE ADHESIVES SUPPLIED WITH
NONMETALLIC NEEDLES

71. SKIN STAPLES
• FAST METHOD
• STAINLESS STEEL STAPLES
• LESS REACTIVE
• FEW MICRO ORGANISMS ARE CARRIED INTO
TISSUES
• EXPENSIVE
• APPLIED WITH GREAT CARE TO ENSURE
EVERSION

72. SKIN STAPLER

73. *Image by 54155059@N03 via Flickr

75. STAPLES & CLIPS VS. SUTURES
• Speed
• Convenience
• Reduced infection rate
• Lower cost
• If done properly, no cosmetic difference

76. SKIN STAPLE REMOVER
*Image by 61687822@N07 via Flickr

77. THE SKIN STAPLING

78. REMOVER

79. *Image via Bing
REMOVAL OF SKIN STAPLES

80. ADHESIVE TAPES OR STRIPS
• FIRST USED IN FRANCE IN 1500 A.D
• CHEAPER
• STERISTRIPS USED TODAY ARE POROUS PAPER
TAPES
• EG : CLOZEX

81. Image via Bing
WOUND CLOSURE STRIPS

82. *Image via Bing

84. *Image via Bing
SCALP WOUND CLOSED WITH STERISTRIPS

85. *Image via Bing

86. PERIOSTEAL SUTURING
• Generally requires a high degree of dexterity in
both flap management and suture placement.
Small needles (P-3), fine sutures (4-0 to 6-0)
and proper needle holder are a basic
requirement

87. PERIOSTEAL SUTURING
• Technique
1- Penetration: The needle point is positioned
perpendicular (90°) to the tissue surface and
underlying bone. It is then inserted completely
through the tissue until the bone is engaged.

88. PERIOSTEAL SUTURING
2- Rotation: The body of the needle is rotated
about the needle point in the direction
opposite to that in which the needle intended
to travel. The needle point is held lightly
against the bone so as not to damage or dull
the needle point

89. PERIOSTEAL SUTURING
3- Glide: The needle point is now
permitted to glide against the bone for
only a short distance. Care must be taken
not to lift or damage the periosteum
4- Rotation: As the needle glides against
bone; it is rotated about the body,
following its circumferenced outline. In
this way, the needle will not be pushed
through the tissue resulting in lifting or
tearing of the periosteum

90. PERIOSTEAL SUTURING
5- Exit: The final stage of gliding and rotation is
needle exit. The needle is made to exit the
tissue through the gentle application of pressure
from above, thus allowing the tip to pierce the
tissue

92. SIMPLE INTERRUPTED SUTURES
• This suture is used for simple laceration
closures or closure of office procedures like
biopsies or lesion removals.
• It is also the basic suture used inside the
wound to close deep sutures.
• It is useful in that a few sutures can be
removed at a time instead of all at once to
allow for slower sound healing

94. CONTINUOUS SUTURES
• The continuous suture as its name suggests, only
has a knot at the beginning and the end.
• There are several methods of continuous suture –
locking and non-locking.
• The knots must be very secure and minimal tesion
on the wound or the wound will come apart if one
loop or knot gives way.
• The advantage is that it is very quick and the
wound tension is even across the wound.

96. HORIZONTAL MATTRESS SUTURE
• Used with wounds with poor circulation
• Helps eliminate tension on wound edges
• Requires fewer sutures to close a wound
• Can be placed quite quickly
• Can be done as a continuous suture

98. VERTICAL MATTRESS SUTURES
• Deep and shallow approximation of the tissue
• Can be used for wounds under tension.
• Can be useful with lax tissue e.g. elbow and
knee.
• Should not be used on volar surface of hands
or feet or on the face because of blind
placement of the deep part of the suture.

100. SUB-CUTICULAR CLOSURE
• Used for cosmetic closures
• Use an absorbable suture if you plan to leave the
sutures in and bury the knots
• Use either nylon or prolene (best) and keep the
suture sliding while you are closing. The suture
then can be easily removed with no exterior marks.
The ends can be taped or a knot on the skin.
• At each entry point, enter across form the last exit
with slight overlap.

102. ELIPTICAL INCISION
The ellipse should be three times as long as it is
wide. This will make closure of the wound much
easier. If the lesion you are removing is likely to be
cancerous, make sure that you leave wide margins
of clear skin around the lesion.

104. 3 CORNERED SUTURE
• Used to close a skin flap which comes to a point.
• Helps close the wound, but maintain circulation to
the tissue.
• Places minimal tension on the wound edges

105. INSTRUMENT
TYING

106. WOUND EVERSION

107. WOUND EVERSION

108. BEST COSMETIC RESULTS
• Smallest size needle
• Monofilament
• Good wound eversion

109. SKIN SUTURE PLACEMENT
• Close wound in segments
• Sutures equidistant from skin edge on either
side
• of wound
• Evert skin edges
• Wound margins loosely approximated
• Repeatedly bisect the wound

110. “WOUND EDGES SHOULD BE
APPROXIMATED, NOT
STRANGULATED!”
• Too tight = tissue necrosis
• Too loose = edges not aligned

111. KNOTS
• A suture knot has three components
1- The loop created by the knot
2- The knot itself, which is composed of a
number of tight “throws”, each throw
represents a weave of the two stands
3- The ears, which are the cut ends of the
suture

113. BASIC KNOT TYING
1 2 3 4
1 – square knot
2 – granny knot
3 - slip knot
4 – surgeon’s knot

114. CONCLUSION
• Clinician should have a sound knowledge of
the material property as well as the technical
aspect of the ART OF SUTURING for better
clinical decision making and appropriate
management.

115. BIBLIOGRAPHY
• Text book of oral and maxillofacial surgery by S.M
Balaji & Neelima Anil Malik.
• Postlethwait, R.W.: Wound healing and surgery.
Somerville, New Jersey, Ethicon, Inc., 1971
• Varma, S., et al.: Comparison of seven suture
materials in infected wound. An experimental study.
J. Surg. Res., 17:165, 1974
• Chaiken, R.W.: Elements of surgical treatment in the
delivery of periodontal therapy. Chicago,
Quintessence, 1977
• Ethicon, Wound closure manual. Somerville, New
Jersey, Ethicon, Inc, 1985, p. 9
• Internet sources.