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Supplement
Aesthetic Surgery Journal
The Surgical Suture 2019, Vol 39(S2) S67–S72
Published by Oxford University
Press on behalf of The American
Society for Aesthetic Plastic
Surgery 2019. This work is written
by (a) US Government employ-
Miriam Byrne, MD, FRCS (Plast); and Al Aly, MD, FACS ee(s) and is in the public domain Downloaded from https://academic.oup.com/asj/article/39/Supplement_2/S67/5377467 by guest on 14 September 2022
in the US.
DOI: 10.1093/asj/sjz036
www.aestheticsurgeryjournal.com
Abstract
Surgeons must select the optimal suture materials for tissue approximation to maximize wound healing and scar aesthetics. Thus, knowledge regarding
their characteristics is crucial to minimize ischaemia, excess wound tension, and tissue injury. This article describes the selection of various suture
materials available today and their intended design. Modern suture material should have predictable tensile strength, good handling, secure knot-tying
properties, and could be enhanced with an antibacterial agent to resist infection. Tensile strength is limited by suture size. The smallest suture size that will
accomplish the purpose should be chosen to minimize tissue trauma and foreign material within tissues. Monofilament suture has lower resistance when
passed through tissues, whereas multifilament sutures possesses higher tensile strength and flexibility but greater tissue friction and pose risks of suture
sinus and infection. Natural absorbable sutures derived from mammalian collagen undergo enzymatic degradation whereas synthetic polymers undergo
hydrolysis. Collagen or polymer structures in the suture can be modified to control absorption time. In contrast, nonabsorbable sutures typically cause
an inflammatory reaction that eventually encapsulates by fibrous tissue formation. Excess reaction leads to chronic inflammation, suboptimal scarring,
or suture extrusion. More recently, barbed sutures have transformed the way surgeons approximate wounds by eliminating knots, distributing wound
tension, and increasing efficiency of closure. Similarly, modern skin adhesives function both as wound closure devices as well as an occlusive dressing.
They eliminate the need for skin sutures, thus improving scar aesthetics while sealing the wound from the external environment.
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Editorial Decision date: January 31, 2019.
The word suture is derived from the Latin sutura, “a sewn accompanying article on the characteristics of needles, so
seam.” Materials including linen, cotton, horsehair, ani- that operative choices are better understood in the greater
mal tendons and intestines, and wire from precious metals scheme of the science of tissue coaptation.
have been used to approximate wounds and act as liga-
tures. Many adaptations over time have led to the highly Suture Characteristics
sophisticated products we use in our practice today.
Surgeons approximate tissue daily, but often their choice The favorable characteristics of a suture are well
of suture and needle are based on what they learned in documented and include possessing the greatest predictable
training or through negative events during their careers. tensile strength consistent with size limitations, good
The surgeon must be well informed regarding the charac- handling properties, and secure knot tying.1
With time,
teristics of their suture choice and select a suitable mate-
rial that will minimize dead space and risk of microbial
invasion while maximizing precise wound approximation From the Department of Plastic, Reconstructive, and Aesthetic
and, ultimately, optimizing scar aesthetics. What suture Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab
or suture combinations to utilize in any particular surgi- Emirates. Dr Aly is Body Contouring Section Co-editor for Aesthetic
Surgery Journal.
cal case varies greatly among surgeons. Thus, knowledge
regarding the multiple available options gives direction Corresponding Author:
and enables surgeons to develop their own predilections. Dr Miriam Byrne, Cleveland Clinic Abu Dhabi, Department of
The purpose of this article is to familiarize the reader Plastic, Reconstructive and Aesthetic Surgery, A Maryah Island,
PO Box 112412, United Arab Emirates.
with the general characteristics of sutures, along with the E-mail: drmiriambyrne@yahoo.com
S68 Aesthetic Surgery Journal 39(S2)
a surgeon develops suture preferences, specific to their Table 1. Varying Sizes of Synthetic Sutures According to Their US Phar-
practice, based around their knowledge of tissue healing macopeia Denotation, Metric Gauge, and Diameter (in millimeters)
and the physical and biological characteristics of suture USP size Reference Metric gauge Diameter (mm)
materials and factors such as infection, biofilm formation,
2 3 Three (3) 6 0.600-0.699
and multi-resistant pathogens. Modern suture materials
are impregnated with a variety of agents that improve their 2 Two (2) 5 0.500-0.599
3,4
handling, antibacterial properties, and visibility.
1 One (1) 4 0.400-0.499
0 Zero (0) 3.5 0.350-0.399
Size and Tensile Strength 2-0 Two zero (00) 3 0.300-0.339 Downloaded from https://academic.oup.com/asj/article/39/Supplement_2/S67/5377467 by guest on 14 September 2022
Suture sizes are commonly denoted using the USP (United 3-0 Three zero (000) 2 0.200-0.249
States Pharmacopeia) system. This numbering system can
be a little confusing, but it centers around the “0” suture. 4-0 Four zero (0000) 1.5 0.150-0.199
Suture sizes increase from USP size 0 (“zero”) to size 1, 5-0 Five zero (00000) 1 0.100-0.149
commonly called “number 1,” to USP size 2 (“number
2”), and upwards. Alternatively, suture sizes decrease 6-0 Six zero (000000) 0.7 0.070-0.099
in size, again from 0, to USP size 2-0, commonly called 7-0 Seven zero (0000000) 0.5 0.050-0.069
“two 0,” 3-0 (“three 0”), and downwards. Table 1 provides 8-0 Eight zero (00000000) 0.4 0.040-0.049
size comparison based on USP denotation, metric gauge,
and diameter. An example of an extremely fine suture for 9-0 Nine zero (000000000) 0.3 0.030-0.039
ophthalmic and microsurgery such as USP size 9-0 has a
metric gauge size of 0.3 and diameter of between 0.030 to potential for infection, making multifilament suture the
0.039 mm. choice for many intestinal surgeries. Multifilament sutures,
The purpose of sutures in general is to approximate tis- when used on the subcutaneous or intradermal level,
sues, without excess tension, while minimizing ischaemia tend to be extruded in the form of a suture sinus or small
and tissue injury. As wound healing progresses, the wound localized abscess, compared with a monofilament, which
strength increases over weeks or months until it approxi- behaves in a cleaner, less reactive manner.
mates the original tensile strength of the tissue. Whether
wound closure is single or multilayered, the smallest size Suture Degradation: Absorbable and
or diameter of suture that will accomplish the purpose
at hand should be chosen, thus minimizing both tissue Nonabsorbable Options
trauma with each passage of the needle and the amount The manner by which a suture degrades influences the
of foreign material left behind. Smaller-diameter sutures material choice for internal use in deeper layers and for
are, however, associated with less tensile strength, and a skin approximation. Absorbable sutures are typically made
balance must be struck between size of suture and main- from either mammalian collagen, which is ultimately
1
tainance of tissue reapproximation. digested by body enzymes, or synthetic polymers that
undergo hydrolysis. Hydrolysis is a process where water
Multi- and Monofilament Sutures penetrates the suture strands, causing breakdown of the
filament’s polymer structure. Maintaining the balance
Whether a suture has a single or multiple strand composition between rapid absorption and the prolongation of tensile
is an important consideration, especially when weighing strength has been aided by treatments and chemical
its potential for harboring bacteria against the need for structuring, which lengthen absorption time.
greater tensile strength. Monofilament sutures pose lower Typically, when a wound is closed with absorbable
resistance on tissue passage, are less likely to accommodate suture, the decrease in tensile strength over the first weeks
organisms, and tend to snug down more readily. On the is in a gradual, linear fashion. During this period, a leu-
other hand, they must be handled carefully, because when kocyte cellular response is mounted to remove cell debris
crushed by certain instruments, they can weaken or break. and physical suture material, and this process overlaps
They are favored in vascular and microvascular surgery with the second stage where the majority of suture mass
where ease of tying down sutures is crucial. is lost. Either of these phases can be affected by infection
When several strands are braided together forming the and protein deficiency, where tensile strength is lost too
multifilament suture, greater tensile strength, flexibility, quickly, and wound dehiscence is manifested clinically.
and pliability is offered. In recent years, coating the suture Hydrolysis produces a lesser degree of tissue reaction com-
has assisted its passage through tissue and decreased pared with the enzymatic degradation process.
Byrne and Aly S69
In contrast, the in vivo tissue response around non- with residual measurable strength present for 3 weeks
degradable material involves fibroblasts that encapsulate and absorption time prolonged to over 90 days. The main
the suture by fibrous capsule formation. Adjacent macro- advantage over plain gut is less tissue reaction.
phages and foreign body giant cells respond in a process
known as frustrated phagocytosis, where they attempt to Specific Suture Materials: Synthetic
enzymatically degrade the nondegradable suture. Absorbable Sutures
For example, nonabsorbable Nylon sutures are com-
monly used to approximate skin edges on the face where One of the most frequently used sutures amongst plastic
aesthetic outcome is crucial. These are removed early to surgeons is an absorbable suture that holds its tensile
avoid tissue inflammation and unwanted tissue response strength for a predictable period of time and shows lower Downloaded from https://academic.oup.com/asj/article/39/Supplement_2/S67/5377467 by guest on 14 September 2022
around the suture material, which would leave undesir- tissue reaction than surgical gut. The original introduction
able track marks. In contrast, nonabsorbable Prolene to the market of one such suture in 1974 was Vicryl, a
sutures can be used for optimal mesh fixation in her- braided, naturally absorbing pliable suture, which was later
nia repair. They are left permanently in situ, where they modified in 1979 to improve smoother tissue passage and
remain encapsulated by fibrous tissue together with the handling and ensure more secure knot tying (Coated Vicryl).
mesh. When enhanced mechanical strength is required The raw material of this braided suture is a copolymer
such as in the closure of sternotomy, steel wires are used of lactide and glycolide coated with polyglactin 370 and
to achieve bony union. calcium sterate. It is absorbed by hydrolysis, with 75% still
present at 2 weeks, 25% at 1 month, and is completely
Specific Suture Materials: Natural absorbed by 56 to 70 days and thus useful for soft tissue
approximation. In 2003, a broad-spectrum antibacterial
Absorbable Sutures 3,4
agent, triclosan, was added. Subsequently, an undyed
Absorbable sutures may be classified as natural (surgical braided suture of similar composition to the original but
gut) or synthetic (Polyglactin in its many forms [eg, Coated treated with gamma rays to have a lower molecular weight
Vicryl Polyglactin 910, Monocryl Poliglecaprone 25, and was designed (Vicryl Rapide) for faster absorption; 50% of
PDS II Polydioxanone]). tensile strength is lost at 5 days with complete absorption
The naturally occurring types of surgical gut are formed by 6 weeks. It is ideally used for short-term wound support
from processed strands of highly purified collagen, which of superficial soft tissue mucosa and skin.
dictates not only the tensile strength but also its degradabil- Since its introduction in 1982, PDS II (Polydioxanone)
ity. A higher percentage of pure collagen along the strand has gained popularity among plastic surgeons. It features
equates to less foreign material in the wound. An exam- a polyester polymer monofilament construct, with 25% of
ple of the composition of one such gut suture is 97% to the tensile strength still remaining at 6 weeks and max-
98% pure strands of collagen (serosa of beef intestine, or imum support for the first 2 weeks (70%). The actual
submucosa of sheep intestine) spun into monofilaments of absorption is insignificant until 3 months and is essen-
varying sizes but uniform diameter to within an accuracy of tially complete by 6 months. Because of its minimal tissue
0.0002 inch. This eliminates variations known as high and reaction, it is also favored in pediatric, cardiovascular, and
low spots, which contribute to frays and breakages in the ophthalmic surgeries.
suture knot that is malpositioned or unsecurely tied down. A synthetic suture specifically for skin closure, Monocryl
Plain surgical gut is a rapidly absorbed suture, gen- (Poliglecaprone 25), was introduced in 1993 and is formed
erally used for closing the epidermis, ligating superficial of a copolymer of glycolide and epsilon-caprolactone. This
blood vessels, and suturing subcutaneous tissue. The ten- monofilament retains 60% to 70% of its tensile strength
sile strength is maintained for 7 to 10 days and absorption at 1 week, with complete loss at 3 weeks and complete
is complete by 70 days. When heat treated, the filaments absorption between 91 and 119 days. Dyed and antibac-
terial versions have a similar profile.3
are absorbed at a more rapid pace and they lose tensile This has been the
strength compared with their nontreated counterparts. suture of choice for many subcuticular skin closures,
Clinically, it can be placed in the mucosa of the lip and eye including abdominoplasty, flap inset, and breast wound
and as an external suture for rhinoplasty closure where closure.
minimal tensile strength is required.
The corollary is chromic gut, which resists the body’s Specific Suture Materials: Natural
enzymatic digestion. The collagen filaments are bathed in Nonabsorbable Sutures
buffered chrome tanning solution salt before formation
into its strands. This process turns the suture yellowish Nonabsorbable sutures are useful for their superior
tan to brown. Tensile strength remains for 10 to 14 days, handling characteristics. Raw silk is produced through
S70 Aesthetic Surgery Journal 39(S2)
a process whereby a continuous filament is spun by the Many orthopedic surgeons prefer to use coated poly-
silkworm. The silk filaments were processed to become a ethylene terephthalate suture (Ethibond Excel), a nonab-
tightly braided, dyed suture coated with waxes or silicone. sorbable braided suture for ligament or tendon repair. It
Although silk suture is classified as a nonabsorbable is coated with polybutylate, thus enabling easy passage
suture in the USP, in the materials literature it is of the fibers through tissue and smooth knot tying. Being
considered a degradable material by material scientists. inert, it elicits minimal reaction and its tensile strength is
Silk biodegradation is mediated by foreign body tissue not known to significantly change with time. In the realm
response. Slow but progressive enzymatic degradation of of body contouring surgery, when employed to either pli-
the fibers will result in gradual loss of tensile strength. cate the abdominal wall or close abdominoplasty incisions,
Surgical stainless steel is used in its 316L low-carbon Ethibond can cause sinuses/granulation tissue due to per- Downloaded from https://academic.oup.com/asj/article/39/Supplement_2/S67/5377467 by guest on 14 September 2022
alloy formula and may be braided into multifilaments. manent presence of a foreign body in the wound. This can
It is most typically encountered by the plastic surgeon lead to problems arising years after surgery.
reconstructing a sternal wound or in hand fracture fix- Prolene, a widely utilized nonabsorbable synthetic
ation. It affords indefinite tensile strength and flexibil- monofilament, is an isostatic crystalline stereoisomer of
ity and lacks toxic elements, but sensitivity to chromium polypropylene. It tends not to lose tensile strength through
and nickel may occur in susceptible patients. Wires can degradation and can be used on skin to diminish reactiv-
be associated with difficult handling, fragmentation, or ity or, in a contaminated field, to minimize delayed sinus
kinking, which can result in fatigue. There is a risk of formation and extrusion. Prolene is commonly utilized
tearing tissue and puncturing skin, thus posing risk of as a pull-through suture in facial lacerations and trauma,
virus transmission and the possibility of unfavorable where aesthetics are paramount and track marks must be
electrolytic reactions. avoided.
A less familiar monofilament suture, which is rela-
Specific Suture Materials: Synthetic tively resistant to infection and contamination, is Pronova
Nonabsorbable Sutures Poly (hexafluoropropylene-VDF). It is a polymer blend
of poly (vinylidene fluoride) and poly (vinylidene fluo-
Nylons were introduced to the market by the DuPont ride-co-hexafluoropropylene) and is employed in ligation
Company in the late 1930s with Nylon 66, the first true and wound closure, where it resists adherence to adjacent
synthetic fiber. Sutures are produced from the long-chain tissues in cardiovascular, ophthalmic, and neurosurgical
aliphatic polymers Nylon 6 and Nylon 6.6. used for sizes procedures.
7-0 and smaller. They lend themselves to a broad range
of applications in surgery including skin approximation, Barbed Sutures
vessel ligation, and microsurgery. With the introduction
of fine needles and sutures (8-0 to 11-0), the scope Barbed sutures, first designed by John Alcamo in
for microscopic surgery has greatly expanded in all 1956, were granted a US patent in 1964. The first FDA-
specialties. For plastic surgeons, it is frequently utilized for approved barbed suture was not available until 2002.
anastomosis, neurorhaphy, and oculoplastic surgeries. For This was a unidirectional 2/0 polypropylene suture
aesthetic plastic surgery, a premoistened or “pliabilized” on a straight needle for midface lift (Contour Thread,
monofilament suture in sizes 3-0 to 6-0 was devised to Surgical Specialties). Subsequently, barbed absorbable
enhance tissue handling and knot tying to make it more polydioxanone suture was produced for wound closure
similar to a braided suture. (Quill Medical).5 The V-Loc unidirectional barbed suture
Nylon monofilament suture (eg, Ethilon) possesses the with a fixed loop was introduced in 2009 (Covidien
characteristics of high tensile strength and extremely low Healthcare) and Stratafix was introduced in 2012. These
reactivity. Both monofilament and its multifilament coun- barbs serve to grip the sutured tissue in a continuous
terpart (eg, Nurolon) degrade approximately 15% to 20% manner and retain tensile strength. The main benefits
per year by the process of hydrolysis and are eventually of barbed sutures include elimination of surgical knots,
encapsulated if left in place (in vivo study). knot-related complications, and increased efficiency
In the 1920s, Mersons Manufacturing Company pro- 6
of wound closure. The size and spacing of the barbs,
duced the first synthetic braided suture preattached to the which are integrally formed into the core, are designed
butt of the needle, which was shown to remain indefinitely to provide maximum holding in soft tissue such as
in the body. Mersilene (polyethylene terephthalate) is fascia and provide tactile feedback to regulate tension.
uncoated and thus has a higher coefficient of friction with They have become particularly popular for abdominal
passage through tissue, but provides consistent suture ten- 7
wall repair following free flap harvest. In some barbed
sion, and minimal breakage. sutures, the barbs are created by cuts through the suture
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