Author(s): <p>Arjun MR*, Anil Melath, Subair K, Swathi S, Jincy Joseph and K Naga Nandini</p>
Sutures are natural or synthetic biomaterial devices used to connect blood vessels and align tissues [1]. Its primary function is to reunite and secure tissues after separation due to surgery or trauma. The purposes of wound closure include erasing the dead space, regular distribution of tension along the deep suture lines, keeping the tractile strength across the wound until the tissue tractile strength is sufficient and aiming to approximate the epithelial portion of the closure. Sutures are the most commonly used material for mechanical wound closure, even though there are other methods like staples, tape, and adhesive [2].
Suture have been introduced since at least 4000 years [3]. Archaeological records from antiquity In Egypt and India shows that linen, animal sinew, flax, wool, grass, Cotton, silk, pig hair, and animal intestines were used for wound closure [3,4].
Polybutester has a lower coefficient of friction and lower tissue reactivity than the older polyester sutures [26].
An ideal suture material is not, and should not be, completely biologically inert. It cannot provoke a tissue reaction, and easier for the surgeon to tie securely.
An Ideal Suture Should have the Following Properties
Yarn deterioration capacity within the organization in synthetic polymers, this happens by hydrolysis [27].
guaranteed by various techniques provided with the use of ethylene oxide, or Cobalt-60, gamma rays.
Thread’s ability to cause minimal inflammatory response of tissue. Based on the material used, it shows the greatest response to catgut which is further decreased with the use of silk, cotton, linen, polyester, polyamide, resorbable plastic, polypropylene, steel and titanium.
Thread’s ability to resist the tensile force on the ends, measured up to the height of a simple knot. Materials such as Steel, plastic and natural thread have the greatest resistance. Conversely, resistance is characteristic of gut, silk, polypropylene, polyglycolic acid, nylon, polyester and steel.
Fluid properties of propagation along capillaries in all directions even for small-diameter pipes against gravity. Based on the material of the suture, it corresponds to the absorption capacity of the liquid in which the thread is Immersed and can be supplied to dry areas.
Characterized by capillary action. Hydrophilicity stands for chemical affinity with which the suture acts on liquid molecules, For example water.
means suture adaptability. This is the ability of the thread to fold and twist without breaking.
Thread ability to form new shape.
The ability of a thread to deform and lengthen and return to original length.
Describes the ductility of the suture and means ease of manipulation and knot it, so it seems to be correlated with Fluency.
The ability of a thread to execute fluidly and there are no difficulties in organization. It depends on the smoothness and approximately the coefficient of friction, that is, on its structure. Monofilament sutures are generally more fluid than multifilament sutures.
Affect thread maneuverability [29].
All suture materials that are digested by body enzymes or hydrolyzed by the tissue fluids are absorbable. They undergo degradation and lose its tensile strength within 60 days [29,30].
which is made up of collagen harvested from small intestine of sheep or goat.[31] One of the staple absorbable suture materials through 1930s while physician use silk or cotton where a non- absorbable material was needed. It is of two types the plain gut and the chromic [30,32,33]. The use of these suture material reduced due to poor knot stability and tensile strength and high reactivity of Fast absorbing gut which is the newer form and which is not treated with chromic salts. Catgut completely absorbed between 35 to 60 days [28, 30].
multifilamented suture material derived from staple Egyptian cotton fibers with minimal tissue reactivity [28].
multifilamented absorbable suture which resembles catgut, which is prepared from bovine deep flexor tendon filament. Collagen is absorbed within 60 days. It has minimal tissue reactivity [28].
PGA is the polymer of glycolic acid, the simplest linear aliphatic polyester, introduced in 1970 [30] and it is the first synthetic absorbable suture material. PGA has excellent tensile strength, knot stability, delayed absorption and reduced tissue reactivity [31]. PGA and its copolymer used as synthetic absorbable suture material and also evaluated in biomedical field [29,30].
Polyglactin was introduced in 1974, which is braided with clear undyed or violet dyed form. It is the copolymer of lactide & glycolide. Vicryl is degraded by hydrolysis and cause tissue reaction. Also, it is manufactured with coating of polyglactin 370 & calcium stearate which provides excellent handling and smooth tie down properties [30].
which is made from paradioxanone. It is useful when extended wound tensile strength is [30]. PDS is absorbed within 180 days after [29]. PDS II a newer product that has decreased stiffness & smooth handling. It has slight tissue reactivity [28].
Maxon is the copolymer of glycolic acid & trimethylene carbonate. It is developed to combine the excellent tensile strength, knot stability of PDS with improved handling properties. Maxon is the most supple, manageable material than PDS and has 60% less rigidity, minimal memory, expensive. It provides great wound support [30].
Sutures that cannot be digested by tissue fluids. They are removed during the end of healing by surgeon [29].
silk is made from natural protein filaments by silkworm larva. The modern silk which is braided, soft, easy to handle & tie and has low tensile strength, moderate tissue reactivity, more inflammatory reaction, high capillary quality. Silk is avoided in area which is prone to infection especially distal extremities. It can also be used during cutaneous surgery around eyelids & lips [29,30].
Linen is the glucose material made from flax. It can be twisted to form fibre to make a suture. It had good knot stability and used for tying pedicles and as ligature [29,30]. Linen has minimal tissue reactivity [28].
Nylon was introduced in1940, which is the synthetic polyamide polymer and also the first synthetic suture material. Mostly used in cutaneous surgery as a monofilament (Ethilon, Dermalon) and as multifilament braided (Nurolon, surgilon). Nylon is of two types that is non absorbable & slowly absorbable [29,30]. A study comparing clear monofilament nylon & PGA in build suture demonstrated less clinical inflammatory response with nylon [31]. Nylon has high tensile strength, excellent elastic property, minimal tissue reactivity & low cost [28].
It is the plastic suture formed by polymerisation of propylene by means of a catalyst. Polypropylene is the extremely inert suture, which has very smooth surface with low adherence to tissue that is ideal for a subcuticular intradermal [29,30]. It has good plasticity and minimal tissue reactivity [28]. When swelling occurs, suture will stitch to accommodate the wound and when it recedes, the suture will remain loose [29,30].
It can be formed as nylon by condensation polymerisation and it is manufactured to provide the high tensile strength, low tissue reactivity, improved handling & knot stability. Mersilene and Dacron are the uncoated braided polyester which has a rough surface, produce drag when pulled through tissue. Ethibond is the coated polyester. These polyesters are not commonly used nowadays because of the cost & coating susceptibility to cracking after knots are tied [29,30].
The newest non- absorbable suture, which is the thermoplastic copolymer composed of butylene terephthalate and polytetramethylene ether glycol. These are the monofilamentous, stronger, less stiff & has low coefficient of friction than nylon or polypropylene. It has the capacity to stretch 50% of it’s length at loads of only 25% of it’s knot breaking level. Good elasticity & flexibility are the unique features. Also reduces the potential for suture marks, induce little inflammatory response [29,30].
In order to eliminate this, the excessive tissue should be undermined, an incision at approximately 30 degrees to the original incision is detected at the weakened tissue. The extra tissue is pulled over the incision, the appropriate amount is excited & wound is closed [30].
Indications: Rapidly healing mucosa
Contraindications: Not used when prolonged approximation of tissue under stress is required [29,30].
Superficial vessels, mucosal surfaces (without stress)
Cannot be used for suturing under tension.
Surgical Silk Indications Mucosal Surfaces Contraindications Cardiovascular Surgery
Subepithelial mucosal surfaces
Should not used when prolonged approximation of tissue under stress is required.
Absorbable suture with extended wound support
Should not used when prolonged approximation of tissue under stress is required.
Skin Closure, Mucosal Surfaces, Cardiovascular Surgery, Plastic Surgery, General Surgery.
None
General plastic surgery, cardiovascular surgery, skin surgery.
none.
Abdominal wall, skin closure, sternal closure, tendon repair, orthopaedic surgery and neurosurgery.
Should not be used with prosthesis of another alloy.
Collagen Indications Ophthalmic Surgery Contraindications Rapidly Healing Mucosa.
Suture removal is done to secure edges of the wound and body parts together from healed wounds without damaging the newly formed wounds. Removal of suture should be atraumatic and clean as possible.[30] Mostly, skin sutures are removed between the interval of 7 to 14 days and the mucosal sutures removed within 5 to 7 days [29]. The recommended timing of suture removal varies between 3 to 14 days which is depend on several factors like wound location, co-morbidity, and sign of early wound complication [34].
In recent times, there has been a surge in the advancement of sutures, introducing additional features like modifications with antimicrobial agents, bioactive molecules such as DNA, drugs, antibodies, proteins, growth factors, and silver. Following years of research, the US Food and Drug Administration approved the first antibacterial suture, Vicryl Plus (triclosan-coated polyglactin 910 suture), in 2002 to mitigate the risk of surgical site infections (SSI). Triclosan coating, initially applied to Vicryl Plus, has been extended to other suture materials to combat bacterial adhesion and prevent or reduce SSI. Bioactive sutures exhibit therapeutic potential in specific procedures, expediting the healing process [35]. Emerging suture technologies include
Suture material selection in both the medical and dental fields involves a careful consideration of factors such as absorbability, material composition, size, strength, biocompatibility, and cost. Ultimately, the choice of suture material depends on the specific requirements of the procedure and the practitioner’s preferences. Understanding the differences and similarities between suture materials in these fields is crucial for ensuring successful wound closure and patient well-being.
