Background: Laceration repair is a common procedure in the Emergency Department (ED). The techniques of wound management and closure are well-covered as a part of any EM rotation, but this often focuses on the technical aspects of irrigation and closure. When it comes to suture selection, this is the scene frequently encountered:
This post will provide an overview of the most common types of sutures available in the ED as well as some suggestions for how to select the correct material for a given repair.
Terminology
- Suture material
- Absorbable (e.g. Vicryl (polygalactin 910), chromic gut)
- Degraded in tissue in less than 60 days
- Traditionally used for closure of subcutaneous tissues or injuries to the tongue or nailbed
- Non-absorbable (e.g. Ethilon (nylon), silk, Prolene (polypropylene)
- Lasts longer than 60 days
- Traditionally used for skin closure
- Monofilament (e.g. Prolene (polypropylene), plain gut)
- Made of one strand of material
- Multifilament (e.g. Vicryl Rapide (polygalactin 910), silk)
- Made of multiple strands woven together in a braid
- More friction when pulled through tissues, however this adds greater security to knots than monofilament
- Greater risk for inflammation and infection than monofilament (Masini 2011)
- Natural (e.g. silk, chromic gut)
- Made of organic materials
- Traditionally more inflammatory than synthetic materials
- Synthetic (e.g. Ethilon (nylon), Vicryl (polyglactin 910))
- Made of laboratory manufactured material
- Absorbable (e.g. Vicryl (polygalactin 910), chromic gut)
- Gauge: Size of suture
- Strength of suture proportional to square of the diameter of the thread
- Usually best to select smallest suture that provides adequate tensile strength as more material increases tissue reaction
- Standardized by United States Pharmacopedia
- Scale runs from 11-0 (smallest) to 7 (largest)
- Sizes are a number or a zero
- #2>#1>0>2-0 (00)
- Zero sizes are pronounced with the number of zeros first
- Eg. 7-0 is pronounced “seven-oh”
- Metric system used in other parts of the world
- Sized in tenths of a millimeter
- Eg. 5-0 is 0.1mm in diameter and size 1 metric
- Needles
- Size
- Measured from thread attachment to needle tip in mm
- Usually sized to correspond with suture gauge
- Shape
- eg. Straight, sections of a circle, double curved
- 3/8ths and 1/2 circle are most common for skin closure
- Types
- Cutting and reverse cutting most common for skin closure
- Cutting: sharp edge of needle on inside of curve
- Reverse cutting
- Sharp edge of needle on outside of curve
- Theoretically reduces chances of suture pulling through tissue
- Taper point: used for surgical applications in soft tissue
- Size
Understanding Suture Packaging
Commonly Used Suture Types in ED
- Both brand and generic names are used, which can be confusing
- Most common manufacturer in the US is Ethicon. Their brands are discussed in this post, but the same principles should apply to other brands
Brand Name | Material | Strength Retention | Full Absorption | Applications | ||
---|---|---|---|---|---|---|
Absorbable | Multifilament | Vicryl | Polygalactin 910 | 50% at 21d | 56-70d | Subcutaneous closure, oral surgery |
Vicryl Plus | Polygalactin 910 treated with antimicrobial | 50% at 21d | 56-70d | Subcutaneous closure, oral surgery | ||
Vicryl Rapide | Polygalactin 910 gamma irradiated to speed absorption | 50% at 5d | 42d | Tongue lacerations, oral injuries, skin closure on trunk and extremities | ||
Monofilament | Plain Gut | Beef serosa or sheep submucosa | 7-10d | 70d | Suturing fatty tissues, oral repairs, nailbed repairs | |
Fast Absorbing Gut | Beef serosa or sheep submucosa heat treated to speed absorption | ~7d | 21-42d | Skin closure on the face | ||
Chromic Gut | Beef serosa or sheep submucosa treated with chromium to slow absorption and tissue reaction | 21-28d | 90d | Tongue lacerations, nailbed repair, subcutaneous closure | ||
Non-absorbable | Multifilament | Ethibond | Polyester/Dacron | Indefinite | N/A | Tendon repair |
Perma-hand Silk | Silk | Gradual loss over time | N/A | Securing drains, lines, and tubes | ||
Monofilament | Ethilon | Nylon 6 | Gradual loss over time | N/A | Most common material for skin closure | |
Prolene | Polypropylene | Indefinite | N/A | Alternative choice for skin closure |
(Data in table from Ethicon Website)
Selecting the Right Material
- Limited data to guide decision
- Most choices based on physician preference, experience, and local standard practice
- General Guidelines
- Careful evaluation of the wound is essential to assess for wound tension and whether deep layer closure will be required
- Wound tension is the amount of perpendicular force that must be applied to a wound to approximate the edges
- Higher tension = more force
- Wounds under higher tension require a larger gauge suture that will tolerate a greater amount of force
- Deep layer closure and other advanced repair techniques can be used to reduce wound tension
- Lower tension repairs are ideal as they result in a better cosmetic outcome
- Anatomic region tends to determine amount of tension on a wound
- Facial wounds are often lower tension than wounds on trunk or extremities
- Within these areas, there are regions of higher tension, like the chin or flexor surfaces which may require different material
- Nonabsorbable monofilament commonly used for skin closure
- Nylon (Ethilon) tends to be favored over polypropylene (Prolene) for its lower cost and its slightly easier handling
- Polypropylene (Prolene) may be favored in infected or inflamed tissues (Lammers 2014)
- Prolene is often colored blue, so may be chosen in areas with hair to help identify sutures for removal
- Absorbable materials
- Reasons to select
- Suture will not be accessible for later removal
- Oral injuries
- Suture removal may be difficult (i.e. pediatric patients, patients with poor follow-up)
- Polygalactin 910 (Vicryl)
- Useful in deep layer closures
- Provides long-term tensile strength and mid range absorption time (50% at 21d), minimizing tissue reaction (Lammers 2014)
- Chromic gut
- Plain gut treated with chromic salts to slow absorption (50% at 21-28d) and minimize tissue reaction
- Useful in oral repairs, nailbed laceration repair (Lammers 2014, Brown 2007)
- Fast absorbing gut
- Heat treated plain gut for more rapid absorption (50% at ~7d)
- Growing trend towards use in repair of facial lacerations in pediatric patients or patients with poor follow-up
- Available literature suggests noninferiority to nonabsorbable materials in cosmeses and patient satisfaction (Xu 2016)
- Gamma irradiated Polygalactin 910 (Vicryl Rapide)
- Preferred by some oral surgeons for mucosal and dental injuries as may lead to more rapid healing over chromic gut (Gazivoda 2015)
- Increasingly popular in repair of lacerations on the torso and extremities in patients whom suture removal may be difficult
- Available data suggests noninferiority to polypropylene (Prolene) in cosmetic outcome with a nonsignificant greater incidence of infection with absorbable material (Tejani 2014)
- Reasons to select
- Careful evaluation of the wound is essential to assess for wound tension and whether deep layer closure will be required
Specific Recommendations Based on Anatomic Region
- Generalized recommendations from Brian Lin of Closing the Gap of what material to start with in a particular region with a particular amount of tension
Anatomic Region | High Tension | Low Tension | Without Removal | Deep Layer |
---|---|---|---|---|
Face | 5-0 nylon (Ethilon) | 6-0 nylon (Ethilon) | 6-0 fast absorbing gut | 5-0 polygalactin 910 (Vicryl) |
Extremities/Trunk | 4-0 nylon (Ethilon) | 5-0 nylon (Ethilon) | 4-0 and 5-0 gamma irradiated polygalactin 910 (Vicryl Rapide) | 4-0 polygalactin 910 (Vicryl) |
Tongue Lacerations | 3-0 chromic gut | 4-0 chromic gut | N/A | N/A |
Nailbed Lacerations | 4-0 and 5-0 chromic gut | 6-0 chromic gut | N/A | N/A |
Hair-Bearing Areas | 4-0 and 5-0 colored polypropylene (Prolene) | 5-0 and 6-0 colored polypropylene (Prolene) | See above | See above |
Take Home Points
- An understanding of the properties of a given suture material helps guide rational selection for a particular application
- All materials have advantages and disadvantages. Selection must be guided by careful evaluation of any wound prior to repair
- “The best suture for a given laceration is the smallest diameter suture, which will adequately counteract static and dynamic tension forces on the skin.” – Brian Lin
- Consider using absorbable materials for epidermal closure in patients where suture removal may be difficult
Read More
CanadiEM: Nice Threads: a Guide to Suture Choice in the ED
Closing the Gap: Stock and Simplify Your Suture Cart Part 1
ALiEM: PV Card: Laceration Repair and Sutures
Ethicon: Wound Closure Overview
References
Masini BD et al. Bacterial adherence to suture materials. J Surg Educ. 2011;68(2):101-4. PMID: 21338964
Lammers RL, Smith ZE. Methods of Wound Closure. Robers and Hedges’ Clinical Procedures in Emergency Medicine, Chapter 35, 644-689.e2. Saunders; 2014.
Brown DJ, Jaffe JE, Henson JK. Advanced laceration management. Emerg Med Clin North Am. 2007;25(1):83-99. PMID: 17400074
Xu B et al. Absorbable Versus Nonabsorbable Sutures for Skin Closure: A Meta-analysis of Randomized Controlled Trials. Ann Plast Surg. 2016;76(5):598-606. PMID: 25643187
Gazivoda D, Pelemiš D, Vujašković G. A clinical study on the influence of suturing material on oral wound healing. Vojnosanit Pregl. 2015;72(9):765-9. PMID: 26554107
Tejani C et al. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med. 2014;21(6):637-43. PMID: 25039547
Thank you very much