Types of sutures,and explain sutures in detail

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https://pmc.ncbi.nlm.nih.gov/articles/PMC3884880/

Sutures: definition

A suture is a sterile thread or strand used to approximate tissues after injury or surgery, maintain haemostasis by ligating vessels, or secure drains and tubes. The word can refer both to the material and to the stitching technique.

A suitable suture should hold tissue together until healing provides adequate strength, cause minimal tissue reaction, handle and knot reliably, and not promote infection.

Classification of sutures

Sutures can be classified in several ways:

By absorption: absorbable or non-absorbable
By filament structure: monofilament or multifilament/braided
By origin: natural or synthetic
By size: for example 2-0, 3-0, 4-0, 5-0
By needle type: taper, cutting, reverse-cutting, etc.
By technique: interrupted, continuous, mattress, subcuticular, and others.

1. Absorbable sutures

Absorbable sutures gradually lose tensile strength and are ultimately broken down or absorbed by the body. They are usually used in tissues that heal without needing long-term external support, especially deep tissues.

Main uses

Subcutaneous tissue and deep dermis
Mucosa, such as oral or vaginal mucosa
Bowel and urinary tract
Fascia, when a delayed-absorbable material is selected
Internal ligation of small vessels
Skin closure in selected patients, particularly children or patients unlikely to return for removal

Absorbable sutures are useful for buried stitches because they reduce tension on the superficial skin closure. They are generally chosen when removal would be impractical or undesirable.

Types of absorbable sutures

Material	Structure	Absorption/strength pattern	Common uses and features
Plain gut	Monofilament, natural	Rapid loss of strength	Mucosa, rapidly healing tissue. More tissue reaction and less predictable absorption than synthetics.
Chromic gut	Monofilament, natural	Longer-lasting than plain gut	Mucosal or internal soft tissue use. Chromium treatment slows absorption.
Fast-absorbing gut	Monofilament, natural	Very short support	Selected superficial facial wounds or mucosa where removal should be avoided.
Polyglactin 910 (Vicryl)	Braided synthetic	Intermediate absorption	General soft-tissue approximation, ligatures, subcutaneous tissue. Good handling, but braided material can harbour bacteria.
Polyglycolic acid (Dexon)	Braided synthetic	Intermediate absorption	Similar soft-tissue uses.
Poliglecaprone 25 (Monocryl)	Monofilament synthetic	Relatively rapid absorption	Subcuticular and intradermal closure, low-tension soft tissue. Smooth and low-reactivity.
Polydioxanone (PDS)	Monofilament synthetic	Delayed absorption, prolonged support	Fascia, slowly healing tissue, paediatric surgery.
Polyglyconate (Maxon)	Monofilament synthetic	Delayed absorption, prolonged support	Fascial closure and tissues requiring prolonged support.

Important points

Absorption does not mean that the suture remains strong until it disappears. Tensile strength commonly declines earlier.
Natural gut is degraded mainly by enzymatic processes and may produce a more variable inflammatory reaction.
Synthetic absorbable materials are mainly degraded by hydrolysis and tend to have more predictable strength loss.
For low-tension intradermal closure, poliglecaprone is commonly suitable. For high-tension or slow-healing tissues, a longer-lasting material such as polydioxanone may be selected.
Roberts and Hedges’ Clinical Procedures in Emergency, p. 41-4.

2. Non-absorbable sutures

Non-absorbable sutures resist degradation and retain useful tensile strength for a prolonged period. They may be removed after skin healing or left permanently inside the body when lasting support is needed.

Main uses

Superficial skin closure
Tendon repair
Vascular surgery
Hernia repair and fixation
Retention sutures
Areas under sustained tension

Types of non-absorbable sutures

Material	Structure	Key characteristics	Common uses
Nylon (Ethilon)	Usually monofilament	Low tissue reactivity, strong, but has memory and can be harder to handle	Skin closure
Polypropylene (Prolene)	Monofilament	Very inert, durable, good for contaminated fields; poor handling due to memory	Vascular anastomosis, skin, hernia repair
Polybutester (Novafil)	Monofilament	Elastic, accommodates swelling	Skin closure where oedema is expected
Silk	Braided natural	Excellent handling and knot security, but more tissue reaction and bacterial adherence	Ligatures, selected external uses; generally avoided for permanent vascular repair
Polyester (Ethibond, Mersilene)	Braided synthetic	Strong, durable, good handling; can provoke more tissue response than monofilaments	Tendon, cardiovascular and orthopaedic applications
Stainless steel	Monofilament or twisted	Very strong, inert but difficult to handle	Sternum, bone, selected retention closures

Synthetic monofilaments such as nylon and polypropylene are often preferred for skin because they have relatively low tissue reactivity. Non-absorbable sutures placed in skin must usually be removed at an appropriate time to avoid track marks and local inflammation.
Roberts and Hedges’ Clinical Procedures in Emergency, p. 41-4.

3. Monofilament versus multifilament sutures

Monofilament

A monofilament suture consists of a single smooth strand.

Examples: nylon, polypropylene, poliglecaprone, polydioxanone, plain gut.

Advantages

Less tissue drag
Lower capillarity, so less potential bacterial wicking
Less tissue reaction
Preferred where infection risk is a concern

Disadvantages

More difficult to handle
Greater package memory, so it may curl
Lower knot security, so extra throws may be required
Can be damaged if crushed with instruments

Multifilament or braided

A multifilament suture contains several filaments twisted or braided together.

Examples: silk, polyglactin 910, polyglycolic acid, polyester.

Advantages

Flexible and easy to handle
Better knot security
Less memory

Disadvantages

Greater tissue drag
Interstices may permit capillary movement of fluid and bacteria
May be less suitable in infected or contaminated wounds

Braided sutures are easy to tie but can harbour bacteria within their interstices. Monofilaments glide more easily and tend to cause less tissue reaction, but are more difficult to knot securely.
Bailey and Love’s Short Practice of Surgery, p. 125. A useful open-access review similarly classifies sutures as absorbable or permanent, natural or synthetic, and mono- or multifilament, while highlighting the infection-related drawbacks of braided material in appropriate clinical contexts (cutaneous closure review).

4. Natural versus synthetic sutures

Natural

Derived from animal, plant, or mineral sources.

Gut: absorbable, collagen-derived
Silk: non-absorbable braided natural fibre
Cotton/linen: rarely used now
Stainless steel: metallic

Natural materials may provoke more tissue inflammation and, particularly for gut, can have less predictable absorption.

Synthetic

Manufactured polymer materials.

Polyglactin 910
Polyglycolic acid
Poliglecaprone
Polydioxanone
Nylon
Polypropylene
Polyester
Polybutester

Synthetic sutures generally offer more predictable tensile-strength retention and lower tissue reactivity.

5. Suture size

Suture size is specified by the United States Pharmacopeia scale.

More zeros = finer, smaller-diameter suture
Example: 6-0 is finer than 5-0, and 5-0 is finer than 4-0.
A 2-0 suture is thicker and stronger than a 4-0 suture.

General principle

Use the smallest diameter that provides adequate support during healing. Larger sutures cause more tissue trauma and leave larger puncture holes, whereas finer sutures improve cosmetic outcome but provide less tensile strength.

Typical examples

Area/tissue	Common approximate sizes
Face	5-0 or 6-0
Scalp	3-0 or 4-0
Trunk and limbs	3-0 or 4-0
Hands/feet	4-0 or 5-0
Deep dermis/subcutaneous layer	3-0 or 4-0 absorbable
Fascia	0, 1, or 2-0 delayed absorbable, depending on site and surgeon preference

These are broad examples, not universal rules. The wound tension, tissue type, patient factors, and operative setting determine the final choice.

6. Suture needles

A surgical needle has three components:

Point: enters tissue
Body: held by the needle holder
Swage: attached end that joins needle to the suture

Most modern sutures are atraumatic, meaning the needle is permanently swaged to the thread. This minimizes the size of the tissue hole.

Common needle points

Needle	Description	Common use
Taper point	Round body tapering to a sharp point; spreads rather than cuts tissue	Bowel, muscle, fascia, peritoneum, blood vessels
Taper-cut	Taper needle with a short cutting tip	Dense soft tissue, fascia
Conventional cutting	Triangular body with cutting edge on inner curve	Tough tissue and skin, but may cut out under tension
Reverse cutting	Cutting edge on outer curve; stronger configuration	Skin, oral mucosa, tendon sheath, tough tissue
Blunt needle	Rounded point	Friable tissue such as liver, kidney, or cervix

For most skin closures, cutting or reverse-cutting needles are used. Reverse-cutting needles are stronger than conventional cutting needles and reduce the risk of the needle cutting through tissue.
Textbook of Family Medicine, 9e, p. 748.

Needle curvature

Straight needles: accessible superficial tissue
1/4-circle: skin and ophthalmic work
3/8-circle: common for skin and superficial wounds
1/2-circle: deeper tissues and abdominal cavity
5/8-circle: deep, confined spaces such as pelvis

7. Types of suturing techniques

A. Simple interrupted suture

Each stitch is placed and tied separately.

Advantages

Precise wound-edge alignment
One failed stitch does not open the entire wound
Useful for irregular, contaminated, or high-tension wounds

Disadvantages

Time-consuming
More knots and more foreign material in the wound

B. Simple continuous or running suture

A single strand runs continuously along the wound, with knots only at the beginning and end.

Advantages

Fast
Even distribution of tension
Uses less material

Disadvantages

If the suture breaks, a longer length of wound can loosen
Less precise adjustment at individual points

C. Running locked suture

Each pass locks through the previous loop.

Use

Haemostatic closure, for example scalp wounds.

Caution

Excessive tension can impair blood supply and cause tissue strangulation.

D. Vertical mattress suture

The stitch passes deep-far, then superficial-near on each side.

Uses

Everted wound edges
High-tension wounds
Areas where accurate dermal approximation is needed

Risk

Can cause ischaemia or “railroad track” scarring if tied too tightly or left too long.

E. Horizontal mattress suture

The stitch runs horizontally across the wound and returns parallel to itself.

Uses

Fragile skin
Tension distribution
Haemostasis

Risk

May compromise blood flow if overly tight.

F. Deep dermal or buried dermal suture

An absorbable stitch is placed within the dermis, with the knot buried.

Uses

Reduces tension on skin edges
Eliminates dead space
Improves cosmetic alignment
Supports a subsequent superficial closure

G. Subcuticular or intradermal running suture

A continuous absorbable suture is placed within the dermis, parallel to the skin surface.

Uses

Clean, low-tension wounds
Cosmetic closures
Usually covered with adhesive strips or dressing

Limitation

Not ideal for infected, irregular, or high-tension wounds.

H. Figure-of-eight suture

The suture crosses in an “8” pattern.

Uses

Haemostasis
Closing small defects
Securing tissue in selected operative situations

I. Purse-string suture

A circular running suture is placed around an opening and tightened like a drawstring.

Uses

Closure around a circular opening
Securing drains or catheters
Certain gastrointestinal or stoma-related procedures

Principles of proper suturing

Obtain meticulous haemostasis and remove devitalised tissue before closure.
Handle tissue gently to preserve blood supply.
Approximate edges without excessive tension.
Evert skin edges slightly, because scars tend to flatten during healing.
Place deep absorbable sutures when needed to reduce surface tension and eliminate dead space.
Do not overtighten sutures. Blanching, indentation, or tissue strangulation suggests excessive tension.
Choose monofilament material when contamination or infection risk is significant.
Use the smallest suitable suture diameter.
Remove external sutures at the appropriate time, based on anatomical site and wound healing.

For traumatic lacerations, available evidence does not show a consistent major difference in infection, dehiscence, or cosmetic outcomes between absorbable and non-absorbable skin sutures in appropriately selected wounds. This can make absorbable material particularly practical in children who may not tolerate later removal. Roberts and Hedges’ Clinical Procedures in Emergency, p. 41-4.

Stapler suture and thread suture

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Stapler suture versus thread suture

The usual terms are:

Stapler closure / skin staples: metal clips applied with a surgical stapler.
Thread sutures: conventional surgical threads placed with a needle and tied as stitches.

Strictly, staples are not sutures, but both are methods of wound closure.

Feature	Stapler closure	Thread suture closure
Material	Usually stainless-steel staples	Absorbable or non-absorbable surgical thread
Method	Stapler applies clips across skin edges	Needle passes thread through tissue; surgeon ties knots
Speed	Very fast	Slower
Precision	Less precise	Highly precise, can align each wound edge individually
Best suited for	Long, straight, low-complexity skin incisions, particularly scalp and some surgical incisions	Irregular wounds, face, hands, wounds needing exact alignment, deep-layer closure
Tissue layers	Mainly external skin	Can close skin, dermis, subcutaneous tissue, fascia, bowel, vessels, tendon, etc.
Removal	Requires staple remover	Non-absorbable threads require removal; absorbable threads dissolve over time
Cosmetic result	Can leave staple marks if retained too long; less ideal on face	Often preferred where cosmetic accuracy matters
Patient discomfort	Can be uncomfortable while present and on removal	Usually less uncomfortable, though removal can also cause discomfort
Cost	Stapler device may cost more	Usually less expensive but takes more operating time

1. Stapler closure

A skin stapler is a handheld device that applies preloaded metal staples across an incision or laceration. Each staple bends inward beneath the skin and holds the two skin edges together.

Advantages

Very quick, especially for long wounds
Simple to apply
Useful in emergency and operating-room settings
Avoids a needle-stick injury to the clinician
Provides reasonable wound-edge eversion in straight wounds

Common uses

Scalp lacerations
Long linear surgical incisions
Some abdominal, orthopaedic, and traumatic wounds
Wounds where rapid closure is more important than fine cosmetic precision

Limitations and disadvantages

Not appropriate when wound edges are irregular, crushed, jagged, or poorly aligned.
Does not close deeper tissue layers. Deep tissue may still need absorbable thread sutures.
Less suitable for face, fingers, feet, joints, or cosmetically sensitive areas.
Can produce cross-hatch or “railroad track” marks if left too long.
May be painful during removal.
Staples should not be used on the foot because they can be uncomfortable during walking.
Tintinalli’s Emergency Medicine: A Comprehensive Study, Wound Closure.

Removal: external staples are removed with a staple-removal device. The timing is generally similar to removal of skin sutures, depending on the location and wound tension.

2. Thread sutures

Thread sutures are the familiar stitches made by passing a needle and surgical thread through tissue, then tying a knot. They permit layer-by-layer repair and exact placement.

Types of thread sutures

A. Absorbable thread

These dissolve or lose strength over time.

Examples:

Plain gut
Chromic gut
Polyglactin 910
Poliglecaprone
Polydioxanone

Uses: deep dermis, subcutaneous tissue, mucosa, fascia, internal organs, and selected skin wounds.

B. Non-absorbable thread

These persist and usually require removal if placed in skin.

Examples:

Nylon
Polypropylene
Silk
Polyester

Uses: external skin, tendon, vascular repair, and situations needing durable support.

Advantages

Best method for precise edge-to-edge approximation
Can be used in superficial and deep layers
Suitable for irregular-shaped wounds
Better choice for face and cosmetically important areas
Individual interrupted stitches allow one stitch to fail without opening the whole wound
Many material, size, and needle choices are available

Disadvantages

Slower than stapling
Requires more skill
Needle-stick risk to the clinician
More tissue handling and more knots
Poor technique or excessive tension can cause infection, ischaemia, scarring, or wound-edge necrosis

Sutures allow the most accurate approximation of wound edges but are time-consuming and operator-dependent.
Roberts and Hedges’ Clinical Procedures in Emergency, p. 41-4.

When to choose which?

Prefer staples when:

Wound is long, linear, and straight
Rapid skin closure is needed
Location is the scalp or selected surgical incision
Fine cosmetic alignment is not the main concern

Prefer thread sutures when:

Wound is irregular or under uneven tension
Precise alignment is required
The wound involves the face, lip border, eyelid, hand, or joints
Deep layers require closure
The wound needs a cosmetic repair

A large review found that the overall superiority of staples versus sutures varies by surgical site and evidence quality, so the closure method should be selected based on location, tissue tension, contamination, wound geometry, and cosmetic needs (review of staples versus sutures). In hip arthroplasty, for example, pooled evidence has associated staples with a higher risk of superficial infection than sutures, although this result cannot be generalized to every wound type (hip-arthroplasty review).

Simple summary: staples are faster and useful for straight skin wounds; thread sutures are slower but more versatile and accurate.

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