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Suture Materials - Complete Guide

Classification Overview

1. Absorbability - absorbable vs. non-absorbable
2. Origin - natural vs. synthetic
3. Structure - monofilament vs. multifilament (braided)

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PART 1 - ABSORBABLE SUTURES

After losing ~75% of strength, sutures will break. Strength is lost before complete absorption occurs.

• Fischer's Mastery of Surgery, 8th ed.

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A. NATURAL ABSORBABLE SUTURES

1. Plain Catgut (Plain Gut)

• Uses: Rapidly healing tissues - mucosal closures, ligating small vessels, oral mucosa, episiotomy
• Avoid in: Infected wounds, tissues requiring prolonged support, skin (leaves marks)
• Note: Sterilized by irradiation or ethylene oxide. Unpredictable absorption rate. Absorbed faster in infected or ischemic tissue.

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2. Chromic Catgut (Chromic Gut)

• Uses: Subcutaneous tissue, oral mucosa, scalp, episiotomy, gynecological procedures, circumcision
• Advantage over plain gut: Chromic salt treatment slows enzymatic digestion, extends strength retention
• Brands: Chromic (Ethicon), Chromic (Medtronic)
• Note: Brown/tan colored. Wet the suture before use for better pliability.

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B. SYNTHETIC ABSORBABLE SUTURES

3. Polyglycolic Acid (PGA) - Dexon

• Brand: Dexon (Medtronic)
• Uses: Deep tissue closure, subcutaneous, abdominal wall, ligatures, urological procedures
• Advantage: Predictable, uniform absorption. Less tissue reaction than gut.
• Coating: Dexon Plus is coated with poloxamer 188 to reduce drag

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4. Polyglactin 910 - Vicryl

• Brands: Vicryl, Coated Vicryl, Vicryl Rapide (all Ethicon Inc.)
• Uses: Deep fascial closure, subcutaneous tissue, subcuticular skin closure, ophthalmology, bowel anastomosis, gynecology
• Vicryl Rapide: Fast-absorbing version used for skin closure (epidermal only) - falls off naturally ~7-10 days, avoids suture removal
• Coating: Polyglactin 370 + calcium stearate = smooth passage through tissue
• Note: Most widely used absorbable suture worldwide. Violet or undyed (white).

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5. Polydioxanone (PDS / PDS II)

• Brand: PDS II (Ethicon)
• Uses: Abdominal wall/fascial closure (preferred slow-absorbing suture), cardiovascular surgery, pediatric surgery, tendon repair, orthopedics
• Key advantage: Monofilament = acapillary (does not wick bacteria), longest strength retention among absorbable sutures
• Note: Purple colored. Stiff handling - requires extra knot throws (4-5). The MOST RECOMMENDED suture for laparotomy fascial closure per multiple surgical societies.

"PDS has an advantage over polyglactin with a longer strength retention profile and absorption time; it is also a monofilament that may resist infection to a greater degree than braided suture." - Sabiston Textbook of Surgery

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6. Poliglecaprone 25 - Monocryl

• Brand: Monocryl (Ethicon)
• Uses: Subcuticular skin closure, soft tissue approximation, plastic surgery
• Advantage: Extremely smooth, pliable monofilament. Excellent cosmetic results for skin.
• Note: Undyed or violet. Loses strength faster than PDS but absorbs more predictably.

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7. Polyglyconate - Maxon

• Brand: Maxon (Medtronic)
• Uses: Similar to PDS - fascial closure, abdominal wall, cardiovascular
• Note: Maintains better strength over 28 days compared to PDS in some studies.

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8. Glycomer 631 - Biosyn

• Brand: Biosyn (Medtronic)
• Uses: Soft tissue approximation, subcutaneous closure, alternative to Monocryl/PDS

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PART 2 - NON-ABSORBABLE SUTURES

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A. NATURAL NON-ABSORBABLE SUTURES

9. Surgical Silk

• Brand: Silk (Ethicon), Ti-cron (coated)
• Uses: Oral/dental surgery, cardiovascular (vessel ties), ophthalmic surgery, gastrointestinal surgery (for ties/ligatures), skin closure where excellent handling needed
• Note: Black. The standard against which all other sutures are compared for handling and knot security. Classified as non-absorbable but DOES lose strength over years - technically a "slowly degradable" natural material.
• Avoid: Infected wounds (wicks bacteria due to braided structure), permanent implantation

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10. Surgical Cotton

• Uses: Ligatures, rarely used in modern surgery
• Note: Gains tensile strength when wet. Largely replaced by synthetic sutures.

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B. SYNTHETIC NON-ABSORBABLE SUTURES

11. Nylon (Polyamide)

• Brands: Ethilon (monofilament, Ethicon), Dermalon (monofilament, Medtronic), Nurolon (braided, Ethicon), Surgilon (braided, Medtronic)
• Uses: Skin closure (most commonly used non-absorbable skin suture), plastic surgery, ophthalmology, neurosurgery, microsurgery (fine gauge), retention sutures
• Note: Black (most common) or clear. High memory makes handling difficult. Loses ~15-20% tensile strength/year via slow hydrolysis - not truly permanent.

"Closure of a simple finger laceration with interrupted Ethilon sutures" - Geeky Medics (clinical photo)

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12. Polypropylene (Prolene, Surgipro)

• Brands: Prolene (Ethicon), Surgipro (Medtronic), Surgilene (Medtronic)
• Uses: Cardiovascular surgery (vascular anastomoses, heart valve repair), hernia repair, plastic surgery (continuous subcuticular skin closure), abdominal wall, fascia, tendon repair
• Key properties: Truly permanent, acapillary, inert. The blue color makes it highly visible intraoperatively. The elasticity accommodates tissue swelling.
• Note: Requires careful handling due to high memory. Used for vascular anastomoses because it does not induce thrombosis. Non-absorbable abdominal closure associated with increased pain and sinus tracts.

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13. Polyester (Dacron/Mersilene/Ti-Cron/Ethibond)

• Brands: Mersilene (uncoated, Ethicon), Ethibond (coated with polybutylate, Ethicon), Ti-Cron (coated, Medtronic), Ticron, FiberWire, Dacron
• Uses: Cardiac surgery (valve replacement, annuloplasty rings), vascular surgery (prosthetic grafts), orthopedic ligament repair, tendon repair, hernia mesh fixation
• Coated versions (Ethibond): Coating reduces tissue drag and improves handling without changing absorption
• Note: Among the strongest non-absorbable sutures. Uniform permanent strength makes it ideal for cardiac applications where permanent support is required.

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14. Polybutester - Novafil

• Brand: Novafil (Medtronic)
• Uses: Skin closure, vascular anastomosis (elasticity accommodates pulsatile flow)
• Advantage: Greater elasticity than nylon or polypropylene; useful where tissue swelling anticipated

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15. Stainless Steel Wire

• Uses: Sternal closure after cardiac surgery, orthopedic fixation (cerclage wires), tendon repair (distal forearm), infected wounds where other sutures fail
• Disadvantages: Difficult to handle, can cut through tissue, creates large knots, fragments can cause injury, makes a large knot. MRI compatibility issues at high-gauge sizes.
• Note: Rarely used in ED or soft tissue surgery due to handling difficulty.

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16. Barbed Sutures (e.g., V-Loc, Stratafix, Quill)

• Brands: V-Loc (Medtronic), Stratafix (Ethicon), Quill (Surgical Specialties)
• Uses: Laparoscopic fascial closure, bowel anastomosis, plastic surgery, bariatric surgery, abdominal wall closure, TKR/THR capsule closure
• Advantages: Eliminates knot (weakest point of suture line), evenly distributes tension, faster placement
• Disadvantages: Barbs reduce core tensile strength by ~25-30%; difficult to remove if needed; cutting barbs into monofilament weakens the material
• Note: RCT data shows superiority vs. regular monofilament for SSI reduction in some series.

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PART 3 - SUTURE SIZE (USP System)

• Rule: Larger number = smaller diameter (0, 00/2-0, 000/3-0, etc. = increasingly thin)
• Rule: A 3-0 suture is ~52% stronger than 4-0; a 4-0 is ~66% stronger than 5-0.
• Campbell's Operative Orthopaedics, 15th ed.

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PART 4 - SITE-SPECIFIC SUTURE SELECTION GUIDE

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PART 5 - KEY COMPARISON TABLE

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Key Principles to Remember

1. Monofilament = acapillary (does not wick bacteria) - preferred in contaminated fields
2. Braided = better handling and knot security - preferred where ease of use matters
3. PDS is the recommended suture for laparotomy closure - slow absorption, monofilament, resists infection
4. Vicryl is the most widely used absorbable suture worldwide for deep tissue closure
5. Prolene is the only truly permanent monofilament - no strength loss over time
6. Silk has the best handling/knot security but provokes the highest tissue reaction among non-absorbables
7. Faster absorption = more tissue reaction (natural > synthetic; enzymatic > hydrolytic)
8. Barbed sutures eliminate the knot - distributing tension evenly but weakening the core material
9. Smaller suture size = less tissue trauma - use the smallest suture that will hold the wound
10. Suture-to-wound length ratio for fascia = 4:1 (traditional); smaller 5mm bites with 5mm spacing is now preferred to reduce hernia risk

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Suture Materials - Complete Guide with Images

Classification Overview

1. Absorbability - absorbable vs. non-absorbable
2. Origin - natural vs. synthetic
3. Structure - monofilament vs. multifilament (braided)

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PART 1 - ABSORBABLE SUTURES

Synthetic absorbable sutures degrade by hydrolysis (water cleaves the polymer chain) - more predictable, less tissue reaction. Natural absorbable sutures degrade by enzymatic proteolysis - faster, less predictable, higher inflammatory response.

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A. NATURAL ABSORBABLE

1. Plain Catgut (Plain Gut)

• Uses: Rapidly healing tissues - oral mucosa, small vessel ligatures, episiotomy, perineal repair, scalp deep layer
• Note: Absorbed faster in infected, ischemic, or highly vascularized tissue. Wet before use for better pliability. Yellow/tan color.
• Avoid: Any wound requiring support beyond 10 days, contaminated wounds

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2. Chromic Catgut (Chromic Gut)

• Uses: Subcutaneous tissue, oral mucosa, scalp, episiotomy, gynecological procedures, circumcision, bladder
• Advantage over plain gut: Chromic salt cross-links collagen, slowing absorption and extending strength retention
• Brands: Chromic (Ethicon), Chromic (Medtronic)
• Color: Brown/dark tan. Distinguished from plain gut (yellow) by darker color.

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B. SYNTHETIC ABSORBABLE

3. Polyglycolic Acid - Dexon (PGA)

• Brand: Dexon, Dexon Plus (coated - Medtronic)
• Uses: Deep tissue closure, subcutaneous, abdominal wall, ligatures, urological procedures
• Color: Undyed (off-white) or green
• Note: The original synthetic absorbable suture. Dexon Plus has poloxamer 188 coating to reduce tissue drag.

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4. Polyglactin 910 - Vicryl

• Brands: Coated Vicryl, Vicryl Rapide (Ethicon)
• Uses: Deep fascial closure, subcutaneous tissue, subcuticular skin, ophthalmology, bowel anastomosis, gynecology
• Vicryl Rapide: Fast-absorbing version for epidermal skin closure only - naturally falls off at ~7-10 days, eliminating the need for suture removal
• Color: Violet or undyed (white)
• Coating: Polyglactin 370 + calcium stearate = smooth passage through tissue
• Note: The most widely used absorbable suture in the world.

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5. Polydioxanone - PDS II

• Brand: PDS II, PDS Plus Antibacterial (Ethicon)
• Uses: Abdominal wall/fascial closure (the recommended choice), cardiovascular surgery, pediatric surgery, tendon repair, urological repair
• Color: Violet (most common) or clear
• Key advantage: Monofilament = acapillary, does not wick bacteria. Longest strength retention of any absorbable suture.

"PDS has an advantage over polyglactin with a longer strength retention profile and absorption time; it is also a monofilament that may resist infection to a greater degree than braided suture." - Sabiston Textbook of Surgery

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6. Poliglecaprone 25 - Monocryl

• Brand: Monocryl, Monocryl Plus Antibacterial (Ethicon)
• Uses: Subcuticular skin closure (excellent cosmetic result), soft tissue approximation, plastic surgery, facial wounds
• Color: Undyed (clear) or violet
• Note: Extremely smooth and pliable - the smoothest of all absorbable monofilaments. Loses strength faster than PDS but very cosmetically forgiving on skin.

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7. Polyglyconate - Maxon

• Brand: Maxon (Medtronic/Covidien)
• Uses: Fascial closure, abdominal wall, cardiovascular, alternative to PDS
• Color: Green
• Note: Maintains better strength at 28 days vs. PDS in some comparative studies.

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8. Glycomer 631 - Biosyn

• Brand: Biosyn (Medtronic)
• Uses: Soft tissue approximation, subcutaneous closure, alternative to Monocryl or PDS
• Color: Violet or undyed

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PART 2 - NON-ABSORBABLE SUTURES

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A. NATURAL NON-ABSORBABLE

9. Surgical Silk

• Brand: Perma-Hand Silk (Ethicon), Sofsilk (Medtronic)
• Uses: Oral/dental surgery, cardiovascular ligatures, ophthalmic surgery, GI ligatures, vessel ties, skin closure where excellent handling matters
• Color: Black (most common) or white
• Note: The standard against which all sutures are compared for handling and knot tying. Technically "slowly biodegradable" - not truly permanent. Braided structure wicks bacteria - avoid in contaminated/infected wounds or where permanent implantation intended.

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B. SYNTHETIC NON-ABSORBABLE

10. Nylon (Polyamide) - Ethilon / Dermalon

• Brands: Ethilon (monofilament, Ethicon), Dermalon (monofilament, Medtronic), Nurolon (braided, Ethicon), Surgilon (braided, Medtronic)
• Uses: Skin closure (the most commonly used non-absorbable skin suture), plastic surgery, ophthalmology, neurosurgery, microsurgery (fine gauges 8-0 to 10-0), retention sutures
• Color: Black (most common), clear, or blue
• Note: High memory makes handling tricky. Not truly permanent - loses strength slowly via hydrolysis over years.

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11. Polypropylene - Prolene / Surgipro

• Brands: Prolene (Ethicon), Surgipro / Surgilene (Medtronic)
• Uses: Vascular anastomoses, cardiac surgery (valve repair/replacement), hernia repair, subcuticular skin closure (cosmetic), abdominal wall, tendon repair, retention sutures
• Color: Blue (highly visible intraoperatively) or clear
• Note: The only truly permanent monofilament. Acapillary, inert, non-thrombogenic = ideal for cardiovascular use. Blue color is deliberately chosen for visibility. Prolene's slight elasticity allows it to give with post-op tissue swelling and return to normal tension.

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12. Polyester - Ethibond / Mersilene / Ti-Cron

• Brands: Mersilene (uncoated, Ethicon), Ethibond Excel (coated with polybutylate, Ethicon), Ti-Cron (coated, Medtronic), FiberWire (Arthrex - for orthopaedic)
• Uses: Cardiac surgery (valve replacement/repair, annuloplasty rings), vascular surgery, orthopaedic tendon/ligament repair, hernia mesh fixation
• Color: Green, white, or multi-colored (FiberWire)
• Note: Among the strongest non-absorbable sutures. Uniform permanent strength makes it the go-to for cardiac valve procedures. Ethibond coating reduces tissue drag without affecting absorption.

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13. Polybutester - Novafil

• Brand: Novafil (Medtronic)
• Uses: Skin closure where swelling anticipated, vascular anastomosis (elasticity accommodates pulsatile vessel movement)
• Color: Blue
• Note: More elastic than both nylon and polypropylene. Accommodates post-op swelling, then returns to normal tension as edema resolves.

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14. Stainless Steel Wire

• Uses: Sternal closure after cardiac surgery (primary indication), orthopaedic cerclage wires, tendon repair (distal forearm), infected wounds where other materials fail
• Color: Silver/metallic
• Note: Difficult to handle, can cut through soft tissue, creates bulky knots. Twist instead of throw for knot security. MRI compatibility issues at higher gauges.

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15. Barbed Sutures - V-Loc / Stratafix / Quill

• Brands: V-Loc (Medtronic), Stratafix (Ethicon), Quill (Surgical Specialties)
• Uses: Laparoscopic/robotic fascial closure, bowel anastomosis, plastic surgery, total joint capsule closure, abdominal wall, vaginal cuff closure
• Advantages:
  • Eliminates knot (the weakest point of any suture line)
  • Distributes tension evenly along wound length
  • Faster placement in laparoscopic settings
• Disadvantages: Weakens the suture core, difficult to remove if needed, limited data on long-term hernia formation

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PART 3 - SUTURE SIZE (USP System)

Remember: Larger number = smaller diameter. A 3-0 is ~52% stronger than 4-0; 4-0 is ~66% stronger than 5-0. - Campbell's Operative Orthopaedics 15th ed.

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PART 4 - SITE-SPECIFIC QUICK SELECTION

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PART 5 - MASTER COMPARISON TABLE

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10 Golden Rules

1. Monofilament = acapillary - will not wick bacteria - preferred in contaminated fields
2. Braided = better handling and knot security - easier to work with
3. PDS is the standard for laparotomy fascial closure - slow absorption, monofilament, resists infection
4. Vicryl is the world's most used absorbable suture for deep tissue
5. Prolene is the only truly permanent monofilament - zero strength loss over time
6. Silk has the best handling and knot security but causes the most tissue reaction
7. Natural sutures degrade faster and cause more inflammation than synthetic
8. Barbed sutures eliminate the knot - the weakest point in any suture line
9. Smaller suture size = less tissue trauma - use the smallest that will hold the tissue
10. Absorbable sutures lose strength before they are fully absorbed - plan support duration accordingly