Different types of Sutures with images
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I now have comprehensive material from authoritative textbooks and multiple diagrams. Here is a complete, well-illustrated guide to suture types:
Types of Sutures
Sutures are classified along two major axes: material (what they're made of) and technique (how they're placed). The classification below follows the structure used in Roberts and Hedges' Clinical Procedures in Emergency Medicine, Andrews' Diseases of the Skin, and Fitzpatrick's Dermatology.
Part 1: Classification by Material
Master Classification Diagram
A. Absorbable Sutures
Defined as losing >50% tensile strength within 60 days of placement. Used primarily for deep (dermal/subcutaneous) layer closure.
| Suture | Type | Tensile Strength Half-Life | Notes |
|---|---|---|---|
| Plain Gut | Natural monofilament | ~7-10 days | Derived from sheep submucosa; high tissue reactivity |
| Chromic Gut | Natural monofilament | ~21 days | Chromium-treated to slow absorption; less reactive than plain gut |
| Polyglycolic Acid (Dexon) | Synthetic multifilament | ~14-21 days | Low tissue reactivity, good handling |
| Polyglactin (Vicryl) | Synthetic multifilament | ~21 days | Most widely used absorbable; Vicryl Rapide absorbs even faster |
| Poliglecaprone (Monocryl) | Synthetic monofilament | ~7-14 days | Excellent tensile strength, low memory |
| Polydioxanone (PDS) | Synthetic monofilament | ~42 days | Longest-lasting absorbable; used for fascia/deep structures |
| Polyglyconate (Maxon) | Synthetic monofilament | ~28 days | Similar to PDS |
B. Non-Absorbable Sutures
Remain indefinitely unless removed. Used for epidermal closure and permanent structural sutures.
| Suture | Type | Memory | Tissue Reactivity | Notes |
|---|---|---|---|---|
| Silk | Natural braided/twisted | Very low | High | Excellent handling and knot security; highest reactivity of common sutures |
| Cotton | Natural twisted | Low | Very high | Rarely used today |
| Nylon (Ethilon, Dermalon) | Synthetic monofilament | High | Low | Standard skin closure; requires extra throws due to high memory |
| Nylon (Nurolon, Surgilon) | Synthetic braided | Low | Low | Better knot security than monofilament nylon |
| Polypropylene (Prolene) | Synthetic monofilament | Very high | Very low | Cardiovascular surgery; lowest tissue reactivity of all sutures |
| Polyester (Mersilene, Ti-Cron) | Synthetic braided | Low | Low | Good knot security; used in cardiac/vascular work |
| Polybutester (Novafil) | Synthetic monofilament | High | Low | Elastic; conforms to wound swelling |
| Stainless Steel | Metallic monofilament | Extreme | Low | Sternum closure; poor handling |
Source: Roberts and Hedges' Clinical Procedures in Emergency Medicine, Table 35.1; Fitzpatrick's Dermatology, Table 202-5
Monofilament vs. Multifilament
| Property | Monofilament | Multifilament (Braided/Twisted) |
|---|---|---|
| Coefficient of friction | Low - passes through tissue easily | High - more drag |
| Capillarity | Low - resistant to bacterial wicking | High - harbors bacteria |
| Memory | High - tends to unravel | Low - knot stays well |
| Knot security | Poor - needs extra throws | Good - fewer throws needed |
| Tissue reactivity | Low | Higher |
Suture Size (USP Scale)
Suture diameter is inversely related to the first digit of the USP designation. Larger number = thinner suture:
| Size | Use |
|---|---|
| 0, 1, 2 | Deep fascia, orthopedics, abdominal wall |
| 2-0, 3-0 | Subcutaneous/deep dermal layers |
| 4-0 | General skin closure (extremities, trunk) |
| 5-0, 6-0 | Face, cosmetically sensitive areas |
Part 2: Classification by Stitch Technique
Basic Suture Patterns
1. Simple Interrupted Suture
The most versatile and widely used stitch. Each suture is placed and tied independently.
- Advantage: If one suture fails, the rest hold. Allows precise tension adjustment at each bite.
- Use: Small punch biopsies, layered closures, high-tension wounds, areas needing exact edge apposition
- Key point: A single suture can be removed to inspect the wound without compromising the full closure
2. Buried (Deep Dermal) Suture
Placed within the dermis with the knot buried away from the surface. This is the workhorse for deep layer closure.
- Advantage: Reduces tension on the surface, promotes wound eversion, minimizes dead space, avoids suture spitting
- Variants: Conventional buried suture (mild eversion) and buried vertical mattress (greater eversion)
3. Simple Running (Continuous) Suture
A single suture placed in a continuous fashion with knots only at each end of the wound.
- Advantage: Much faster than interrupted; evenly distributes tension
- Disadvantage: If suture breaks anywhere, the entire closure is compromised
- Use: Long wounds under minimal tension with well-approximated edges
4. Running Locked (Ford Interlocking) Suture
A variant of the simple running suture where the needle passes through the previous loop before entering tissue.
- Advantage: Creates pressure along the wound edge - useful in highly vascularized areas for additional hemostasis
- Use: Scalp wounds, areas with active oozing
5. Running Subcuticular (Intradermal) Suture
Multiple horizontal bites placed alternately in the dermis, just below the epidermis. The suture runs parallel to the skin surface and is not visible externally.
- Advantage: No external suture marks ("railroad tracks"); can be left in place 2-3 weeks; ideal if patient cannot return for removal
- Use: Trunk and extremity closures; cosmetically sensitive wounds
6. Horizontal Mattress Suture
Two parallel bites placed horizontally across the wound, with the suture crossing perpendicular to the incision.
- Advantage: Excellent tension reduction; useful as a retention suture for large wounds; good wound eversion
- Caution: Can strangulate poorly vascularized tissue (e.g., flaps) - use with care
7. Vertical Mattress Suture
Two bites placed in the same plane perpendicular to the wound - one deep and wide, one shallow and narrow (near-far, far-near pattern).
- Advantage: Closes both deep and superficial layers simultaneously; promotes strong wound eversion
- Use: Areas prone to inversion (e.g., back of neck, dorsum of hand); high-tension closures
8. Purse-String Suture
Multiple horizontal bites taken circumferentially around a circular wound, then pulled tight to close it concentrically.
- Use: Partial or complete closure of circular defects (e.g., after punch excisions); reduces healing time for second-intention wounds
Quick Reference Summary
| Technique | Pattern | Best Use |
|---|---|---|
| Simple Interrupted | Individual knots | Most wounds; high-tension areas |
| Buried Dermal | Knot buried in dermis | Deep layer closure; reduces surface tension |
| Simple Running | Continuous, end knots | Long, low-tension wounds; fast closure |
| Running Locked | Continuous with loops | Vascular areas; hemostasis |
| Subcuticular | Intradermal horizontal | Cosmetic closure; no stitch marks |
| Horizontal Mattress | Wide horizontal bites | Tension relief; large wounds |
| Vertical Mattress | Deep + superficial bites | Wound eversion; prone to inversion |
| Purse-String | Circumferential | Circular defects |
Sources: Roberts and Hedges' Clinical Procedures in Emergency Medicine (9780323354783); Andrews' Diseases of the Skin (9780323547536); Fitzpatrick's Dermatology (9780071837781); Pfenninger and Fowler's Procedures for Primary Care (9780323052672)
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