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Surgical suture
Surgical suture and 6-0 gauge polypropylene thread held with a needle holder. Packaging
shown above.

A surgical suture, also known as a stitch or stitches, is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery. Application generally involves using a needle with an attached length of thread. There are numerous types of suture which differ by needle shape and size as well as thread material and characteristics. Selection of surgical suture should be determined by the characteristics and location of the wound or the specific body tissues being approximated.[1]

In selecting the needle, thread, and suturing technique to use for a specific patient, a medical care provider must consider the tensile strength of the specific suture thread needed to efficiently hold the tissues together depending on the mechanical and shear forces acting on the wound as well as the thickness of the tissue being approximated. One must also consider the elasticity of the thread and ability to adapt to different tissues, as well as the memory of the thread material which lends to ease of use for the operator. Different suture characteristics lend way to differing degrees of tissue reaction and the operator must select a suture that minimizes the tissue reaction while still keeping with appropriate tensile strength.[2]

Needles

[edit]
A surgeon suturing a wound in a person's thumb

Historically, surgeons used reusable needles with holes (called "eyes"), which must be threaded before use just as is done with a needle and thread prior to sewing fabric. The advantage of this is that any combination of thread and needle may be chosen to suit the job at hand. Swaged (or "atraumatic") needles with sutures consist of a pre-packed eyeless needle already attached (by swaging) to a specific length of suture thread. This saves time, and eliminates the most difficult threading of very fine needles and sutures.

Two additional benefits are reduced drag and less potential damage to friable tissue during suturing. In a swaged suture the thread is of narrower diameter than the needle, whereas it protrudes on both sides in an eyed needle. Being narrower, the thread in a swaged suture has less drag when passing through tissue than the needle, and, not protruding, is less likely to traumatize friable tissue, earning the combination the designation "atraumatic".[citation needed]

There are several shapes of surgical needles. These include:[citation needed]

  • Straight
  • 1/4 circle
  • 3/8 circle
  • 1/2 circle. Subtypes of this needle shape include, from larger to smaller size, CT, CT-1, CT-2 and CT-3.[3]
  • 5/8 circle
  • compound curve
  • half curved (also known as ski)
  • half curved at both ends of a straight segment (also known as canoe)

The ski and canoe needle design allows curved needles to be straight enough to be used in laparoscopic surgery, where instruments are inserted into the abdominal cavity through narrow cannulas.

Needles may also be classified by their point geometry; examples include:

  • taper (needle body is round and tapers smoothly to a point)
  • cutting (needle body is triangular and has a sharpened cutting edge on the inside curve)
  • reverse cutting (cutting edge on the outside)
  • trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point)
  • blunt points for sewing friable tissues
  • side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery

Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for interrupted sutures, where each suture is only passed once and then tied.

Sutures can withstand different amounts of force based on their size; this is quantified by the U.S.P. Needles Pull Specifications.[citation needed]

Thread

[edit]

Materials

[edit]
Further information: Suture materials comparison chart
Micrograph of a H&E stained tissue section showing a non-absorbable multi-filament surgical suture with a surrounding foreign-body giant cell reaction

Suture material is often broken down into absorbable thread versus non-absorbable thread, which is further delineated into synthetic fibers versus natural fibers. Another important distinction among suture material is whether it is monofilament or polyfilament (braided) [2]

Monofilament versus polyfilament

[edit]

Monofilament fibers have less tensile strength but create less tissue trauma and are more appropriate with delicate tissues where tissue trauma can be more significant such as small blood vessels. Polyfilament (braided) sutures are composed of multiple fibers and are generally greater in diameter with greater tensile strength, however, they tend to have greater tissue reaction and theoretically have more propensity to harbor bacteria.[1]

Other properties to consider

[edit]
  • Tensile strength: the ability of the suture to hold tissues in place without breaking.
  • Elasticity: the ability of the suture material to adapt to changing tissues such as in cases of edema.
  • Tissue reactivity: inflammatory response of the surrounding tissue that can cause materials to break down quicker and lose tensile strength. Non absorbable synthetic suture have the lowest of tissue reactivity, while the absorbable natural fibers have the highest rates of tissue reactivity.[4]
  • Knot security: the ability of the suture to maintain a knot that holds the thread in place.[2]

Absorbable

[edit]

Absorbable sutures are either degraded via proteolysis or hydrolysis and should not be utilized on body tissue that would require greater than two months of tensile strength. It is generally used internally during surgery or to avoid further procedures for individuals with low likelihood of returning for suture removal.[2] To-date, the available data indicates that the objective short-term wound outcomes are equivalent for absorbable and non-absorbable sutures, and there is equipoise amongst surgeons.[5]

Natural absorbable

[edit]

Natural absorbable material includes plain catgut, chromic catgut and fast catgut which are all produced from the collagen extracted from bovine intestines. They are all polyfilaments which have different degradations times ranging from 3–28 days.[2] This material is often used for body tissue with low mechanical or shearing force and rapid healing time.

Plain gut (polyfilament)

[edit]
  • Description: Maintains original strength for 7–10 days and full degradation occurs in 10 weeks.
  • Advantages/disadvantages: Excellent elasticity allowing for adaptation to tissue swelling. Passes through the skin with very little tissue trauma occurrence. Poor handling and high tissue reactivity causing quick loss of tensile strength.
  • Common use: best used in rapidly healing tissues with good blood supply i.e. mucosal tissues.[6]

Chromic gut (polyfilament)

[edit]
  • Description: Maintains original strength for 21–28 days and full degradation occurs in 16–18 weeks.
  • Advantages/disadvantages: Excellent elasticity allowing for adaptation to tissue swelling. Passes through the skin with very little tissue trauma occurrence. Improved handling and decreased tissue reactivity due to chromic salt coating.
  • Common use: skin closure (face), mucosa, genitalia.[6]

Fast gut (polyfilament)

[edit]
  • Description: Treated with heat to further break down protein and allow for more rapid absorption in bodily tissues. Tensile strength less than a week (3–5 days).[2]
  • Advantages/disadvantages: Excellent elasticity allowing for adaptation to tissue swelling. Passes through the skin with very little tissue trauma occurrence.
  • Common use: Advised for skin closure only generally on the mucosa or face.[6]

Synthetic absorbable

[edit]

Synthetic absorbable material includes polyglactic acid, polyglycolic acid, poliglecaprone, polydioxanone, and polytrimethylene carbonate. Among these are monofilaments, polyfilaments and braided sutures. In general synthetic materials will keep tensile strength for longer due to less local tissue inflammation.[2]

Poliglecaprone (monofilament, Monocryl, Monocryl Plus, Suruglyde)

[edit]
  • Description: copolymer of synthetic materials. Loses tensile strength quickly; sixty percent lost in the first week. All strength lost within 3 weeks.[7]
  • Advantages/disadvantages: high tensile strength, excellent elasticity, excellent cosmetic outcomes, decreased hypertrophic scarring, minimal tissue reaction, good knot security originally; however, the material makes the security unreliable over time, thus it is important to keep ears of material long.
  • Common use: Advised for subcutaneous and superficial tissue closure.

Polyglycolic acid (polyfilament, Dexon)

[edit]
  • Description: synthetic polymer that loses all tensile strength in by 25 days. Either dyed green for visibility or undyed.
  • Advantages/disadvantages: minimal tissue reaction, good tensile strength, good handling, but poor knot security.
  • Common use: subcutaneous tissue.

Polyglactin 910 (polyfilament, Vicryl)

[edit]
  • Description: loss of all tensile strength in 28 days.
  • Advantages/disadvantages: minimal tissue reaction, good tensile strength, good knot security,
  • Common use: subcutaneous tissue, skin closure (avoid dyed Vicryl on face).

Polyglactin 910 Irradiated (polyfilament, Vicryl Rapid)

[edit]
  • Description: sourced as vicryl is with irradiation to break down material for quicker absorption. Loss of all tensile strength in 5–7 days.
  • Advantages/disadvantages: minimal tissue reaction, good tensile strength, fair good handling and good knot security.
  • Common use: scalp and facial laceration closure.

Polyglyconate (monofilament, Maxon)

[edit]
  • Description: co polymer product of synthetic materials. Loses 75% of the tensile strength after 40 days.
  • Advantages/disadvantages: minimal tissue reaction, excellent tensile strength, good handling.
  • Common use: subcutaneous use often an alternative to PDS due to better handling and slightly superior tensile strength.

Polydioxanone closures (PDS, monofilament)

[edit]
  • Description: loss of tensile strength in 36–53 days.
  • Advantages/disadvantages: minimal tissue reaction, good tensile strength, but poor handling.
  • Common use: subcutaneous with need of high tensile strength (abdominal incision closure).[6]

Non-absorbable

[edit]

These sutures hold greater tensile strength for longer periods of time and are not subject to degradation. They are appropriate for tissues with a high degree of mechanical or shear force (tendons, certain skin location). They also supply the operator with greater ease of use due to less thread memory.[6]

Natural
[edit]

Silk (polyfilament, Permahand, Ethicon; Sofsilk, Covidien)

  • Description: surgical silk is a protein derived from silkworms that is coated to minimize friction and water absorption.
  • Advantages/disadvantages: This material has good tensile strength, is easy to handle and has excellent knot security. However, it is rarely used internally due to its significant tissue reaction which causes loss of tensile strength over months.
  • Common use: Due to advancements in sutures, there is no longer indication for use of surgical silk. However, it is still commonly used in dentistry for mucosal surfaces[8] or to secure surgical tubes on the bodies surface.
Synthetic
[edit]

Synthetic materials include nylon, polypropylene and surgical steel all of which are monofilaments with great tensile strength.[2]

Nylon (monofilaments, Dermalon, Ethilon)

  • Description: polyamide
  • Advantages/disadvantages: Excellent tensile strength. However, poor handling and poor knot security due to high material memory.
  • Common use: Excellent for superficial skin closure due to minimal tissue reactivity.[6] It is the most commonly used skin suture due to its excellent adaptability to potentially expanding tissues (edema).[9]

Nylon (polyfilaments, Nurolon, Surgilon, Supramid)

  • Description: polyamide
  • Advantages/disadvantages: Excellent tensile strength, increased usability, and increased knot security as compared to its monofilamentous counterpart. However, its polyfilamentous nature is said[weasel words] to increase risk of infection.
  • Common use: soft tissue, vessel ligations and superficial skin (specifically facial lacerations).[6]

Braided polyester (polyfilament, Ethibond, Dagrofil, Synthofil, PremiCron, Synthofil)

  • Description: made from polyethylene terephthalate, there are various brands and configurations of this type of suture. Many are braided, coated in silicone and dyed for visibility.
  • Advantages/disadvantages: Good handling, good knot security and high tensile strength due to low tissue reactivity. However, this suture can create more tissue trauma when passing through the skin and is more expensive than its counterparts
  • Common use: Rare, pediatric valvular surgery,[10] alternative to surgical steel for orthopedic surgery due to superior handling.[11]

Polybutester (monofilament, Novafil)

  • Description: A copolymer of polyester.
  • Advantages/disadvantages: low tissue reactivity, good handling, high tensile strength that is greater than most other monofilaments, good elasticity during increasing edema.
  • Common use: rare, tendon repairs, plastics (pull out subcuticular stitch)[6]

Surgical steel

  • Description: synthetic mixture of multiple alloys.
  • Advantages/disadvantages: Tensile strength is exceptional with very little tissue reactivity, thus maintaining minimal degradation over time. This suture material has very poor handling.
  • Common use: orthopedics, sternum closure.[2]
During the first dressing, Redon's drain was removed and the sutures were checked (surgical suture)

Sizes

[edit]

Suture sizes are defined by the United States Pharmacopeia (U.S.P.). Sutures were originally manufactured ranging in size from #1 to #6, with #1 being the smallest. A #4 suture would be roughly the diameter of a tennis racquet string. The manufacturing techniques, derived at the beginning from the production of musical strings, did not allow thinner diameters. As the procedures improved, #0 was added to the suture diameters, and later, thinner and thinner threads were manufactured, which were identified as #00 (#2-0 or #2/0) to #000000 (#6-0 or #6/0).[citation needed]

Modern sutures range from #5 (heavy braided suture for orthopedics) to #11-0 (fine monofilament suture for ophthalmics). Atraumatic needles are manufactured in all shapes for most sizes. The actual diameter of thread for a given U.S.P. size differs depending on the suture material class.

USP
designation		 Collagen
diameter (mm)		 Synthetic absorbable
diameter (mm)		 Non-absorbable
diameter (mm)		 American
wire gauge
11-0 0.01
10-0 0.02 0.02 0.02
9-0 0.03 0.03 0.03
8-0 0.05 0.04 0.04
7-0 0.07 0.05 0.05
6-0 0.1 0.07 0.07 38–40
5-0 0.15 0.1 0.1 35–38
4-0 0.2 0.15 0.15 32–34
3-0 0.3 0.2 0.2 29–32
2-0 0.35 0.3 0.3 28
0 0.4 0.35 0.35 26–27
1 0.5 0.4 0.4 25–26
2 0.6 0.5 0.5 23–24
3 0.7 0.6 0.6 22
4 0.8 0.6 0.6 21–22
5 0.7 0.7 20–21
6 0.8 19–20
7 18

Techniques

[edit]
See also: Surgical knot
A wound before and after suture closure. The closure incorporates five simple interrupted sutures and one vertical mattress suture (center) at the apex of the wound.
Suturing two operation wounds with eleven simple stitches

Many different techniques exist. The most common is the simple interrupted stitch;[12] it is indeed the simplest to perform and is called "interrupted" because the suture thread is cut between each individual stitch. The vertical and horizontal mattress stitch are also interrupted but are more complex and specialized for everting the skin and distributing tension. The running or continuous stitch is quicker but risks failing if the suture is cut in just one place; the continuous locking stitch is in some ways a more secure version. The chest drain stitch and corner stitch are variations of the horizontal mattress.[citation needed]

Other stitches or suturing techniques include:

  • Purse-string suture, a continuous, circular inverting suture which is made to secure apposition of the edges of a surgical or traumatic wound.[13][14]
  • Figure-of-eight stitch
  • Subcuticular stitch. A continuous suture where the needle enters and exits the epidermis along the plane of the skin. This stitch is for approximating superficial skin edges and provides the best cosmetic result. Superficial gapping wounds may be reduced effectively by using continuous subcuticular sutures.[15] It is unclear whether subcuticular sutures can reduce the rate of surgical site infections.when compared with other suturing methods.[16]

Placement

[edit]

Sutures are placed by mounting a needle with attached suture into a needle holder. The needle point is pressed into the flesh, advanced along the trajectory of the needle's curve until it emerges, and pulled through. The trailing thread is then tied into a knot, usually a square knot or surgeon's knot. Ideally, sutures bring together the wound edges, without causing indenting or blanching of the skin,[17] since the blood supply may be impeded and thus increase infection and scarring.[18][19] Ideally, sutured skin rolls slightly outward from the wound (eversion), and the depth and width of the sutured flesh is roughly equal.[18] Placement varies based on the location.

Stitching interval and spacing

[edit]

Skin and other soft tissue can lengthen significantly under strain. To accommodate this lengthening, continuous stitches must have an adequate amount of slack. Jenkin's rule was the first research result in this area, showing that the then-typical use of a suture-length to wound-length ratio of 2:1 increased the risk of a burst wound, and suggesting a SL:WL ratio of 4:1 or more in abdominal wounds.[19][20] A later study suggested 6:1 as the optimal ratio in abdominal closure.[21]

Layers

[edit]

In contrast to single layer suturing, two layer suturing generally involves suturing at a deeper level of a tissue followed by another layer of suturing at a more superficial level. For example, Cesarean section can be performed with single or double layer suturing of the uterine incision.[22]

Removal

[edit]

Whereas some sutures are intended to be permanent, and others in specialized cases may be kept in place for an extended period of many weeks, as a rule sutures are a short-term device to allow healing of a trauma or wound.

Different parts of the body heal at different speeds. Common time to remove stitches will vary: facial wounds 3–5 days; scalp wound 7–10 days; limbs 10–14 days; joints 14 days; trunk of the body 7–10 days.[23][better source needed]

Removal of sutures is traditionally achieved by using forceps to hold the suture thread steady and pointed scalpel blades or scissors to cut. For practical reasons the two instruments (forceps and scissors) are available in a sterile kit. In certain countries (e.g. US), these kits are available in sterile disposable trays because of the high cost of cleaning and re-sterilization.

Expansions

[edit]

A pledgeted suture is one that is supported by a pledget, that is, a small flat non-absorbent pad normally composed of polytetrafluoroethylene, used as buttresses under sutures when there is a possibility of sutures tearing through tissue.[24]

Tissue adhesives

[edit]

Topical cyanoacrylate adhesives (closely related to super glue), have been used in combination with, or as an alternative to, sutures in wound closure. The adhesive remains liquid until exposed to water or water-containing substances/tissue, after which it cures (polymerizes) and forms a bond to the underlying surface. The tissue adhesive has been shown to act as a barrier to microbial penetration as long as the adhesive film remains intact. Limitations of tissue adhesives include contraindications to use near the eyes and a mild learning curve on correct usage. They are also unsuitable for oozing or potentially contaminated wounds.[citation needed]

In surgical incisions it does not work as well as sutures as the wounds often break open.[25]

Cyanoacrylate is the generic name for cyanoacrylate based fast-acting glues such as methyl-2-cyanoacrylate, ethyl-2-cyanoacrylate (commonly sold under trade names like Superglue and Krazy Glue) and n-butyl-cyanoacrylate. Skin glues like Indermil and Histoacryl were the first medical grade tissue adhesives to be used, and these are composed of n-butyl cyanoacrylate. These worked well but had the disadvantage of having to be stored in the refrigerator, were exothermic so they stung the patient, and the bond was brittle. Nowadays, the longer chain polymer, 2-octyl cyanoacrylate, is the preferred medical grade glue. It is available under various trade names, such as LiquiBand, SurgiSeal, FloraSeal, and Dermabond. These have the advantages of being more flexible, making a stronger bond, and being easier to use. The longer side chain types, for example octyl and butyl forms, also reduce tissue reaction.

History

[edit]
Sewing wound after herniotomy, 1559
Old refillable surgical thread supplier (middle of 20th century)

Through many millennia, various suture materials were used or proposed. Needles were made of bone or metals such as silver, copper, and aluminium bronze wire. Sutures were made of plant materials (flax, hemp and cotton) or animal material (hair, tendons, arteries, muscle strips and nerves, silk, and catgut).[citation needed]

The earliest reports of surgical suture date to 3000 BC in ancient Egypt, and the oldest known suture is in a mummy from 1100 BC. A detailed description of a wound suture and the suture materials used in it is by the Indian sage and physician Sushruta, written in 500 BC.[26] The Greek father of medicine, Hippocrates, described suture techniques, as did the later Roman Aulus Cornelius Celsus. The 2nd-century Roman physician Galen described sutures made of surgical gut or catgut.[27] In the 10th century, the catgut suture along with the surgery needle were used in operations by Abulcasis.[28][29] The gut suture was similar to that of strings for violins, guitars, and tennis racquets and it involved harvesting sheep or cow intestines. Catgut sometimes led to infection due to a lack of disinfection and sterilization of the material.[30]

Joseph Lister endorsed the routine sterilization of all suture threads. He first attempted sterilization with the 1860s "carbolic catgut", and chromic catgut followed two decades later. Sterile catgut was finally achieved in 1906 with iodine treatment.

The next great leap came in the twentieth century. The chemical industry drove production of the first synthetic thread in the early 1930s, which exploded into production of numerous absorbable and non-absorbable synthetics. The first synthetic absorbable was based on polyvinyl alcohol in 1931. Polyesters were developed in the 1950s, and later the process of radiation sterilization was established for catgut and polyester. Polyglycolic acid was discovered in the 1960s and implemented in the 1970s. Today, most sutures are made of synthetic polymer fibers. Silk and, rarely, gut sutures are the only materials still in use from ancient times. In fact, gut sutures have been banned in Europe and Japan owing to concerns regarding bovine spongiform encephalopathy. Silk suture is still used today, mainly to secure surgical drains.[31]

See also

[edit]
  • Alexis Carrel – French surgeon and biologist (1873–1944)
  • Barbed suture – Type of knotless surgical suture
  • Butterfly closure – Small self-adhesive medical dressing
  • Cheesewiring – Cutting of tissue by a taut element
  • Chitin – Long-chain polymer of a N-acetylglucosamine
  • Cyanoacrylate – Type of fast-acting adhesive
  • Knot – Method of fastening or securing linear materials
  • Ligature – Piece of thread (suture) tied around an anatomical structure
  • Outline of medicine – Diagnosis, treatment, and prevention of illness
  • Sewing – Craft of fastening textiles with a needle and thread
  • Surgical staple – Staples used in surgery in place of sutures
  • Wound closure strip – Porous surgical tape used for closing small wounds

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Surgical suture

View on Grokipedia
from Grokipedia
A surgical suture is a sterile consisting of a needle attached to a specialized thread or filament designed to approximate and secure the edges of divided tissues, such as , muscle, or organs, following or to facilitate and minimize complications like or dehiscence. Sutures have a rich history spanning millennia, with the earliest documented use occurring around 3000 BCE in , where materials like , animal tendons, and needles were employed to close wounds; this practice evolved through civilizations such as the Romans and Indians, who utilized , , and even ant mandibles as natural ligatures. By the , advancements like sterilized and chromic gut sutures improved outcomes, and modern innovations in the introduced synthetic polymers, reducing tissue reactivity and risks. Contemporary surgical sutures are broadly classified by the U.S. (FDA) as Class II medical devices, subject to special controls including performance testing for tensile strength, knot security, and to ensure safety and efficacy. They are categorized primarily as absorbable or non-absorbable based on whether the body degrades the material over time. Absorbable sutures typically lose 50% of their tensile strength within 60 days and are fully degraded within 90–240 days via or enzymatic breakdown, depending on the material; natural options like purified from bovine or ovine intestines () degrade faster, while synthetic varieties such as polyglactin 910 (), (PDS), and poliglecaprone 25 (Monocryl) vary in duration and are ideal for internal tissues where removal is impractical. Non-absorbable sutures, intended for permanent support or external wounds requiring removal, are composed of materials like (), (Ethilon), (Ethibond), and , offering high tensile strength and low tissue drag but necessitating manual extraction after 7–21 days depending on location. Sutures are further distinguished by structure as monofilament (single strand, e.g., or PDS, prized for smooth passage through tissue and reduced infection risk) versus multifilament (braided or twisted, e.g., or polyglactin, providing superior handling and security but potentially harboring bacteria if not coated), and sized using the (USP) scale, where coarser sizes (e.g., 2-0) are used for high-tension areas like , and finer sizes (e.g., 6-0) for delicate sites like vessels or corneas. In clinical practice, suture selection depends on factors such as wound location, tension, risk, and rate; techniques vary from simple interrupted stitches to continuous running sutures. As of 2025, developments including barbed self-anchoring sutures, bioengineered antimicrobial and bioactive coatings, bioelectric sutures for enhanced , and smart sutures with embedded sensors continue to improve minimally invasive procedures and patient outcomes.

Introduction

Definition and purpose

Surgical sutures are sterile surgical threads designed to approximate the edges of divided tissues, facilitating wound closure, promoting , and reducing the risk of . They serve as a critical tool in surgical procedures by enabling precise alignment of tissue layers, which supports the natural healing process through primary . According to regulatory standards, sutures are classified as Class II medical devices intended for soft tissue approximation and/or ligation. The primary purposes of surgical sutures include achieving to control bleeding, ensuring tissue approximation for optimal edge alignment, obliterating dead space to prevent fluid accumulation and formation, and promoting eversion of edges to minimize scarring and enhance cosmetic outcomes. These functions collectively minimize complications such as dehiscence and while supporting tissue regeneration. For instance, proper eversion maximizes epidermal contact and reduces tension on the , aiding in scarless . Surgical sutures find common applications across diverse medical fields, including for abdominal wound closure, orthopedics for tendon repair and cerclage, cardiovascular procedures for vascular , for precise cosmetic closures, and for repair. Their versatility stems from adaptability to various tissue types and procedural demands. Basic principles guiding suture use emphasize tension distribution to avoid excessive stress on tissues, biocompatibility to minimize inflammatory responses, and appropriate tensile strength tailored to the specific tissue type—such as higher strength for musculoskeletal tissues versus finer gauges for delicate dermal layers. Selection considers factors like location and expected mechanical loads to ensure secure knotting and long-term integrity.

Historical context overview

The use of surgical sutures dates back to ancient civilizations, with the earliest documented evidence appearing in around 3000 BCE, where physicians employed linen threads and animal sinew to close s on both the living and in mummification practices. In ancient , around 600 BCE, the , often regarded as the father of surgery, described innovative closure methods in the , including the use of large black ants whose heads were applied to pinch edges together as natural staples, as well as bark fibers from trees like the asmantaka for threading sutures. These early techniques relied on readily available natural materials and laid foundational principles for approximation, though risks remained high due to the absence of sterilization. During the medieval period, advancements in the Islamic world elevated suture practices, with 10th-century Arab surgeon Abu al-Qasim al-Zahrawi (Albucasis) pioneering the use of —derived from animal intestines—for internal stitches and for external wounds, as detailed in his comprehensive 30-volume . These materials offered improved tensile strength and reduced tissue reaction compared to earlier options. By the 16th century in Europe, French military surgeon further popularized sutures, integrating them into and emphasizing ligatures over to control bleeding, which marked a shift toward more humane and effective surgical interventions. The transition to modern suturing accelerated in the late with Joseph Lister's introduction of techniques in 1867, which drastically reduced postoperative infections and enabled safer use of natural materials like and . In the early , mechanical alternatives emerged, such as the first surgical stapler invented by Hungarian surgeon Hümér Hültl in 1908, which used metal staples to approximate tissues more rapidly, serving as a precursor to contemporary devices. Key regulatory milestones followed, including the U.S. Food and Drug Administration's (FDA) enforcement of sterility standards for surgical sutures under the 1938 Federal Food, Drug, and Cosmetic Act, with intensified oversight in the 1940s amid wartime medical demands to ensure device safety and efficacy. The mid-20th century saw a pivotal shift toward synthetic materials, with the introduction of polymers like polyglycolic acid revolutionizing suture design by providing predictable absorption rates, greater uniformity, and reduced inflammatory responses compared to animal-derived options. This era's innovations, driven by chemical advancements, set the foundation for today's diverse suture portfolio while maintaining the core objective of secure wound closure.

Components

Needles

Surgical needles are precision instruments designed to penetrate biological tissues with controlled trauma, facilitating the accurate placement of suture material during surgical procedures. The basic of a surgical needle comprises three primary components: the point, the body, and the attachment end. The point, located at the distal tip, determines the manner of tissue entry and is engineered to balance penetration ease with minimal damage; common variants include tapered points for smooth displacement of soft tissues, cutting points with sharpened edges for tougher structures like , and blunt points to avoid tearing friable tissues. The body forms the shaft, providing structural integrity and defining the needle's , while the attachment end connects to the suture, either via an open eye or a seamless swage. Needles are classified by body shape and point configuration to suit diverse surgical needs. Straight-bodied needles allow direct manual control and are typically employed for superficial closures, such as skin suturing, where visibility and access are straightforward. Curved-bodied needles, the predominant type, arc in fractions of a circle—ranging from 1/4 to 3/8 circle for confined spaces like cardiovascular or urologic procedures, to 1/2 or 5/8 circle for broader access in general surgery—to enable efficient tissue passage without excessive manipulation. Specialized forms include trocar-point needles, featuring a tapered, three-faceted tip for minimally invasive techniques, reducing the risk of unintended organ perforation. Cutting points, often reverse-cutting with the cutting edge on the convex side, excel in dense tissues by slicing cleanly and minimizing pull-through, whereas non-cutting tapered or blunt variants preserve tissue integrity in vascular or gastrointestinal applications. Construction materials prioritize strength, flexibility, and to withstand surgical stresses without deformation or breakage. Most surgical needles are fabricated from 300-series alloys, valued for their resistance, sharpness retention, and ability to maintain form under torsion. For enhanced durability in demanding applications, such as cardiovascular , tungsten-rhenium alloys may be incorporated to increase tensile strength. Surface coatings, including or (PTFE), are applied to diminish frictional drag on tissues, thereby reducing insertion force and postoperative . Attachment methods influence handling efficiency and sterility. Eyed needles feature a closed or open loop at the proximal end, necessitating intraoperative threading of the suture, which suits reusable scenarios but risks and time loss. In contrast, swaged (or eyeless) needles integrate the suture directly into the shank via a crimped or molded attachment, ensuring a smooth, atraumatic profile and pre-sterilization; this design prevents suture slippage, enhances knot security, and is standard for disposable, single-use sutures in contemporary practice. Needle selection hinges on tissue characteristics, procedural demands, and anatomical constraints to optimize outcomes and minimize complications. For delicate, low-density tissues like those in ophthalmic or microsurgery, fine-gauge tapered or blunt (e.g., 10-0 ) are preferred to avoid excessive trauma. In contrast, denser tissues such as abdominal or require robust cutting (e.g., 3/8 circle reverse-cutting) to ensure clean penetration with reduced fatigue. Access limitations, as in laparoscopic procedures, favor half-circle or ski-shaped designs for instrument compatibility, while overall needle length and are scaled to match depth and suture caliber, always prioritizing the smallest viable to limit tissue disruption.

Threads

Surgical suture threads form the essential ligature component that approximates and holds tissue edges together during closure and . These threads are engineered to balance mechanical performance with , enabling precise surgical manipulation. The primary configurations of suture threads are monofilament and polyfilament, each offering distinct advantages in clinical application. Monofilament threads consist of a single, uniform strand of material, which allows for smooth passage through tissues, minimizes tissue drag, and reduces the risk of bacterial harboring due to the absence of voids. In contrast, polyfilament threads are composed of multiple finer strands that are either braided or twisted together, resulting in enhanced pliability, superior knot security, and higher overall tensile strength compared to monofilaments of equivalent , though they may require coatings to mitigate potential risks from interstices. The core functions of suture threads revolve around providing sufficient tensile strength to withstand physiological stresses during the healing process, ensuring reliable security to prevent unraveling under tension, and offering optimal handling properties that facilitate ease of tying and placement without excessive memory or stiffness. Tensile strength refers to the maximum load the thread can endure before breaking, which is critical for maintaining integrity, while security determines the 's resistance to slippage, influenced by the thread's of and construction. Handling properties, including flexibility and knot run-down, allow surgeons to manipulate the thread efficiently, reducing operative time and tissue trauma. Manufacturing of surgical suture threads involves or processes followed by rigorous sterilization to achieve a of at least 10^{-6}, ensuring no viable microorganisms remain. Common sterilization methods include (EtO) gas, which penetrates packaging effectively for heat-sensitive materials, and , a radiation-based technique using sources that provides deep penetration without residues, suitable for both monofilament and polyfilament threads. Post-sterilization, threads are packaged in moisture-proof, gas-permeable materials such as foil-laminated pouches or envelopes to preserve sterility, prevent degradation, and protect against environmental contaminants until the point of use. Key general properties of suture threads include their , which influences strength and tissue penetration; , typically ranging from 18 to 45 inches to accommodate various procedure depths; and color coding, where dyes or natural hues (e.g., violet for certain synthetics) aid in rapid identification during . These attributes are standardized to ensure consistency, with diameters inversely related to numbering systems for precise selection. Effective knotting is vital for thread performance, with the square knot serving as a fundamental technique that involves two opposing half-hitches to achieve balanced tension and minimal slippage across most thread types. The , featuring an initial double throw followed by additional single throws, enhances initial security for larger-diameter threads or high-tension closures, promoting secure approximation without compromising thread integrity.

Suture Materials

Absorbable sutures

Absorbable sutures are surgical threads designed to be broken down and eventually eliminated by the body through biological processes, providing temporary support until tissue occurs. These materials degrade primarily via two mechanisms: enzymatic degradation for sutures, which involves breakdown by proteolytic enzymes in body fluids, and hydrolysis for synthetic sutures, a non-enzymatic reaction where molecules cleave the chains. Absorption timelines vary, with short-term options losing tensile strength in 1-2 weeks and long-term ones maintaining it for 3-6 months, allowing selection based on the required duration of support. Natural absorbable sutures are derived from sourced from the of bovine or ovine intestines, offering biodegradability through enzymatic . Plain gut sutures, untreated forms of this material, typically retain about 50% of their tensile strength for 7-10 days before significant degradation, with complete absorption occurring over 60-70 days, making them suitable for superficial or short-term closures. Chromic gut sutures are treated with chromic salts to the and delay enzymatic breakdown, extending tensile strength retention to 10-21 days and complete absorption to 90-120 days, which reduces the risk of premature dissolution in inflamed tissues. Fast-absorbing variants of gut sutures, often heat-treated, accelerate the process to provide tensile support for only 5-7 days with full absorption in 7-14 days, ideal for areas where minimal scarring is desired, such as facial skin. Synthetic absorbable sutures, composed of that undergo , offer more predictable degradation profiles and reduced tissue reactivity compared to natural options. Poliglecaprone 25 (Monocryl), a monofilament of glycolide and ε-caprolactone, maintains effective tensile strength for 10-14 days and achieves complete absorption in 90-120 days, commonly used for approximation like subcutaneous layers. Polyglycolic acid (Dexon), a braided multifilament homopolymer, retains 70% tensile strength at 2 weeks and is fully absorbed in 60-90 days, providing robust handling for gastrointestinal procedures. (Vicryl), a of and glycolide in braided form, holds 75% tensile strength for 14 days and completes absorption in 56-70 days; its irradiated variant, Vicryl Rapid, shortens this to 10-14 days for faster resorption in external applications. (PDS), a monofilament , sustains 50-70% tensile strength for 42 days and absorbs completely over 180 days, suitable for slow-healing sites like the . Polyglyconate (Maxon), another monofilament of glycolide and trimethylene , similarly retains tensile strength for 42-92 days with full absorption in approximately 180 days, offering high pliability for vascular and biliary . The primary advantages of absorbable sutures include the elimination of suture removal procedures, reducing discomfort and follow-up visits, and their suitability for internal applications such as gastrointestinal, urogenital, or cardiovascular sites where retrieval is impractical. However, they can elicit a localized inflammatory response due to degradation byproducts, particularly with natural types, and their strength loss may be less predictable in certain physiological conditions like or high metabolic activity.

Non-absorbable sutures

Non-absorbable sutures are surgical threads designed to provide prolonged or permanent mechanical support to tissues without degrading in the body, either remaining or being removed post-healing. These materials are essential in procedures requiring long-term tensile strength, such as those involving slow-healing tissues or external closures. Unlike absorbable alternatives, they resist enzymatic and hydrolytic breakdown, encapsulating within fibrous tissue over time to minimize migration or . Non-absorbable sutures are categorized into natural and synthetic types. Natural materials include , derived from silkworm cocoons, which offers good handling and knot security but may elicit mild tissue reactions due to its protein composition; and , both plant-based fibers, provide similar pliability but are less commonly used today owing to higher reactivity risks. Synthetic variants dominate modern practice for their consistency and , encompassing (polyamide), a versatile monofilament with high initial strength; (e.g., ), a hydrophobic monofilament resistant to tissue ingrowth; (e.g., Ethibond), typically braided for enhanced grip; and (PTFE), prized for its inertness in vascular applications. These sutures exhibit high tensile strength and low reactivity, maintaining over 50% of their original strength indefinitely , which suits applications in skin closure, repairs, and cardiovascular surgeries like vascular grafts where durability prevents dehiscence. Braided configurations, such as , excel in knot security and ease of tying, ideal for deep tissues, while monofilaments like and facilitate smooth passage through tissues with reduced drag and risk due to their non-porous nature. For external applications, such as wounds or orthopedic fixes needing extended support, non-absorbable sutures are selected to ensure structural during remodeling. In cardiovascular contexts, materials like PTFE minimize thrombogenicity and promote endothelialization. Surface-placed non-absorbable sutures are typically removed after 7-14 days to avert track marks or hypertrophic scarring, with timing adjusted by site—earlier for areas (3-5 days) and later for extremities.

Material properties and classifications

Surgical sutures are evaluated based on several mechanical properties that determine their performance during and after implantation. Initial tensile strength refers to the maximum load a suture can withstand before breaking under straight pull, while knot tensile strength measures the same under knotted conditions, which is critical for maintaining closure integrity. Elasticity allows the suture to stretch and recover without permanent deformation, accommodating tissue movement and reducing breakage risk. Suture memory, or the material's tendency to return to its packaged coil shape, influences handling ease; high memory can cause uncoiling resistance, complicating tying. Biological properties also play a key role in suture compatibility with host tissues. Tissue reactivity describes the inflammatory response elicited by the material, with synthetic sutures generally provoking minimal reaction compared to natural ones, thereby supporting faster healing and lower complication rates. Capillarity, the ability of multifilament sutures to wick fluids along their strands, can facilitate bacterial migration and increase infection risk in contaminated wounds. Suture materials are classified by origin, structure, and standardized sizing systems to ensure consistency and performance. Natural sutures derive from biological sources such as animal or , while synthetic ones are manufactured from polymers like polyesters or polyamides, offering greater uniformity and reduced . The (USP) classifies nonabsorbable sutures into three classes: Class I composed of or synthetic fibers of monofilament, twisted, or braided construction with larger than 0.15 mm; Class II composed of multifilament or synthetic fibers with equal to or less than 0.15 mm; Class III composed of coated multifilament metallic or synthetic fibers with equal to or less than 0.15 mm, with sizes ranging from 11-0 (finest) to 7 (coarsest) defined by and minimum knot-pull tensile strength. In , the (EP) and (BP) use a metric decimal system for thread gauge (0.01 to 10), specifying diameters and breaking loads harmonized with USP for global interoperability. Recent advancements include antimicrobial-coated sutures (e.g., triclosan-impregnated polyglactin) to reduce surgical site infections and novel bioengineered materials like high-performance soluble sutures for improved , as of 2025. Additional factors enhance suture functionality and safety. Sterility assurance levels (SAL) for surgical sutures are typically set at 10^{-6}, meaning the probability of a single viable microorganism surviving sterilization is less than one in a million, achieved through methods like or gamma . Dyes, such as gentian violet, may be added to improve intraoperative without compromising strength, though undyed options are preferred for superficial or long-term use to avoid tattooing. Coatings, including combined with polymers like polyglactin, provide to reduce tissue drag and improve security in braided sutures. Sutures are further categorized by filament structure: monofilament (single strand) versus polyfilament (multifilament, braided, or twisted). Monofilament sutures exhibit lower risk due to their smooth surface and lack of interstices for bacterial harboring, but they possess higher and are harder to securely. Polyfilament sutures offer superior handling, flexibility, and strength from their pliable nature, though they generate more tissue drag and elevate capillarity-related potential.

Sizing and Selection

Size standards

Surgical sutures are sized according to standardized systems that specify and tensile strength to ensure uniformity and reliability in clinical use. The (USP) system is the predominant standard in the United States, categorizing sutures from the finest (11-0) to the coarsest (7), with sizes denoted by numbers and zeros (e.g., 6-0 indicates six times finer than size 0). For collagen-based sutures, diameters range from approximately 0.07 mm for size 6-0 to 1.2 mm for size 7, while synthetic sutures have comparable but marginally narrower limits to optimize handling and knot security. The metric sizing system, aligned with international pharmacopeias, directly measures suture in millimeters (e.g., metric 0.7 corresponds to 0.07 mm for USP 6-0, and metric 1.5 for USP 5-0 at 0.15 mm) and specifies minimum tensile strength in kilograms for each size. This system facilitates global consistency, with synthetic materials often exhibiting higher strength per than due to their uniform structure. Representative ranges for common USP sizes are shown below for synthetic sutures, which are more widely used today:
USP SizeAverage Diameter (mm)Minimum Tensile Strength (N)
6-00.070–0.0993.0
5-00.100–0.1495.0
3-00.200–0.24910.0
00.350–0.39925.0
20.500–0.59950.0
70.899–1.157180.0
These values ensure the suture provides adequate strength without excessive tissue trauma. To enhance visibility and differentiation during surgery, standardized color coding is employed: non-absorbable sutures are typically dyed black for easy identification and removal, while absorbable synthetic sutures are dyed violet to distinguish them from natural undyed options. This convention, adopted by major manufacturers, reduces procedural errors. Suture size directly correlates with required tensile strength and tissue delicacy; finer sizes like 6-0 are selected for microvascular or ophthalmic procedures to minimize , whereas coarser sizes like 2-0 provide the robustness needed for fascial closures in . Internationally, the (EP) and (BP) systems harmonize with USP and metric standards but impose slightly stricter or varied limits on diameter (e.g., EP 0.7 allows 0.070–0.099 mm, aligning with USP 6-0) and knot-pull tensile strength to reflect regional testing protocols. These variations ensure interoperability while accommodating local manufacturing tolerances.

Factors influencing choice

The selection of surgical sutures is determined by a combination of clinical, procedural, and practical elements to ensure optimal , minimize complications, and align with patient-specific needs. Key considerations include the biological properties of the tissue being repaired, the patient's overall profile, the nature of the surgical procedure, economic factors, and adherence to established guidelines for infection control. These factors guide surgeons in balancing tensile strength, absorption rates, and to achieve secure closure while reducing risks such as or dehiscence. Tissue characteristics play a central role in suture choice, particularly vascularity and mechanical demands. In highly vascularized tissues, such as the or , absorbable sutures are preferred because rapid allows the material to degrade without long-term interference, reducing the risk of foreign body reactions. Conversely, in areas with low , like or poorly perfused , non-absorbable sutures are selected to provide prolonged support and avoid incomplete absorption that could lead to chronic inflammation. For high-tension sites, such as tendons or , stronger non-absorbable materials like or are chosen to withstand mechanical stress and prevent failure, as these tissues heal slowly and require sustained tensile strength. Patient-specific factors, including allergy risks and healing capacity, further refine suture selection. Natural materials like , derived from , carry a risk of reactions, manifesting as localized or , so they should be avoided in patients with known sensitivities; synthetic alternatives like polyglactin are safer in such cases. In patients with impaired healing, such as those with , non-absorbable or slowly absorbing synthetic sutures may be prioritized to maintain wound integrity longer, as delays synthesis and increases susceptibility. The type of procedure influences material properties to optimize outcomes. For cosmetic surgeries on the face or , fine monofilament sutures, such as polypropylene or poliglecaprone, are favored for their smooth passage through tissue, minimal tissue drag, and reduced scarring due to lower inflammatory response. In emergency settings, rapid-absorbing absorbable sutures like fast-absorbing gut are often used for superficial closures to expedite healing and eliminate the need for removal, particularly in pediatric or uncooperative patients. Economic and logistical aspects, including and , also impact decisions without compromising . Synthetic sutures generally more than natural ones, with prices varying by manufacturer, region, and market conditions, but offer greater reliability in strength and sterility, justifying their use in complex cases. Sterile packaging is essential for all sutures to prevent , with pre-sterilized synthetic options enhancing in resource-limited settings. Professional guidelines emphasize suture selection as part of broader prevention strategies. The Association of periOperative Registered Nurses (AORN) recommends evaluating tissue type and procedure demands to choose sutures that maintain integrity and minimize bacterial adherence, such as monofilaments in contaminated wounds. Similarly, (WHO) guidelines for preventing surgical site infections highlight the role of suture materials in reducing exogenous risks, advising absorbable synthetics in clean procedures to avoid persistent foreign bodies that could harbor pathogens. These recommendations underscore the need for tailored choices to support healing across diverse surgical contexts.

Surgical Techniques

Placement and spacing

The placement of surgical sutures involves precise insertion to approximate wound edges securely while minimizing tissue trauma and promoting optimal healing. Basic techniques include the simple interrupted suture, where individual stitches are placed and tied separately, allowing for precise control and adjustment in areas requiring strength, such as lacerations under tension. In contrast, the continuous running suture begins with an initial interrupted stitch that is not cut, followed by a series of connected loops along the , making it efficient for closing long, straight incisions like those in . For effective spacing, sutures on are typically placed 5 mm apart to balance cosmetic outcomes and reduce risk, with the needle entering and exiting to the edge to distribute tension evenly. This approach ensures edge without . The bite depth, or distance from the edge to the needle's entry and exit points, is generally 4-6 mm to prevent tissue tearing while capturing sufficient for secure closure; shallower bites risk superficial holding, while deeper ones may cause unnecessary trauma. To promote eversion of edges for better formation, the bite is made wider at the deeper dermal level than at the surface, creating a slight outward flip of the . Instruments essential for placement include needle drivers, which grasp and guide the needle through tissue, and toothed forceps, used to stabilize the edges without crushing them. Knots can be tied by hand for fine control or instrument-tied using the needle drivers to wrap the suture ends, forming secure square or surgeon's knots. Common errors in placement include tying sutures too tightly, which can cause tissue ischemia by compressing vessels and leading to , or too loosely, increasing the risk of and poor approximation. Additionally, uneven spacing or bites can result in irregular healing or edge inversion.

Layered and specialized closures

Layered closure techniques in surgical suturing involve approximating wounds in multiple planes to reduce dead space, enhance tensile strength, and promote optimal healing across tissue layers. The subcutaneous layer, primarily composed of adipose tissue, is typically closed using absorbable sutures such as polyglactin or polydioxanone (PDS) to eliminate potential dead space and minimize the risk of seroma or hematoma formation. The dermal layer follows, where buried interrupted or running sutures—often absorbable for deeper wounds or non-absorbable for added strength—approximate the dermis to provide structural support and edge alignment, preventing wound inversion and reducing tension on the overlying skin. Finally, the skin layer is closed with fine, monofilament sutures like nylon or polypropylene to achieve precise edge eversion and cosmetic outcomes, particularly in visible areas. This multi-layer approach is especially beneficial in deep or contaminated wounds, as it distributes tension evenly and lowers the incidence of dehiscence compared to single-layer methods. Specialized suturing patterns extend layered closures for complex anatomies or high-tension scenarios. mattress sutures, which involve wide, deep bites followed by superficial passes, promote edge eversion and are ideal for irregular wound edges in , ensuring better approximation without excessive tissue strangulation. Subcuticular sutures, placed intradermally in a running fashion, create nearly invisible scars by burying the suture entirely beneath the ; this technique is favored in for facial or aesthetic closures, where monofilament absorbable materials like PDS minimize foreign body reactions. Purse-string sutures, a continuous circumferential tightened like a , are employed for circular defects such as those from skin excisions or ostomy sites, reducing defect size and facilitating tension-free closure. To address tension in layered closures, adjuncts like undermining and retention sutures are integrated. Undermining involves dissecting the subcutaneous plane adjacent to the edges to mobilize tissue and relieve surface tension, enabling primary closure of larger defects without excessive strain on sutures. Retention sutures, typically heavy non-absorbable materials placed through all layers or with protective bolsters, reinforce high-tension areas such as the , reducing dehiscence rates in wounds despite potential increases in intra-abdominal pressure. Preventing complications requires matching suture strength to tissue layers—for instance, PDS for fascial components due to its prolonged tensile strength and absorbability, which supports while avoiding chronic sinus tracts from permanent materials. These methods collectively optimize outcomes in specialized applications, such as subcuticular techniques in cosmetic procedures or sutures in acute trauma repairs.

Removal procedures

The removal of surgical sutures is a critical post-operative step primarily applicable to non-absorbable types, aimed at minimizing scarring while ensuring integrity has been sufficiently restored. Timing for removal is determined by the healing rate and anatomical location to balance tensile strength recovery with cosmetic outcomes; facial sutures are typically removed after 3 to 5 days due to rapid epithelialization and low tension, while sutures are removed at 7 to 10 days, trunk at 10 to 14 days, upper extremities (arms) at 7 to 10 days, and lower extremities (legs) at 10 to 14 days. These intervals prevent complications such as suture tracks or excessive scarring from prolonged retention. The standard technique involves maintaining sterile conditions to reduce infection risk, beginning with cleaning the area using antiseptic solution. are used to grasp one end of the suture gently, elevating it slightly, while suture —such as iris or littauer with curved tips—are positioned close to the skin surface to cut the opposite strand without traumatizing the . Sutures are then removed sequentially from one end of the to the other, applying gentle traction to extract the material while preserving edge approximation and avoiding undue stress on healing tissue. Following removal, the site is inspected for signs of dehiscence, such as edge separation or oozing, and may be reinforced with adhesive strips if needed. Essential tools include sterile suture scissors for precise cutting and thumb forceps (e.g., Adson or tissue forceps) for traction, often provided in pre-packaged kits to ensure . In special cases, removal may be delayed beyond standard timelines for patients at elevated risk, such as those with compromised immunity or active , until the issue is resolved to avoid exacerbating dehiscence. Surgical staples serve as an alternative closure method in high-tension areas like the or trunk, allowing quicker bulk removal with a staple extractor while following similar timing guidelines. Patients are instructed on post-removal wound care to prevent premature disruption, including keeping the area clean and dry for 24 to 48 hours, avoiding soaking in baths, and gently patting dry after showers rather than rubbing. They should monitor for redness, swelling, or discharge and avoid strenuous activity that could strain the site until full healing, typically applying petroleum-based ointments to promote minimization.

Alternatives and Innovations

Tissue adhesives

Tissue adhesives serve as non-invasive alternatives to traditional sutures for closing , particularly in scenarios where rapid and painless application is beneficial. These materials bond wound edges together, promoting without the need for needle penetration or subsequent removal. They are especially valuable in outpatient settings, offering a convenient option for superficial closures. The primary types of tissue adhesives used in surgery include cyanoacrylates and fibrin glues. Cyanoacrylates, such as (e.g., Dermabond) and n-butyl-2-cyanoacrylate (e.g., Histoacryl), are synthetic monomers that rapidly polymerize to form a strong, flexible film over the wound. Fibrin glues, on the other hand, are biological adhesives derived from human plasma components, including fibrinogen and , which mimic the natural clotting process to create a clot. The mechanisms of action differ between these types. Cyanoacrylates adhere through anionic triggered by contact with moisture in the tissue, resulting in a quick-setting bond that typically hardens within seconds and provides immediate wound edge approximation. In contrast, fibrin glues facilitate and tissue sealing by enzymatically converting fibrinogen to in the presence of and calcium, forming a biodegradable matrix that supports platelet aggregation and wound stabilization. Applications of tissue adhesives are primarily limited to low-risk wounds. They are commonly used for superficial lacerations up to 4 cm in length, especially on the face and extremities, where precise edge approximation is feasible; in pediatric cases to minimize distress; and in cosmetic procedures to avoid visible scarring from sutures. However, they are contraindicated for high-tension areas, such as joints or the back, and contaminated or irregular wounds, where sutures provide superior strength and security. Tissue adhesives offer several advantages over sutures, including faster application times—often under a minute per —reduced patient during closure, and lower rates due to the barrier formed by the film. Cyanoacrylate-based products received FDA approval for topical closure in 1998, marking their integration into standard clinical practice for appropriate indications. Despite these benefits, tissue adhesives have notable limitations. Cyanoacrylate bonds can become brittle under mechanical stress, exhibiting lower tensile strength compared to sutures, which may lead to dehiscence in dynamic areas. Their polymerization reaction is exothermic, potentially causing minor tissue irritation or burns if applied excessively. Additionally, these adhesives are generally more costly than traditional suturing materials, limiting their use in resource-constrained environments. Fibrin glues, while biocompatible, carry risks of disease transmission if not properly sourced from screened plasma.

Recent advancements

Recent advancements in surgical sutures have focused on enhancing prevention, tissue integration, and procedural efficiency through innovative materials and designs. sutures, such as triclosan-coated variants like Plus, have seen updates in coating technology by 2023, improving uniform distribution and sustained efficacy to combat surgical site infections (SSIs). Similarly, silver nanoparticle-impregnated sutures have emerged as a promising alternative, incorporating silver with hyperbranched for long-term antibacterial activity on poly() bases, potentially reducing SSI incidence through localized ion release. Clinical studies indicate that triclosan-coated sutures can lower SSI risk by up to 43% in specific procedures like perineal closures. Bioactive and barbed sutures have evolved to support knotless closures, distributing tension evenly across tissues. Devices like and V-Loc, originally introduced in the 2000s, enable faster approximation without knots, which minimizes reactions. A 2025 meta-analysis confirmed their safety and efficacy in , noting faster approximation without knots, which minimizes reactions. Smart materials represent a frontier in suture technology, enabling responsive degradation tailored to wound environments. Research from 2023 demonstrated pH-sensitive hydrolytic degradation in sutures like Monocryl, where acidic conditions accelerate breakdown to match or stages, optimizing timelines. In 2025, a study introduced soluble collagen-based sutures that absorb faster than traditional synthetics, promoting enhanced tissue regeneration with tensile strengths comparable to while reducing inflammatory responses. Needle innovations complement these sutures by integrating with advanced surgical systems. Additionally, electrospun nanofiber coatings on needles and sutures enable controlled , releasing antibiotics or growth factors at sites; recent studies highlight polycaprolactone-based s achieving sustained release over weeks, improving outcomes in contaminated fields. Market trends underscore the shift toward bio-absorbable options, projected to reach $2.5 billion globally by 2025, driven by demand for reduced follow-up interventions. Emerging 2024 technologies include 3D-printed custom sutures, allowing patient-specific geometries via additive manufacturing to enhance fit and in complex anatomies.

History

Ancient and early modern developments

While archaeological evidence suggests the use of sutures in as early as 3000 BCE, the earliest surviving written records date to around 1550 BCE, as described in the , which details the application of linen threads to close wounds and promote healing. In , the , composed circa 500 BCE, outlined advanced suturing techniques, including the innovative use of ant heads as natural clips to approximate wound edges after their bodies were removed, alongside materials like bark, , and . During the classical era, (c. 460–370 BCE) described suturing methods in the , using linen threads and bronze needles for wound closure. Roman physician (c. 25 BCE–50 CE) described precise suturing methods in his work De Medicina, including the use of soft linen threads and fibulae (pins) for wound closure and management. In the 2nd century CE, Greek surgeon of advanced tendon repair by employing and sutures to reconnect severed tissues in gladiators, emphasizing the importance of material strength and to restore function. In the medieval Islamic world, Abū al-Qāsim al-Zahrāwī (936–1013 CE), known as Albucasis, made significant contributions in his encyclopedic Kitāb al-Taṣrīf, pioneering the use of for internal absorbable sutures and for external cosmetic closures to minimize scarring. His techniques influenced global surgery, though adoption in was gradual due to cultural and material preferences. The marked refinements in suture application, with French surgeon (1510–1590) popularizing ligatures and sutures for and wound closure during wartime procedures, reducing reliance on and improving outcomes in contaminated environments. By the late 19th century, British surgeon (1827–1912) revolutionized suture safety through antisepsis, applying carbolic acid to sterilize threads, instruments, and wounds, which dramatically lowered infection rates in surgical closures. American surgeon William Halsted (1852–1922) further advanced vascular suturing with fine silk threads, prioritizing minimal tissue trauma and precise approximation to enhance patency in delicate anastomoses. During this period, silver wire emerged as a non-absorbable option for orthopedic and repairs, offering high tensile strength for load-bearing applications. These developments laid the groundwork for the shift toward synthetic materials in the 20th century.

20th-century and contemporary evolution

In the early , catgut remained the dominant absorbable suture material, but efforts toward standardization improved its reliability and safety. The established standardized sizing for sutures in 1937, facilitating consistent manufacturing and clinical use. By the late 1930s, introduced as the first synthetic non-absorbable suture, prized for its high tensile strength, low tissue reactivity, and resistance to degradation, which surpassed natural materials like in handling and durability. The advent of penicillin in the 1940s dramatically lowered postoperative infection rates in sutured wounds, transforming surgical outcomes by mitigating risks that had previously limited suture efficacy. Mid-century innovations shifted toward synthetic absorbables, addressing 's inconsistencies in absorption and strength retention. In 1969, launched Dexon, the first commercial synthetic absorbable suture composed of polyglycolic acid, which offered predictable degradation via and reduced inflammatory response compared to . This was followed in 1974 by Ethicon's (polyglactin 910), a braided that provided superior knot security and tensile strength during the critical wound-healing phase. For non-absorbable applications, particularly in , polypropylene sutures like Ethicon's —developed in the —emerged as a monofilament option with exceptional flexibility and minimal thrombogenicity, enabling finer closures in delicate tissues. The 1976 Medical Device Amendments classified surgical sutures as Class II devices, mandating premarket notification (510(k)) clearance to ensure safety and performance through standardized testing. Entering the 21st century, suture design incorporated advanced features to enhance healing and reduce complications. The U.S. cleared the first barbed sutures, such as by Quill Medical, in 2004; these knotless, self-anchoring monofilaments distribute tension evenly, shortening operative times in procedures like gastrointestinal and cosmetic . In 2003, introduced triclosan-coated sutures like Coated Plus, which inhibit bacterial colonization on the suture surface, lowering surgical site infection rates by up to 30% in contaminated wounds. Contemporary developments in the include bioactive sutures engineered for or inflammation sensing, such as those coated with to combat biofilms while promoting tissue regeneration. Emerging AI-optimized designs leverage to tailor suture properties like degradation rates and tensile strength for specific tissues, improving customization in . Globally, sutures' evolution has been supported by regulatory harmonization, with the including synthetic absorbable and non-absorbable sutures in its interagency list of priority medical devices for essential reproductive, maternal, newborn, and child health interventions. standards, governed by , ensure sutures undergo rigorous testing for , , and implantation effects, fostering international consistency and safety in production.

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