Dr.

khaled hassan

Assist. Prof. and Consultant of Oral and Maxillofacial Surgery

Misr International University

Wound Preparation
Control bleeding; ligation of obvious bleeding
vessels and application of occlusive pressure
dressings
The pressure dressings also provide temporary
immobilization
Local anesthetics offer advantages beyond their
anesthetic properties
Careful cleansing of skin and wounds
Debridment Excision of tissue from wounds

Tissue forceps

The Needle

Round

Reverse cutting

Conventional cutting

Correct position of the fingers for holding the needle holder

suture materials
classified by
size,
resorbability,
whether or not they are monofilament or polyfilament.

Classification of suture materials

Absorbable
synthetic, e.g. vicryl (braided)
natural, e.g. catgut
Non-absorbable
synthetic, e.g. Prolene, nylon
natural, e.g. silk (braided)

Plain Gut
This natural product
derived from sheep or cattle intestine.
poor tensile strength
relatively high tissue reactivity.
Plain gut retains a significant tensile strength
for 4 to 5 days,
Chromic gut (soaked in chromic acid salts)
proteolytic absorption

Polyglycolic Acid (Dexon)

the first synthetic absorbable suture

superior tensile and knot strength
having delayed absorption and
diminished tissue reactivity.
(28 days absorption by hydrolysis
supplied in braided form for ease of handling.

Polyglactic Acid (Vicryl, Polysorb)

introduced in 1974
copolymer of lactide and glycolide,
Vicryl, like Dexon, retains only 8% of its
original tensile strength by 28 days.
Vicryl is degraded by hydrolysis
minimal tissue reaction.
Vicryl is braided and is either clear (undyed) or
violet (dyed).

Nonabsorbable Suture Materials

resistant to degradation from living tissue.
However, this term nonabsorbable is relative
because many of these sutures are eventually
degraded.
They include silk, nylon, polypropylene

Silk
natural protein filaments spun by the silkworm
larva as it builds its cocoon.
Modern silk is braided, soft,.
it has the lowest tensile strength.
The strength decreases progressively over
about 1 year, and the suture is absorbed by the
end of 2 years .
It elicits more inflammatory reaction
high capillarity owing to its braiding

Nylon
introduced in 1940, first synthetic suture
synthetic polyamide polymer fiber
Nylon is the most widely used nonabsorbable suture in
cutaneous surgery as a monofilament (Ethilon).
degradation through hydrolysis at very slow rates. at 2
years

advantage
high tensile strength,
excellent elastic properties,
minimal tissue reactivity
low cost.

Nylon
disadvantage
prominent memory,
Ethilon can be soaked in alcohol to decrease
its memory and increase its pliability.

Multi-filamentous braided nylon sutures

(Nurilon, Surgilon) --- slightly increased
infection
rate
and
increased
cost.
Nevertheless ,the braided form makes it more
pliable and easier to handle.

Polypropylene
(Prolene)
a plastic suture
extremely inert suture
very slippery

Disadvantages
compromised knot security.
plasticity.

Wound Closure Tapes

advantages
hold wound edges together without penetration
of the skin surface
maintain the integrity of the epidermis, resulting
in less tension on the wound and more
resistance to infection than in sutured wounds.
they are commonly used in conjunction with
sutures.
Skin tapes can be applied to healing wounds
following cutaneous suture removal.

SUTURING TECHNIQUES
ideal wound closure technique include

providing maximal wound eversion,

maintaining tensile strength throughout the wound healing process,
being technically simple and fast for the surgeon to perform
allowing for precise wound edge approximation without leaving
suture marks.

The natural tendency of the sutured wound edge is to invert after

wound contracture has occurred. Therefore ,it is important to evert
the edges of the wound during closure. Everted wounds heal as
flat scars, whereas flat wounds heal with a depression following
wound contraction

Permanent suture marks can develop when the wound is too tight or
left in place too long. This results from pressure on the skin
during the time that the suture is left in place and can be
exacerbated by tension on the wound, edema, large bites of tissue,
and infection.

Interrupted Suture
This is the simplest and most frequently used type
Technique
The needle enters 4 mm away from the margin of the
flap (mobile tissue) and exits at the same distance on the
opposite side.
The two ends of the suture are then tied in a knot and
are cut 0.8 cm above the knot.
Over-tightening of the suture must also be avoided (risk
of tissue necrosis), as well as overlapping of wound
edges when positioning the knot.
Advantage
sutures are placed in a row, inadvertent loosening of one
or even losing one will not influence the rest.

Interrupted Suture

surgeons knot

safety knot

Dog Ear
After closing a long incision, it is
common that one of the two ends
of the incision has extra length
and a puckered appearance or a
"dog ear" exists.
This technique removes the
excess tissue and allows for a
cosmetic closure.
The remaining tissue is tented upward, and a scalpel excises the
excess and extends the incision.
The Wound can then be sutured
closed the remaining distance

Continuous Suture
Indication
used for the suturing of wounds that are
superficial but long.
Advantage
it is quicker and requires fewer knots, so that the
wound margins are not tightened too much, thus
avoiding the risk of ischemia of the area.
Disadvantage
if the suture is inadvertently cut or loosened, the
entire suture becomes loose.

Continuous with lock (blanket

suture) is far more stable and firm
and gives traction on the wound
edges at right angles to the wound

Mattress Suture
interrupted and continuous horizontal and vertical
Indication
in cases where strong and secure reapproximation of
wound margins is required.
The vertical suture may be used for deep incisions,
while the horizontal suture is used in cases which
require limiting or closure of soft tissues over osseous
cavities, e.g., postextraction tooth sockets.

Advantages of Mattress sutures

reducing bleeding socket

encourages eversion of the margins of the
wound,
bringing greater areas of raw tissue into
contact.
Water tight (proof) closure

sutures removal
Sutures in mucous membrane
are removed after 5 to 7 days.
In the skin alternate stitches
are often taken out about the
third to fifth day and the
remainder between the fifth
and eighth days. A good
guide is that as soon as they
begin to get loose they should
be taken out.
They should first be cleaned
and then removed.