• wide variety of sutures materials and brands available
  • need to be familiar with the important characteristics of the ones you use
  • a small sample of some classic and commonly used materials are detailed to demonstrate important considerations in selection - the list is by no means exhaustive

For each suture that you use, you need to know:

  • absorbable or nonabsorbable
    • if absorbable, how rapidly
  • monofilament or multifilament (braided)
  • amount of tissue reaction that it stimulates
  • knot security and ease of handling
  • unique properties of that material

Rapidly absorbable

(significant loss of tensile strength by 14 days)

Chromic Gut

Chromic Gut

  • derived from sheep intestinal submucosa and bovine intestinal serosa
  • treated with formaldehyde
  • chromic Gut: treated with chromic salt
    • increases strength
    • slow loss of tensile strength
    • decreases tissue reaction
  •  absorbed by phagocytosis
  • rapidly absorbable
    • loses tensile strength (33% in 7 days, 67% in 28 days)
    • complete removal from tissue prolonged (can be found encapsulated at previous sites years later)
    • rapid premature loss of strength in infected wounds, after exposure to digestive enzymes (eg. stomach), in highly vascular tissue, and protein-depleted patients
  • causes significant foreign body reaction
  • relatively good handling characteristics
    • stiff in larger sizes
    • good knot security
      • minimum of 3 throws are recommended for a secure knot
      • four throws for starting knot and five throws for ending knot on continuous patterns
    • ends need to be left 3-5 mm long as tend to untie when wet
  • should NOT be used to close the abdominal wall because of rapid, unpredictable loss of strength
  • economical
  • use largely been replaced by synthetic materials

 

characteristics summary

  • natural
  • rapidly absorbable
  • multifilament
  • reactive in tissue

Polyglycolic acid (Dexon)

Dexon 

  • made of a glycolic acid polymer
  • absorbed by hydrolysis
  • rapidly absorbable
    • most of its tensile strength lost within 2 weeks of implantation
    • removed from the body within 3-4 months
    • more rapid absorption in alkaline environment (eg. urinary bladder)
  •  significant tissue drag
    • may cut delicate tissues
    • available with coating
      • decreases drag
      • poorer knot security (need extra throws)
  •  comparison with chromic gut:
    • stronger
    • more predictable strength loss
    • less reactive
    • more rapid and complete removal from body
  •  can be used to close clean tissue layers that regain sufficient strength within 7-10 days


Characteristics summary

  • synthetic
  • rapidly absorbable
  • braided multifilament

Polyglactin 910 (Vicryl)

Vicryl 

  • composed of copolymer of glycolide and epsilon-caprolactone
  • rapidly absorbable by hydrolysis
    • loses tensile strength quickly (50 % within 7 days)
    • completely removed from body within 4 months
  • initially very strong (strongest of absorbable)
    • initial strength allows selection of 1-2 sizes smaller than would normally
  • minimal tissue reaction
  • soft, pliable material with excellent handling
    • minimal tissue drag
  • good knot security
    • required throws for secure knot formation is unknown (follow those for polydioxanone)
    • 4 throws for a secure knot
    • 5 throws at the start and 6-7 at end of continuous pattern
  • used for soft tissue suturing when prolonged wound support is not necessary (eg. subcutaneous and intradermal layers) 

Characteristics summary

  • synthetic
  • rapidly absorbable
  • braided multifilament

Vicryl Strand

Poliglecaprone 25 (Monocryl)

Monocryl

  • composed of copolymer of glycolide and epsilon-caprolactone
  • rapidly absorbable by hydrolysis
    • loses tensile strength quickly (50 % within 7 days)
    • completely removed from body within 4 months
  • initially very strong (strongest of absorbable)
    • initial strength allows selection of 1-2 sizes smaller than would normally
  • minimal tissue reaction
  •  soft, pliable material with excellent handling
    • minimal tissue drag
  • good knot security
    • required throws for secure knot formation is unknown (follow those for polydioxanone)
    • 4 throws for a secure knot
    • 5 throws at the start and 6-7 at end of continuous pattern
  •  used for soft tissue suturing when prolonged wound support is not necessary (eg. subcutaneous and intradermal layers) 

Characteristics summary

  • synthetic
  • rapidly absorbable
  • monofilament
  • strong
  • minimally reactive


Monocryl Strand

Slowly absorbable

(significant strength remains for at least 30 days but lost by 60 days)

Polydioxanone (PDS II)

  • composed of paradioxanone polymers
  • absorbed by hydrolysis
  • slowly absorbable
    • over 50% strength remains after 6 weeks
    • complete removal from the body up to 6 months
    • strength maintained in alkaline environment (suitable to close urinary bladder)
  • strong
  • minimal tissue reaction
  • acceptable handling qualities but larger sizes are stiff
  • minimal tissue drag
  • reasonable knot security
    • 4 throws for secure knot
    • 5 throws at start and 6-7 at end of continuous pattern
    • popular choice for general soft tissue suturing
    • recommended when prolonged tissue support desired.

Characteristics summary

  • synthetic
  • slowly absorbable
  • monofilament
  • strong
  • minimally reactive

Polyglyconate (Maxon)

Maxon Package
  • composed of glycolic acid and trimethylene carbonate
  • absorbed by hydrolysis
  • slowly absorbable
    • 50% tensile strength lost by 3 weeks
    • complete absorption takes 6-7 months
    • retains strength in alkaline environment (can use for urinary bladder closure)
  • strength similar to polydioxanone
  • minimal tissue drag
  • stiff
    • tends to conform tissues to suture rather than conforming to tissues
  • good knot security when extra throws placed
    • 4 throws for secure knot 5 throws at start and 6-7 at end of continuous pattern
  • more economical than PDS
  • handling characteristics have limited use in small animals but could be selected for most soft tissue suturing

Characteristics summary

  • synthetic
  • slowly absorbable
  • monofilament
  • strong
  • minimally reactive
Maxon Strand

Nonabsorbable

Silk

Silk Package
  • derived from silkworm cocoon
  • technically nonabsorbable
    • slowly loses tensile strength over 6 months
    • may be completely absorbed after 2 years
    • not recommended if prolonged strength or persistence is desired (e.g. securing a prosthetic device)
  • induces significant tissue reaction
  •  excellent handling characteristics
  • good knot security
  • economical
  • should NOT use in infected or contaminated areas
    • potentiates infection (less bacteria required to induce infection)
    • harbor bacteria within braid leading to persistent infection
  • uncommonly used
  • use largely replaced by synthetic monofilament materials

Characteristics summary

  • natural
  • nonabsorbable (absorbed over several years)
  • multifilament
  • reactive

Nylon Strand

Polymerized caprolactum (supramid)

Supramid Package

  • composed of synthetic twisted multifilament polyamide encased in a smooth sheath
  • very strong
  • somewhat stiff to handle
  • reactive when used in skin (increased if casing breaks)
  • should NOT be buried because of high rate of draining tract formation
  • economical
  • primarily used as a skin suture in food animals

Characteristics summary

  • synthetic
  • nonabsorbable
  • multifilament
  • coated
  • very reactive
Supramid Strand

Polyesters (Mersilene, Ethibond)

Mersilene Package

  • composed of synthetic multifilament polyester
  • very strong
  • retains tensile strength when implanted
  • significant tissue drag
    • coating improves but decreases knot security
  • moderate tissue reaction when implanted
  • contraindicated in infected or contaminated wounds
    • potentiates infection
    • bacteria reside within braid leading to persistence of infection and chronic draining tracts
  • primarily used for tendon and ligament repairs because of excellent strength
    • eg. extracapsular cruciate repairs
    • results in significant incidence of chronic draining tracts
    • use gradually being replaced by monofilament options

Characteristics summary

  • synthetic
  • nonabsorbable
  • multifilament
  • strong

Nylon (Dermalon or Ethilon)

Nylon Package

  • available as both monofilament or multifilament
  • composed of a polyamine
  • monofilament form (Ethilon)
    • inert
    • minimal tissue reaction
    • nonabsorbable by definition but loses 30% of strength within 2 years of implantation
  • multifilament form (Dermalon)
    • essentially no strength after 6 months
    • somewhat stiff to handle
    • uncommonly used
  • significant memory, especially in larger sizes
  • knot security is relatively poor so care necessary to ensure secure knots
    • 4 throws required for a secure square knot
    • additional throws necessary for continuous patterns (5 on beginning knot and 6 on ending knot)
    • suture ends may be sharp so avoid in areas where could cause trauma
  • mainly used as a skin suture, but can be buried if necessary

Characteristics summary

  • synthetic
  • nonabsorbable but strength loss over time
  • minimally reactive
  • available as monofilament or multifilament

Polybutester (Novafil)

Novafil Package
  • composed of a copolymer of polyglycol and polybutylene terephthalates
  • good tensile strength
  • strength maintained when implanted
  • slippery to handle
  • more flexible and elastic than polypropylene or nylon
  • minimal tissue reaction
  • reasonable knot security but need to ensure throws adequately tightened
  • nice handling qualities once experience gained with knots
  • mainly used as a skin suture, but can be buried if necessary

Characteristics summary

  • synthetic
  • nonabsorbable
  • monofilament
  • minimally reactive

Novafil Strand

Polypropylene (Prolene)

Prolene Package

  • composed of a propylene polymer derived from propane gas
  • not as strong as nylon
  • retains initial strength when implanted
  • minimal tissue drag
  • minimal tissue reaction
  • best knot security of synthetic monofilaments
  • very nice handling qualities once experience gained with knots
  • least likely of the monofilament nonabsorbable sutures to potentiate infection or induce thrombi
  • used as skin suture and if need to permanently implant suture (eg. prosthetic device)

Characteristics summary

  • synthetic
  • nonabsorbable
  • monofilament
  • least reactive of sutures
Prolene Strand

Summary Charts

Table 1: Summary of Characteristics of Commonly used suture materials

Absorbable

Mono vs. multi filament
Loss of tensile strength
Complete absorption
Tissue reactivity
# throws for secure knot (interrupted)
Chromic gut
Multi
Rapid (67% by 28 days)
60 days? (can be prolonged)
significant
3-4 (knots may loosen when wet)
Polyglycolic acid (coated Dexon)
Multi
Rapid (most by 2 weeks)
90-120 days
mild
4
Polyglactin 910 (coated Vicryl)
Multi
Rapid (most by 3 weeks)
60-90 days
mild
4
Poliglecaprone 25 (Monocryl)
Mono
Rapid (50% by 1 week, 80% by 2 weeks)
120 days
mild
4
Polyglyconate (Maxon)
Mono
Slow(45% by 3 weeks)
180 days
mild
4
Polydioxanone (PDS II)
Mono
Slow (31% by 6 weeks)
180 days
mild
4

 

Table 2: Summary of Characteristics of Commonly used suture materials

Nonabsorbable

Mono vs. multi filament
Loss of tensile strength
Tissue reactivity
# throws for secure knot (interrupted)**
Silk
Multi
30% at 14 days, 50% at 1 year
significant
4
Polymerized caprolactum (Supramid)
Multi
Negligible
significant
4
Polyesters (Mersilene, Ethibond)
Multi
Negligible
significant
4-5
Nylon (Ethilon, Dermalon)
Mono
30% at 2 years
mild
4
Nylon (Nurolon, Surgilon)
Multi
80% at 180 days
mild
4
Polybutester (novafil)
Mono
Negligible
mild
4
Polypropylene (Prolene)
Mono
Negligible
mild
3-4

** At least 4 throws recommended for all nonabsorbable materials. For continuous patterns, add one additional throw for the beginning knot and 2 additional throws for the ending knot.

Information from a suture pack

Monocryl