Suture Materials & Selection

Absorbable sutures are degraded by the body over time through hydrolysis (synthetic) or enzymatic degradation (natural/gut). They are used for buried (deep) sutures where removal is not practical. Non-absorbable sutures maintain tensile strength indefinitely and must be removed. They are used for epidermal (surface) closure where precise suture removal timing controls scar quality. The key distinction: absorbable sutures are chosen for their tensile strength retention profile (how long they hold before weakening), while non-absorbable sutures are chosen for their handling properties and tissue reactivity.

Monofilament sutures consist of a single strand. They have less tissue drag, pass through tissue smoothly, and resist bacterial harboring. However, they have more memory (tendency to return to packaged shape), making knot security a consideration. Typically requiring 4–5 throws. Braided (multifilament) sutures consist of multiple strands woven together. They handle better, have excellent knot security (3–4 throws), and are more pliable. However, the interstices between strands can harbor bacteria (wicking effect), increasing infection risk in contaminated wounds.

Natural sutures (gut, silk) generally provoke more tissue reactivity than synthetic materials. Gut sutures are derived from sheep or bovine intestinal submucosa and are degraded enzymatically. Chromic gut is treated with chromium salts to delay absorption. Silk is a braided natural protein with excellent handling but the highest tissue reactivity of any commonly used suture. Synthetic sutures (polyglactin, poliglecaprone, polydioxanone, nylon, polypropylene) are engineered polymers with predictable degradation profiles and lower tissue reactivity. They have largely replaced natural sutures in modern dermatologic surgery.

Absorbable sutures are the workhorses of deep (buried) closure in dermatologic surgery. The critical parameter is tensile strength retention. How long the suture maintains its holding power before degradation weakens it.

Non-absorbable sutures are used for epidermal (surface) closure and must be removed at the appropriate time to prevent suture marks.

Suture size and material selection vary by anatomic location based on skin thickness, tension, and cosmetic demands.

TAFT stands for Tension, Apposition, Finishing Touches. A conceptual framework for layered wound closure: T. Tension Relief: Buried (deep) absorbable sutures eliminate dead space, approximate tissue layers, and relieve tension from the skin surface. This is the most critical layer. The buried vertical mattress with inverted knot is the cornerstone technique. A. Apposition: Epidermal (surface) sutures precisely align the wound edges and achieve eversion. These sutures should bear ZERO tension. All tension was handled by the deep layer. FT. Finishing Touches: Wound taping (Steri-Strips), adhesive, and dressing selection optimize the healing environment. The TAFT framework emphasizes that a well-placed deep layer makes the surface closure almost effortless. If the surface sutures are under tension, more buried sutures are needed.

Needle choice affects tissue trauma, ease of passage, and wound healing. The three main needle types used in dermatologic surgery: Cutting needle: triangular cross-section with the cutting edge on the inner (concave) curvature. Good for tough tissue (palms, soles) but creates a track toward the wound edge that can promote suture pull-through. Reverse cutting needle: cutting edge on the outer (convex) curvature. The standard choice for skin closure. The flat inner surface faces the wound edge, reducing the risk of suture pull-through. Tapered (round) needle: no cutting edge; separates tissue fibers rather than cutting them. Used for deep fascial closure, subcutaneous tissue, and mucosa. Not effective for skin passage.