What is the best suture material for buried dermal sutures in facial wounds?

Monocryl (poliglecaprone 25) is considered the ideal buried dermal suture for clean facial wounds. It combines low tissue reactivity, excellent handling with minimal memory, smooth tissue passage, and predictable absorption over 90-120 days. Its monofilament configuration also resists bacterial wicking, reducing infection risk compared to braided alternatives like Vicryl.

What is the difference between how natural and synthetic absorbable sutures degrade?

Natural sutures (plain gut, fast-absorbing gut, chromic gut) are degraded by proteolysis, an enzymatic process that triggers a significant inflammatory response and higher tissue reactivity. Synthetic sutures (Monocryl, Vicryl, PDS) are degraded by hydrolysis, a chemical process that produces minimal inflammatory reaction. This fundamental difference makes synthetic sutures preferred for cosmetically sensitive areas.

Why are reverse cutting needles standard in dermatologic surgery?

Reverse cutting needles have the cutting edge on the outer (convex) curvature, meaning the flat wall of the needle track faces the wound edge. This significantly reduces the risk of suture pull-through (cheese-wiring) compared to conventional cutting needles, where the cutting edge faces the wound. The 3/8 circle reverse cutting needle is the most commonly used configuration, allowing comfortable wrist supination-pronation for superficial to mid-depth tissue bites.

When should PDS be chosen over Monocryl for buried sutures?

PDS (polydioxanone) should be chosen over Monocryl for high-tension closures on the scalp, trunk, and extremities where prolonged wound support is needed. PDS retains 50% tensile strength at 28-42 days compared to only 7-14 days for Monocryl, and takes 90-180 days for complete absorption. The tradeoff is that PDS has more memory than Monocryl, making it slightly more difficult to handle.

What suture is best for epidermal closure when suture removal is impractical?

Fast-absorbing gut is the suture of choice when suture removal visits are impractical, such as in elderly patients, pediatric patients, and for skin graft fixation. It loses 50% tensile strength by 3-5 days and is completely absorbed in 21-42 days, effectively falling out on its own before a removal visit would be needed. The main drawback is higher tissue reactivity compared to synthetic alternatives, as it degrades via proteolysis.

Suture Materials

Creator: Dr. Yehonatan Kaplan
Published: 2025-03-01
Keywords: suture materials, absorbable, nonabsorbable, Monocryl, Vicryl, PDS, nylon, needle

A thorough guide to suture materials used in dermatologic surgery, covering physical properties, absorbable vs. nonabsorbable classifications, natural vs. synthetic materials, and needle anatomy. Understanding suture characteristics is fundamental to selecting the appropriate material for each clinical scenario.

By Dr. Yehonatan Kaplan (M.D., Fellow ACMS)·Published: 2025-03-01·Updated: 2026-03-07·Reviewed: 2026-03-07

suture materialsabsorbablenonabsorbableMonocrylVicrylPDSnylonneedle

Physical Properties of Suture Materials

Suture selection requires understanding multiple physical properties that determine performance in tissue. No single suture excels in all properties. Selection requires balancing characteristics for the specific clinical application.

Property	Definition	Clinical Significance
Configuration	Monofilament (single strand) vs. multifilament (braided/twisted)	Monofilament: less infection risk, less friction, more memory. Multifilament: better handling, better knot security, higher capillarity (wicking)
Tensile strength	Maximum force the suture withstands before breaking	Must exceed wound closure tension; higher gauge = lower tensile strength
Knot strength	Force required to cause knot slippage or breakage	Braided sutures have superior knot security; monofilaments require additional throws
Memory	Tendency to return to original packaged shape	High memory = difficult handling, tendency to uncoil; low memory = easier handling
Elasticity	Ability to stretch and return to original length	Important in areas with postoperative edema. Elastic sutures accommodate swelling without cutting through tissue
Tissue reactivity	Degree of inflammatory response induced in tissue	Higher reactivity = more scarring, more granuloma risk; natural materials cause more reaction than synthetic
Capillarity	Ability to wick fluid along the suture strand	Braided sutures wick bacteria into wounds; monofilaments resist bacterial migration
Coefficient of friction (COF)	Resistance to passage through tissue	Low COF = smooth passage; high COF = tissue drag and trauma; coated sutures reduce friction

Absorbable Sutures

Absorbable sutures are designed to lose tensile strength and be degraded by the body over time. They are the primary choice for buried/deep sutures in dermatologic surgery where permanent foreign material is undesirable. Absorption occurs via proteolysis (natural materials) or hydrolysis (synthetic materials).

Suture	Material	Config	Tensile Strength Loss	Complete Absorption	Key Features
Plain gut	Bovine/ovine intestinal submucosa	Twisted mono	50% at 7 days	~70 days	Natural; high tissue reactivity; proteolytic degradation; rarely used today
Fast-absorbing gut	Heat-treated plain gut	Twisted mono	50% at 3-5 days	21-42 days	Ideal for epidermal closure on grafts and pediatric patients. Falls out before suture removal needed
Chromic gut	Chromium salt-treated gut	Twisted mono	50% at 14-21 days	~90 days	Chromium slows absorption; less reactive than plain gut; historically common but largely replaced by synthetics
Polyglycolic acid (Dexon)	Polyglycolic acid	Braided	50% at 14-21 days	60-90 days	First synthetic absorbable; good handling; replaced by Vicryl in most practices
Polyglactin 910 (Vicryl)	Copolymer glycolide + lactide	Braided	50% at 21 days	56-70 days	Most widely used buried braided suture; excellent handling and knot security; coated version (Vicryl Rapide) absorbs faster
Polydioxanone (PDS)	Polydioxanone	Monofilament	50% at 28-42 days	90-180 days	Longest-lasting absorbable monofilament; excellent for high-tension closures; more memory than Monocryl
Poliglecaprone 25 (Monocryl)	Copolymer glycolide + caprolactone	Monofilament	50% at 7-14 days	90-120 days	BEST monofilament absorbable suture. Low memory, excellent handling, minimal tissue reactivity, smooth tissue passage

Nonabsorbable Sutures

Nonabsorbable sutures are not degraded by the body and must be physically removed or remain permanently. In dermatologic surgery, they are used primarily for superficial/epidermal closures (removed at specified intervals) and occasionally as permanent buried sutures in high-tension areas.

Suture	Material	Config	Key Features	Common Uses
Silk	Natural protein (silkworm fibroin)	Braided	Best handling of any suture; highest tissue reactivity among nonabsorbables; degrades slowly over 1-2 years	Bolster tie-overs; rarely for skin closure due to reactivity
Nylon (Ethilon)	Polyamide polymer	Monofilament	Low tissue reactivity; good tensile strength; moderate memory; gradually loses 15-25% tensile strength/year via hydrolysis	Most common superficial skin suture in derm surgery
Nylon (Nurolon)	Polyamide polymer	Braided	Better handling than monofilament nylon; higher reactivity; capillarity concerns	Less commonly used; some prefer for mucosal closures
Polypropylene (Prolene)	Polypropylene polymer	Monofilament	Highest tensile strength; lowest tissue reactivity; best infection resistance; no degradation; high memory; smooth passage	Skin closure in contaminated/irradiated wounds; running subcuticular closures; high-tension closures
Polyester (Mersilene, Ethibond)	Polyester polymer	Braided	Excellent knot security; low elongation; coated versions reduce friction; permanent strength retention	Deep permanent closures; fascial repair; rarely in dermatologic surgery
Polybutester (Novafil)	Polybutester copolymer	Monofilament	Unique elasticity. Stretches with edema, returns to length as swelling resolves; low memory	Areas prone to significant postoperative edema; rarely available/used

Suture Size Selection

Suture size (gauge) is designated by the USP (United States Pharmacopeia) system. Larger numbers after the dash indicate smaller diameter (e.g., 6-0 is finer than 3-0). Suture size selection depends on tissue strength, wound tension, and anatomical location.

Size	Diameter Range	Typical Use in Derm Surgery
2-0	0.30-0.34 mm	Deep buried sutures in high-tension areas (back, trunk, scalp)
3-0	0.20-0.25 mm	Deep buried sutures in moderate-tension areas (extremities, trunk)
4-0	0.15-0.20 mm	Deep buried sutures in low-to-moderate tension (face, neck); superficial sutures on trunk
5-0	0.10-0.15 mm	Deep buried sutures in minimal-tension areas (eyelid, ear); superficial sutures on face
6-0	0.07-0.10 mm	Superficial sutures on eyelid, lip vermilion, nose tip; running subcuticular on face

Needle Anatomy and Types

Surgical needle anatomy consists of three parts: the point/tip (penetrates tissue), the body (strongest portion, determines needle shape), and the shank/swage (attachment to suture. Weakest point of the needle-suture unit). Understanding needle geometry is critical for efficient and atraumatic tissue passage.

Needle Curvature

Needles are classified by their arc: straight (Keith needles, rarely used in derm), 1/4 circle (ophthalmic), 3/8 circle (most common in dermatologic surgery. Allows wrist rotation for superficial tissue bites), 1/2 circle (deep tissue, confined spaces), and 5/8 circle (pelvic/deep cavities, rarely used in derm). The 3/8 circle needle is the workhorse of dermatologic surgery because it allows comfortable supination-pronation wrist motion for superficial to mid-depth tissue bites.

Needle Point Geometry

Cutting needles are required for skin surgery because the dense dermal collagen resists passage of non-cutting needles.

Needle Type	Cross-Section	Cutting Edge Location	Clinical Significance
Conventional cutting	Triangular	Inner (concave) curvature	Cutting edge faces wound edge. Increased risk of suture pulling through tissue ("cheese-wiring")
Reverse cutting	Triangular	Outer (convex) curvature	Cutting edge faces AWAY from wound. LESS risk of tissue tear-through; STANDARD in dermatologic surgery
Spatula/side-cutting	Flat with lateral edges	Lateral edges only	For corneal and scleral surgery; splits tissue planes laterally
Taper point (round)	Round	No cutting edge. Spreads tissue	For soft, easily penetrated tissue (fascia, bowel); NOT for skin

Suture Allergy

True suture allergy is uncommon but can occur, particularly with natural suture materials. Natural gut sutures (plain, fast-absorbing, chromic) are derived from bovine or ovine intestinal submucosa and contain collagen. Patients with collagen sensitivity or alpha-gal syndrome may develop allergic reactions. Chromic gut sutures contain chromium salts, which can trigger contact dermatitis in chromium-sensitive individuals. Synthetic sutures very rarely cause true allergic reactions. Multifilament sutures can harbor bacteria and cause foreign body granulomas that mimic allergic reactions but are inflammatory rather than immunologic in nature. Silk, being a natural protein, occasionally causes hypersensitivity reactions.

Special Considerations in Dermatologic Surgery

Suture selection in Mohs and dermatologic surgery follows specific patterns that optimize outcomes for cutaneous wounds. The typical layered closure uses a deep absorbable suture (buried vertical mattress with Monocryl or Vicryl) followed by a superficial nonabsorbable suture (interrupted or running with nylon or polypropylene) or fast-absorbing gut. For areas under minimal tension with excellent deep closure, the superficial suture may be omitted entirely or replaced with wound closure strips (Steri-Strips). Running subcuticular closure with polypropylene or Monocryl provides an excellent cosmetic result on the face by avoiding transverse suture marks.

Frequently Asked Questions

Suturing Techniques Surgical Instruments in Dermatologic Surgery Full-Thickness Skin Grafts (FTSG)Mohs Micrographic Surgery Technique

Recent Evidence

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References

[1]Park KY, Suh EJ, Koh IJ, et al. Suture materials and suturing techniques for cutaneous wound closure. J Cutan Med Surg. 2015. doi:10.1177/1203475415582089
[2]Ashraf I, Butt E, Veitch D, Wernham A. Dermatological surgery: an update on suture materials and techniques. Part 1. Clin Exp Dermatol. 2021. doi:10.1111/ced.14770 PMID: 34056751
[3]Robinson JK, Hanke CW, Siegel DM, Fratila A. Surgery of the Skin: Procedural Dermatology, 3rd Edition. Elsevier. 2019.
[4]Miller CJ, Antunes MB, Sobanko JF. Surgical technique for optimal outcomes: Part I. Cutting, handling, and suturing tissue. J Am Acad Dermatol. 2015. doi:10.1016/j.jaad.2015.02.1143

About This Article

Author: Dr. Yehonatan Kaplan, M.D., Fellow ACMS

Last Medical Review: 2026-03-07

Audience: Dermatologic Surgeons

Clinic: Kaplan Clinic · DermUnbound Research Program