Absorbable Sutures

Brian Lin MD





PEARLS

Current literature suggests that absorbable suture can be used for closure of superficial traumatic skin lacerations.

Consider absorbable sutures in patients for whom taking out non-absorbable sutures is going to be problematic.

Match the type & location of the wound with the suture material’s degradation properties and give wound care instructions that include gently removing remaining suture material from wound after the time of effective wound closure as passed.





Traditionally, absorbable sutures are used for deep sutures that are placed into the dermis to take tension off a wound and allow for better approximation of the epidermis with non-absorbable sutures.





Non-absorbable nylon or polypropylene sutures are used for superficial wound closure because they are stronger, easier to work with and allow for great wound edge apposition and eversion for the best possible cosmetic outcome.

Evidence has been building over the past 10 years that absorbable suture for closure of superficial traumatic lacerations is appropriate.





Consider absorbable sutures in patients for whom taking out non-absorbable sutures is going to be problematic.

A 16 month old child who requires sedation or aggressive holding to place the sutures initially.



An adult without health insurance for whom the additional suture-removal visit is going to be a significant financial burden.





What does the current evidence say about the use of absorbable suture for closure of superficial traumatic lacerations?





Karounis H, et al. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004 Jul;11(7):730-5. [Free open access link]

Randomized controlled trial that compared the use of absorbable plain gut sutures with non-absorbable nylon sutures in the closure of pediatric lacerations.





Enrolled patients ages 1-18 years old who presented with lacerations that were less than 12 hours old.





Excluded a lot of patients including those with:

Lacerations easily closed with adhesives.



Wounds prone to infection like bite wounds.



Wounds crossing joints with high tension.



Complicated wounds with tendon, nerve or cartilage involvement.



Patients with immunocompromising conditions like diabetes, immunodeficiency, collagen vascular disease or bleeding disorders.



Scalp wounds.





Patients were randomized to receive either absorbable plain gut sutures or non-absorbable nylon sutures. Patients were evaluated at 1 week after repair by a wound-care nurse and again at 4-5 months by a blinded plastic surgeon. The plastic surgeon evaluated the cosmetic outcome on a visual analog scale, a validated and commonly used method for assessing wounds and also assessed for scar revision.





95 patients were enrolled and there was no statistical difference between the groups.





CONCLUSION: The use of absorbable vs non-absorbable sutures were equivalent for superficial wound closure.





Luck RP, et at. Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2008 Mar;24(3):137-42. [PMID 18347489]

Looked specifically at closure of pediatric facial lacerations.

88 pediatric patients were randomized to fast-absorbing cat-gut sutures or nylon sutures. The patients were evaluated at about 1 week and 3 months using the visual analog scale.

No significant difference was found in the visual analog scale scores. There was also no difference found in the rates of wound infection, dehiscence, keloid formation or in rates of parent or caregiver satisfaction.

CONCLUSION: The use of fast-absorbing cat-gut suture is a viable alternative to non-absorbable sutures of pediatric facial lacerations.





Luck R, et al. Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2013 Jun;29(6):691-5. [PMID 23714755]

Studied healthy, 1-18 yo patients with 1-5cm facial lacerations. Patients were randomized to fast-absorbing cat-gut or nylon and patients were evaluated at 1 week and at 3-4 months.

Looked at the cosmetic outcome as evaluated by a blinded physician as well as by the caregivers of the patients.



The mean visual analog scores among the caregivers found no significant difference, while the mean physician visual analog score differed by 10 points and was statistically significant, favoring nylon over cat-gut.

CONCLUSION: Non-inferiority of cat-gut compared to nylon could not be established in this study.





Tejani C, et al. A comparison of cosmetic outcomes of lacerations on the extremities and trunk using absorbable versus nonabsorbable sutures. Acad Emerg Med. 2014 Jun;21(6):637-43. [Free open access link]

This is the first study to look at both adult and pediatric patients. Examined the use of absorbable Vicryl Rapide sutures for closure of extremity and trunk wounds.

Randomized, controlled study design. Patients were evaluated by blinded plastic surgeons.



No significant difference in cosmetic outcomes, but population size was too small to draw conclusions about secondary outcomes like complications, wound dehiscence, infection and train-tracking along the wound-edge margins.





CONCLUSION: Established non-inferiority of Vicryl Rapide sutures compared with non-absorbable prolene sutures in terms of cosmesis.





In this study both suture types resulted in lower visual analog scale scores than the previously discussed studies had shown. The authors hypothesized that these lower scores are reflective of the exclusion of facial lacerations from the study population, since these wounds tend to heal better than wounds on other areas of the body.





There was a greater percentage of wound infections and train-tracking in the Vicryl Rapide group than in the non-absorbable prolene group. The numbers were too small to establish statistical significance, but these differences are important to consider because we do not want to introduce a new technique that causes problems for our patients.





TYPES OF ABSORBABLE SUTURES:





Degradation properties are key in selecting the type of absorbable suture. There is a very big difference between the time it takes for a suture to absorb and the effective wound support provided by the suture.

Effective wound support refers to the amount of time the knot stays in place and the suture maintains its tensile strength.

The degradation time is the amount of time it takes for the threads of the suture to actually dissolve.





Absorbable suture type Effective wound support Degradation time Best use Material notes Plain gut 8-9 days 30 days Chest or extremity wounds Fast-absorbing plain gut 5-7 days 14-28 days Facial wounds Gut sutures that have been heat-treated to aid in dissolving. Chromic gut 10-21 days 3 months Not ideal for superficial wound closure Gut sutures that have been treated with chromium to decrease their tissue reactivity and slow their absorption. Vicryl (polygalactin) 21 days 3 months Not ideal for superficial wound closure. Polygalactin synthetic suture. Vicryl Rapide 10 days 42 days Better than chromic gut or Vicryl for superficial wound closure Vicryl that has been gamma-irradiated to decrease absorption time.





Keep in mind that hydrolysis of the suture is dependent on a moist environment. When used for superficial wound closure, the buried portion of the suture will dissolve, but the visible portion on the skin will linger much longer.





The longer any suture remains in the wound, the greater the risk of wound inflammation, stitch-abscess formation and overall poor cosmetic outcomes.





When you use absorbable sutures, do not give the patient the false expectation that they are going to dissolve into thin air. Tell them the amount of time that the suture will provide effective wound support and that after that amount of time, they should use a pair of tweezers to gently pull at the residual sutures on the skin and remove them. If they face resistance, the suture knot is probably not completely hydrolyzed and they should wait a day or 2 and then try again.





Fast-absorbing plain gut and Vicryl Rapide are a bit difficult to use. They are slippery, brittle and break easily. Before using them on a patient, practice a few times on a model until you feel comfortable handling the suture.





