Types of Sutures

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The Difference Between Various Types of Sutures

Sutures and surgery go hand in hand. Not even newer ways
of closing wounds such as use of clips or staples will ever end
this relationship. While staples and clips may be used
externally for many types of wounds, internal procedures
almost always need a type of a suture.
Suture classifications

Sutures can be broadly classified into two groups:

Absorbable sutures

Non-absorbable sutures
Absorbable sutures as the name suggests will eventually be absorbed in the body and after some
time there will be no trace of them. There are many types and sizes of these sutures and each
type is best suited for a particular surgical job or part of the body. The strengths of these sutures
also differ. Other differences include:

Source of raw material

There are both natural and synthetic absorbable sutures. Each type is further classified into
whether the strands making the suture are single or multiple. Single strand absorbable sutures are
called monofilament while multiple strand types are called multi-filament absorbable sutures.

Examples of absorbable sutures

PDO (polydioxanone) suture

This is a monofilament synthetic absorbable suture made from polyester. They come plain or
colored in FDA permitted dyes. This suture is best suited for internal soft tissue approximation. It
is especially good in pediatric cardiovascular procedures and in tissues where growth is ongoing.
The suture is good where support is needed for up to 6 weeks.

PDO Sutures

PGA (polyglycolide acid) sutures

This is a multifilament and braided absorbable suture made from polyglycolic acid. It is coated
with N-laurin and L-lysine to make it smooth. The absorption time is about 90 days and is made
plain or colored violet. The suture is very reliable and will remain effective through the critical
wound healing time. It forms secure knots that are not likely to give way. It is good for
subcutaneous wound closure and for various internal surgical uses.

PGA Sutures

PGCL (polyglycolide-co-caprolactone)

PGCL is a synthetic monofilament absorbable suture that comes dyed or plain. The main
indication is in soft tissue approximation, repair and in ligating bleeders. It is not suitable for
cardiovascular or neurovascular procedures. Tension strength gradually reduces and it's over in
about 4 weeks. It has low incidence of inflammation. The elderly, malnourished or people with
possible delayed wound healing should not use PGCL.

PGCL Sutures

Catgut absorbable sutures

These are natural absorbable sutures made from purified collagen tissues of cows' intestines. It is
suitable for quickly regenerating tissues. Some countries have phased out the use of catgut on
human surgeries and are only used in vet operations.

Non-absorbable sutures
These are sutures that are not degraded by the body. Although the body can try to do this, the
process is so slow that the suture if left in place can remain there permanently. When used
externally, these sutures have to be removed in about 7-10 days of surgery. As with the
absorbable type of sutures, here there are also synthetic and natural types. These are further
divided into mono-filament and multi-filament. Multifilament sutures are further divided
according to the way their strands are connected. They can either be:

Braided

Braided and twisted

Braided and coated

Each of these types is best for specific surgeries.

Examples of non-absorbable sutures

Nylon monofilament and multifilament sutures are made from long-chain aliphatic polymers
of nylon 6. They are used in a wide variety of surgical situations. They can be used in
ophthalmic, cardiovascular and even in neurosurgical procedures. They come dyed mostly in
green or blue or even black. This enhances visibility during procedures. Nylon sutures have high
tensile characteristics and hold firmly for the duration of time they are supposed to be in place.
They easily go back to their shape even after being deformed. This is especially true for
monofilament nylon sutures. There is minimal tissue reaction where nylon is used and so
inflammation and infection rate is low.

Silk

Silk sutures are non-absorbable and made from natural proteinaceous silk material called fibroin.
It is made into multifilament and braided type which is then coated with wax or silicon to reduce
water retaining capacity and for easy handling. These sutures are appropriate for many types of
surgeries such as ophthalmic, neurosurgery, cardiovascular and in closing many types of open
traumatic or surgical wounds. Despite the fact that silk is not absorbable, it gradually loses its
tensile power and for this reason may not be very ideal where permanent tension is required. The
initial tissue reaction is minimal and soon the suture is encapsulated by tough fibrous connective
tissues.

Silk Sutures
Polyester

Polyester sutures are synthetic and non-absorbable. They are made from polyethylene
terephthalate. They are long lasting and their tension doesn't change. This characteristic and
minimal tissue reaction makes them ideal for esthetic surgeries. Polyester non-absorbable sutures
are also good for heart operations. They come coated or in plain format.

Polyester Sutures

Polypropylene sutures

This is another class of synthetic non-absorbable sutures. It has good tensile and holding
properties. It is made of isotactic crystalline stereoisomer of polypropylene. This suture is ideal
for heart and vascular operations. Other areas of use include ophthalmologic and neurosurgical
operations.

Polypropylene Sutures

Sutures come in different sizes with needles of different sizes and of various tip characteristics.
The type of suture and needle to use is determined by the operation and the specific part where
the suture and needle are to be used.

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Types of Suture | Suture Materials
What are the different suture types?

Surgical Sutures are normally classified into two types, absorbable and non-absorbable. They
can also be classified based on their construction, either mono-filament or multi-filament,
coating provided, absorption profile and also whether they are made from natural or synthetic
materials. Sutures can also be classified according to their usage e.g. cardiovascular sutures,
ophthalmic sutures, general sutures, orthopaedic sutures etc.

Absorbable and Non-absorbable sutures

Sutures can be divided into two types those which are absorbable and will break down
harmlessly in the body over time without intervention, and those which are non-absorbable and
must be manually removed if they are not left indefinitely. The type of suture used varies on the
operation, with the major criteria being the demands of the location and environment and
depends on the discretion and professional experience of the Surgeons.

Sutures to be placed internally would require re-opening if they were to be removed. Sutures
which lie on the exterior of the body can be removed within minutes, and without re-opening the
wound. As a result, absorbable sutures are often used internally; non-absorbable externally.

Sutures to be placed in a stressful environment, for example the heart (constant pressure and
movement) or the bladder (adverse chemical presence) may require specialized or stronger
materials to perform their role; usually such sutures are either specially treated, or made of
special materials, and are often non-absorbable to reduce the risk of degradation.

Absorbable sutures include :- Polyglycolic Acid sutures, Polyglactin 910 , Catgut, Poliglecaprone 25 and
Polydioxanone sutures.

Non-Absorbable sutures include :- Polypropylene sutures, Nylon (poylamide), Polyester, PVDF, silk and
stainless steel sutures.

Monofilament and Multifilament Sutures

Sutures can also be divided into two types on the basis of material structure i.e. monofilament
sutures and multifilament or braided sutures. Braided sutures provide better knot security
whereas monofilament sutures provide better passage through tissues. In general, Monofilament
sutures elicit lower tissue reaction compared to braided sutures. Multifilament sutures are
braided and often coated with various materials like silicon, wax, PTFE, polycaprolactone,
calcium stearate etc.
Monofilament sutures include :- Polypropylene sutures, Catgut, Nylon, PVDF, Stainless steel,
Poliglecaprone and Polydioxanone sutures.

Multifilament or braided sutures include :- PGA sutures, Polyglactin 910, silk and polyester sutures.

Classification of sutures based on suture size

Surgical Sutures and ligatures are available in a number of sizes. Sutures are classified into
different sizes based on the diameter of the thread. United States Pharmacopeia's classification of
sutures into various sizes is widely accepted across the world.

The following U.S.P. and metric suture sizes chart shows the diameter range for collagen and
synthetic sutures.

Synthetic and Natural Sutures

Surgical sutures can also be divided into two types on the basis of raw material origin i.e. natural
and synthetic sutures.

Natural sutures include silk and catgut sutures whereas all other sutures are synthetic in nature.

Coated and Un-Coated Sutures

Some types of sutures are available with specialized coatings on the surface to enhance
properties like knotting, easy passage through tissue and reduce tissue reaction. Normally,
coating is applied to braided sutures rather than monofilament sutures. It is easier to coat braided
sutures compared to monofilaments. Coating materials like chromium salt, silicon, wax, PTFE,
polycaprolactone, calcium stearate. Polymeric coating materials are known to be more bio-
compatible than conventional coating materials like chromium salts, beeswax, pafaffin, gelatin
etc. There are new functional coatings like antibacterial or antimicrobial coating given to both
monofilament and multifilament sutures, stem cell coating for improving healing properties.

Coated sutures include :- PGA sutures, Catgut Chromic, Polyglactin 910, silk and polyester sutures, braided
or twisted nylon, Poliglecaprone and Polydioxanone sutures.

Un-coated sutures include :- Monofilament Polypropylene sutures, monofilament Nylon, PVDF, Stainless
steel.

Sutures Classification based on usage

Sutures are also classified into various types based on the usage or application. Sutures are
normally classifed into general sutures, cardiovascular sutures, valve sutures, orthopaedic
sutures, dental sutures, gynaec, veterinary sutures, cosmetic surgery sutures, ophthalmic sutures
etc. A variety of suture materials may be used for a particular application based on the
requirements. However, the suture sizes, length, needle profiles, etc., will be with a small change
for a particular application.
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