Monday, August 31, 2009

Suture Allergy vs Suture Reactivity

This past week I was once again asked about suture allergy.  It has prompted me to revisit the issue which I have posted about twice now. (photo credit).
Sutures by the vary nature of being foreign material will cause a reaction in the tissue.  This tissue reactivity is NOT necessarily a suture allergy.
Many factors may contribute to suture reactivity.
  • The length of time the sutures remain.  The longer the sutures are in, the more reactivity occurs.
  • The size of the sutures used.  The larger the caliber of the suture, the more reactivity.  The increase of one suture size results in a 2- to 3-fold increase in tissue reactivity.
  • The type of suture material used.  Synthetic or wire sutures are much less reactive than natural sutures (eg, silk, cotton, catgut).  Monofilament suture is less reactive than a braided suture.
  • The region of the body the suture is used affects tissue reactivity.  The chest, back, extremities, and sebaceous areas of the face are more reactive.
In general, accepted time intervals for superficial suture removal vary by body site, 5-7 days for the face and the neck, 7-10 days for the scalp, 7-14 days for the trunk, and 14 days for the extremities and the buttocks.  The deeper placed sutures will never be removed.
Sutures meant to dissolve (ie vicryl sutures) placed too high in the dermis (which happens often when the dermis is thin) can “spit” several weeks to several months after surgery. This is a reactive process, NOT a suture allergy.  It usually presents as a noninflammatory papule (looks very much like a pimple) and progresses with extrusion of the suture through the skin. The suture material may be trimmed or removed if loose, and it is not needed for maintaining wound strength.  Rarely does this affect the scar outcome.

The remaining portion is a “repost” about suture allergies:
Allergic reactions to suture materials are rare and have been specifically associated with chromic gut. However, Johnson and Johnson mention known triclosan allergy as a contraindication for use of certain sutures (see below). Contact allergy to triclosan is uncommon.
Surgical gut suture (Plain and Chromic) is contraindicated in patients with known sensitivities or allergies to collagen or chromium, as gut is a collagen based material, and chromic gut is treated with chromic salt solutions.
MONOCRYL Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP(triclosan).
PDS Plus Antibacterial suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).
VICRYL*suture should not be used in patients with known allergic reactions to Irgacare MP (triclosan).  [In rechecking facts, I found that only Vicryl Plus has the triclosan, so simple vicryl or coated vicryl should be okay.]
Surgical Stainless Steel Suture may elicit an allergic response in patients with known sensitivities to 316L stainless steel, or constituent metals such as chromium and nickel. Skin staples are surgical steel so should be used with the same precautions.
Dermabond -- Tissue glues should not be used in patients with a known hypersensitivity to cyanoacrylate or formaldehyde.

SO WHAT IS LEFT TO USE
So what is left to use in a patient who may have or has a proven allergy to suture or closure material?
Silk, Dexon, Nylon(monofilament or braided), Prolene, INSORB (absorbable staples), and any of the above listed (in the allergy section) to which the patient in question doesn't react negatively.
The choice of a particular suture material will have to based further on the wound, tissue characteristics, and anatomic location. Understanding the various characteristics of available suture materials will be even more important to make an educated selection.
The amount of suture placed in a wound, particularly with respect to the knot volume, affects inflammation. The suture size contributes more to knot volume than the number of throws. The volume of square knots is less than that of sliding knots, and knots of monofilament sutures are smaller than those of multifilament sutures.


REFERENCES
Allergic Suture Material Contact Dermatitis Induced by Ethylene Oxide: G. Dagregorio, G. Guillet; Allergy Net Article
Johnson and Johnson Product Information
Current Issues in the Prevention and Management of Surgical Site Infection - Part 2; MedScape Article
MECHANICS OF BIOMATERIALS: SUTURES AFTER THE SURGERY; Raúl De Persia, Alberto Guzmán, Lisandra Rivera and Jessika Vazquez
Materials for Wound Closure by Margaret Terhune, MD; eMedicine Article
Product Allergy Watch: Triclosan; MedScape Article by Lauren Campbell; Matthew J. Zirwas
New References
  • Surgical Complications; eMedicine Article, May 29, 2009; Natalie L Semchyshyn, MD, Roberta D Sengelmann, MD
  • Engler RJ, Weber CB, Turnicky R. Hypersensitivity to chromated catgut sutures: a case report and review of the literature. Ann Allergy. Apr 1986;56(4):317-20. [Medline].
  • Fisher AA. Nylon allergy: nylon suture test. Cutis. Jan 1994;53(1):17-8. [Medline].

Related Posts
Allergies from Suture Material (September 7, 2007)
Suture Allergies Revisited  (April 30, 2008)
Suture (June 7, 2007)
Basic Suture Techniques (June 8, 2007)

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14 comments:

Dreaming again said...

I spit sutures after my thymectomy. It was very strange!

Midwife with a Knife said...

I've had a series of wound complications for my very first month as an attending, but almost all infection related (rather than allergic/suture reactivity reactions).

I found the brief review you presented really fascinating, though. Stuff I hadn't thought about before.

Dawn S. said...

My daughter is not really allergic to much, but she cannot tolerate the adhesives in tape of bandages because it either tears off the top layer of skin or turns red and blisters, scabs, and sometimes scars her.

She is undergoing a staged excision for a large (4.5" x 2.5" nevus on her upper arm. So far, she had the first excision using Hibiclens to clean the area and then 40 Vicryl for the interior stitches and 40 Prolene for the exterior stitches. It was covered with Bactroban and a nonstick pad, wrapped in gauze and an elasticized wrap was put around it to keep the bandaging in place. They supplied us with extra Bactroban and bandages. She had absolutely no reactions, infections, hives, etc., and other than the wound stretching (about 2mm wide), it looked great.

She had the second excision a week ago and although there was only one change (per information supplied by their staff) to that whole procedure above, she had a totally different reaction. The only difference was that they used black 40 nylon McKesson stitches instead of the 40 Prolene. Other than the color of the stitches, nothing looked different at that time. The next day, the wound was super itchy and there were about 20 small red, raised dots that were around the incision, but none of them were coming from the incision and did not appear to be coming from the stitches/stitch holes. Each day it got worse until the had some that had turned into 1/4" lines of inflammation and some looked like there was pus in them. We gave her Benadryl which brought down some of the swelling, inflammation, and itching, but it was still itchy, red, and swollen. We brought her back to the office and they said that this happens sometimes, that the wound may have overheated (although the weather was warmer the first time around and we had it covered for two weeks straight. They also advised us to uncover the wound and allow it to cool it as much as possible. A few days later, after being left uncovered, the pinkish red spots and lines are still raised and inflamed, but they are scabbing and some of the skin is splitting as if it had died, dried up, and is now peeling. It is still itchy, but she has never once touched or scratched any part of it. The doctor's office advised me that the reaction could last for a month (ugh!).

We have the last staged excision to do late in November.

We have done nothing different with the wounds. Does this sound like it is an allergy to the suture, suture reactivity, or something else?

Can you recommend anything different be done before, during, or after the last excision to prevent this nasty reaction?

Thanks.

rlbates said...

Dawn, ask them to go back to the first routine. It may actually have been the Bactroban rather than the nylon sutures, so if they will allow you try Aquafor ointment instead.

A patient of mine who was allergic to tapes of all kind taught me that Scotch tape is more non-allergic than any other kind. She never reacted to it when we had to use tape.

Best wishes to your daughter.

Anonymous said...

6 weeks ago I had a nickel-sized basal cell carcinoma removed from the middle of my forehead. The 2 1/2 in. incision was stitched interior with monocryl 50. From the beginning it was painful, red, with whelps wherever the outer stitches went in and out, but that became better. The problem is that the upper part healed and the bottom part nearer the nose bridge didn't. Eruptions happen every 24-48 hours with an opaque off white discharge shooting out, but no stitches coming out. The two or three holes try to heal, but then it happens again. The dermatology surgeon tested it and found no infection but doesn't know what to do. I am back with the Uni. of TX dermtologist professor. We tried a steroid creme, but my skin can't take it....more problems....so, what are we going to do????

rlbates said...

Anon 2/09/13
Any visible suture material should be removed. Avoid antibiotic ointments like Neosporin which can cause their own reaction. Try simple ointment like Aquafor. Time. Perhaps a round of oral corticosteroids. Be sure there isn't residual cancer. Keep working with your doctors. Best to you

PKN said...

Last September I had surgery on my ankle (gastroc release, Achilles tendon debridement and repair, lateral ankle ligament reconstruction). Shortly after the surgery I started to "spit stitches" as you described. The surgical report describes the wound being closed with 3-0 PDS and 3-0 Monocryl (gastroc, ankle, and Achilles incisions) plus #1 Vicryl suture on the ankle capsule. Staples and dermabond were used to finish.

I had two places where the stiches came out on my gastroc incision and one place on the Achilles (which got very large, painful, and swollen, then burst releasing lots of blood). Both areas have scaring where the stitches came out, and the process took a couple of months to resolve on the gastroc (draining and for the stitch to come out; it was too short to be pulled out). I'm still not sure the Achilles is completely resolved.

Here is where the problem comes in: I have just been diagnosed with breast cancer and will be having a mastectomy in two weeks. I am very concerned about having a similar problem with the stitches. I have mentioned this to the plastic surgeon, and he seems to feel there are alternatives, but doesn't seem to have much knowledge of this type of reaction.

My question to you is what is the best way to prevent this "stitch spitting" from happening with the stitches on my mastectomy? Would using a non-synthetic material be better than another type of synthetic? Any other suggestions for a better outcome with this surgery?

rlbates said...

Anon (02/11/13), the best way to prevent "spitting stitches" begins with the surgeon's choice of material so work with him/her and then on his technique (care of stitch placement, not too close to the surface, using as small of gauge suture as area allows, tying as few knots as possible and stitch that will allow stitch to hold as this reduces suture material which has to be absorbed). Best to you.

Marie Smith said...

So glad I found your blogs with info on suture allergy vs sensitivity. I had an upper eye bleph one week ago. Lots of bruising on left eye which is healing day by day. Both lids were a red/purple color for a week and are just starting to turn pink. At my post op, my PS removed several "dissolving" stitches which were pretty much still in tact. Unfortunately, there are a few he missed. I asked at my post op what the sutures were made of. When he said "collagen" I got a little upset. Ten plus years ago, I was using collagen to replace tissue on my face after having a mole removed. I did not react to the skin test but, after a year of using collagen, my body reacted with bumps in the area which came and went for another year without any further injections. My PS said that the sutures are not made of the same material, but I think he's not being honest with me. The two areas where I feel that sutures may still remain are redder than the rest of my lids. I was told to apply Vaseline several times a day until they came out. I'd rather he take them out if he can so I can heal more quickly. I live quite a distance from my doctor and he's also off to a conference this afternoon! Do you think they'll come out on their own soon? Is it necessary to remove them? Do you think this is a concern at all? Thanks so much for any advice!

rlbates said...

Marie, I must fall back on the blog disclaimer and remind you that I am not here to be your treating physician. The collagen used for fillers and in sutures are two different things. If you are not trusting of your current PS, then consult with another one.

Kimberly T said...

I will be using some medical terms in this post, as I have very limited education as a Medical Assistant. I've had a total of 4 laporoscopies. 3 performed in the early 90's for abd adhesions and 1 about 6 weeks ago for the same and to remove the appendix that was adhered to the abd wall. First three surgeries went well, used an OB/GYN who incised laterally at the inside/bottom of my umbilical area. This recent surgery was performed by a GS who incised horizontally in the same area thus crossing the "T" upside down. I hopes this make sense. I am having a serious suture reactivity 4 weeks postop. All other suture sites are perfect and healing greatly, but this one umbilical is making me crazy. It has broke open, when it first broke open I got a 1/4 tsp amnt of yellow red cloudy pus. Been on two rounds of ATB yet it is still open and draining. I have been asked to use wet warm soaks BID and cover with dry dressing the rest of the time. After two weeks, I see no improvement. My GS said it's just going to take time. In the meantime it itches so bad, sharp painful stabbing in this area at times, have not located or seen any suture material. Can it be so simple as to time? Or should there be an attempt to cut back into the site, remove said suture and close? I guess I'm stumped. In addition to this suture, when this infection/inflammation started my whole body is exhausted, SOB with excertion and just plain tired. Is this possibly due to the inflammation or a possible secondary issue? If secondary is probable then I will follow up with my PC. Any thoughts?

rlbates said...

Kimberly, follow up with your GS and PCP. It will take time. Any visible suture material can be removed as it "spits."

Anonymous said...

I have a undetermined auto immune disease I recently had a cyst removed from the cheek area inside my mouth the doctor used a gut suture inside my mouth and now I've had incredible swelling for seven days could this be an reaction to gut

rlbates said...

Anon (5/29/13), it could be a suture reaction or it may be an inclusion cyst. Go back to your surgeon and have him/her look at it. Best to you