Sutureless Blood Vessel Repair

Updated 3/2017-- photos and all links removed (except to my own posts) removed as many no longer active. 

If this works in humans as it has in rats, then it will be a huge advance in microvascular repair.  The full article is referenced below (I did not read in it’s entirety due to pay wall).   (photo credit)

We have developed a new method of sutureless and atraumatic vascular anastomosis that uses US Food and Drug Administration (FDA)-approved thermoreversible tri-block polymers to temporarily maintain an open lumen for precise approximation with commercially available glues. We performed end-to-end anastomoses five times more rapidly than we performed hand-sewn controls, and vessels that were too small (<1.0 mm) to sew were successfully reconstructed with this sutureless approach. Imaging of reconstructed rat aorta confirmed equivalent patency, flow and burst strength, and histological analysis demonstrated decreased inflammation and fibrosis at up to 2 years after the procedure. This new technology has potential for improving efficiency and outcomes in the surgical treatment of cardiovascular disease.

…………………….

Currently, vascular microanastomosis (photo credit) is done by suturing.  Arteries 1 mm in diameter usually require 5 to 8 stitches, and veins require 7 to 10 stitches.  There is a risk of thrombosis even with the most meticulous repair -- total thrombosis rate 8%, with  no significant patency difference noted between the continuous suture technique and the interrupted suture technique in any vessel category.

REFERENCE

1.  Vascular anastomosis using controlled phase transitions in poloxamer gels; Edward I Chang, Michael G Galvez, Jason P Glotzbach, Cynthia D Hamou, Samyra El-ftesi, C Travis Rappleye, Kristin-Maria Sommer, Jayakumar Rajadas, Oscar J Abilez, Gerald G Fuller, Michael T Longaker, Geoffrey C Gurtner;  Nature Medicine, 2011; DOI: 10.1038/nm.2424

2.  Sutureless Method for Joining Blood Vessels Invented; ScienceDaily (Aug. 28, 2011)

3.  Technique for Microanastomosis; Wheeless Textbook of Orthopaedics, June 28, 2011

4.  Vascular Skills Lab Two (pdf)

Suture Material and Skin Irritation

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I have written about Suture Allergy vs Suture Reactivity so was very interested in this new article accepted for publication in the journal of Plastic and Reconstructive Surgery (online ahead of publication). 

The article comes from researchers in Greece who chose to use digital image analysis to evaluate the erythema  associated with tissue reaction to suture material. 

The sutures evaluated were polydioxanone (PDS II(R), Ethicon, Sint-Stevens-Woluwe, Belgium), polypropylene blue (Polypropylene(R), Assut Sutures, Ascheberg-Herbern, Germany), polyamide 6 (Ethilon(R), Ethicon, Neuchatel, Switzerland), metallic clips (APPOSETM, ULC Tyco, Hampshire, UK), and polyglactin (Vicryl Rapid(R), Ethicon, Norderstedt, Germany).

Digital photos of 100 patients(70 females, 30 males; all Caucasian) were compared by software, evaluating red color superiority (mean value of red color) in the region surrounding the wound.  Most of the patients were Fitzpatrick skin type II and III (46 and 47 respectfully).  Mean age was 42 years old, ranging from 15 to 86 years. Each underwent the excision of cutaneous and subcutaneous lesions.

Surgical wounds included those after excision of skin or subcutaneous lesions on the face (68%), neck (14%), abdominal wall (12%), axilla (1%) and back (5%). All other anatomical areas were excluded from this study in order to produce sample homogeny as concerns the healing of skin wounds in different body areas.

The researchers excluded wounds which could not be primarily closed without tension or were located over a bony prominence to minimize other confounding factors as were wounds with any kind of post-operative complications, e.g. hematoma, dehiscence or infection for the same reason.

The researchers used two different suture materials in each patient to improve comparison between suture material and skin type.  This was done by dividing each surgical wound into two halves.  Each half was sutured with two different suture materials for each wound. The same number of sutures were used on each half of the wound.  The patients were randomly assigned a pair of suture materials by the means of a sealed envelope method.

The pairing of five different kinds of suture material yielded ten pairs (PDS II- Polypropylene, PDS II - Ethilon, PDS II -metallic clips, PDS II – Vicryl Rapid, Polypropylene - Ethilon,  Polypropylene-metallic clips, Polypropylene-Vicryl Rapid, Ethilon - metallic clips, Ethilon – Vicryl Rapid, metallic clips-Vicryl Rapid).

Each pair was tested on ten patients.  Sutures were removed on the 10th post-operative day.

According to the aforementioned comparisons polydioxanone was found to have the best performance, followed by polyglactin, polyamide, polypropylene and metallic clips. All the above mentioned differences between suture materials were statistically significant (p<0.05).

Their conclusions:

The absorbable sutures used for skin closure in our study were removed after the period of time which is indicated for non-absorbable suture material and respective to the site of the wound. Less skin erythema was observed after the use of absorbable materials (polydioxanone and polyglactin) than with the three nonabsorbable materials (polypropylene, polyamide and metallic clips).

This leads to the conclusion that, when used in skin closure and removed after 10 days, absorbable materials produce less tissue reaction in the form of erythema than non-absorbable sutures do.

So their small study would indicate that PDS II created the least skin redness at 10 days, followed by Vicryl Rapid, Polypropylene, Ethilon, and metallic clips.

REFERENCE

Significant differences in skin irritation of common suture materials assessed by a comparative computerized objective method; Plastic & Reconstructive Surgery: POST ACCEPTANCE, 17 November 2010; doi: 10.1097/PRS.0b013e3182043aa6; Original Article: PDF Only

FDA Looking at Triclosan

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

The Washington Post had a story by Lyndsey Layton this past week:  FDA says studies on triclosan, used in sanitizers and soaps, raise concerns.

The Food and Drug Administration said recent research raises "valid concerns" about the possible health effects of triclosan, an antibacterial chemical found in a growing number of liquid soaps, hand sanitizers, dishwashing liquids, shaving gels and even socks, workout clothes and toys.

The FDA and the Environmental Protection Agency say they are taking a fresh look at triclosan, which is so ubiquitous that is found in the urine of 75 percent of the population, according to the Centers for Disease Control and Prevention. The reassessment is the latest signal that the Obama administration is willing to reevaluate the possible health impacts of chemicals that have been in widespread use.

No where in the article is the use of triclosan use in suture mentioned, yet in my research on allergy/reactivity to suture material I found that it is.  From my post, Suture Allergy vs Suture Reactivity :

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…….

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.]

More from the Washington Post article:

The FDA was responding to inquiries from Rep. Edward J. Markey (D-Mass.), who has been pushing federal regulators to take stronger action to restrict the use of triclosan and other chemicals that have been shown in laboratory tests to interfere with the delicate endocrine system, which regulates growth and development………

Markey wants triclosan banned from all products designed for children and any product that comes into contact with food, such as cutting boards.

Suture is not classified for use in only adults or only children.    Part of the issue with triclosan is that not enough is know about the chemical.  Do we need to not use any of the sutures with triclosan?

I am fond of PDS though I rarely use PDS Plus.  I use a lot of Vicryl, again rarely Vicryl Plus.

It seems that it is mostly the “Plus” sutures that have the triclosan, so perhaps it would be wise in children to not use those sutures until more is known.  Anyone have any thoughts on this?

Historical Sutures

I apologize if any of you tire of my posts on surgical history from the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I discovered recently.  I continue to be fascinated by it.  Today, I want to share the section on sutures.

In no part of surgical technique is sterility of so great importance as in the preparation of ligatures and sutures.  They are implanted in wounded tissues, and any germs which they may contain are placed in the most favorable conditions for growth, being harbored in a foreign body (the ligature), and supplied with abundant nutriment in the form of extravasated blood and damaged tissue cells.  Any material for ligatures or sutures, therefore, which cannot be sterilized with certainty should be thrown out of the surgical armamentarium.  A number of surgeons have at one time or another decided that catgut fell under this ban, and have refused to employ it under any circumstances.  It is now pretty generally admitted, however, that it can be sterilized by a number of methods with sufficient certainty to warrant its general employment.

Sutures and ligatures are primarily divided into those which are capable of disintegration within the tissues, and those which remain unchanged either permanently or for a very long period of time.  The names absorbable and non-absorbable are applied to these two classes.  All the non-absorbable materials can be sterilized by boiling in water or in a steam sterilizer.

Absorbable Sutures

Catgut

Various animal tendons, strips of hide, and nerves have been employed as sutures and ligatures, but they have been almost entirely supplanted by catgut.  It is cheap, it can always be obtained in any size, and in strands of sufficient length, and if properly prepared, it has great strength.  Moreover, it is quickly disintegrated in the tissues, the ordinary sizes being wholly taken up in the course of a week or two, so that no foreign body remains in the wound indefinitely.  Its one disadvantage is the fact that it cannot be sterilized by steam or boiling water, for in both of these it cooks to a jelly in a few minutes.

Sterilization of Catgut – It can be boiled in alcohol in a water bath or sand bath, but as alcohol boils at 174° F, the temperature is not sufficient to kill all germs.  This method is therefore unreliable.

Catgut may be sterilized by dry heat.  Boeckmann’s method is as follows:  The catgut is soaked in ether one week to remove the fat.  Single strands are then wound in rings, and each wrapped in paraffin paper and sealed in a paper envelope.  The envelopes are placed in a dry sterilizer and heated to 300° F for three hours on two successive days.

Catgut may be sterilized by chemicals.  Claudius’s method is the simplest.  Commercial catgut without any preparation is wound in single layers on glass spools and dropped into a jar containing one part of iodine and one part of potassium iodid to one hundred parts of distilled water.  The jar is tightly covered and allowed to stand for one week.  For use the spool containing the catgut is removed and immersed in sterile water, in order to free the catgut from the excess of iodin.  Spools which have been partially used can be resterilized until the catgut becomes brittle, which it is apt to do if it remains for more than three months in the above mentioned solution.  After one week’s immersion in the iodin solution, the spools may be removed and kept in alcohol.  This is the simplest reliable method for sterilizing catgut in the office.

Catgut may be so treated with chemicals that it can be boiled in water.  This result may be obtained by soaking the catgut in a solution of formaldehyde, but during the entire process the catgut must remain tightly stretched upon glass plates or large spools.  A simpler method is that of Elsberg.  The raw gut is freed from fat by immersion in ether or chloroform, or a mixture of one part chloroform and two parts ether.  It is then wound tightly in a single layer on large glass spools, having a hole in each flange in which the ends of the gut can be tied.  The spools are boiled for ten minutes in a saturated solution of ammonium sulphate with one per cent of carbolic acid.  The spools are then removed with sterile forceps, rinsed for half a minute in warm sterile water, and placed placed in strong alcohol.  Partially used spools can be resterilized, and the solution of ammonium sulphate in which they are boiled can be used indefinitely by the addition of water to take the place of that which has evaporated.

Catgut may be sterilized by boiling in some substance which has a higher boiling point than water, and which at the same time will not so alter the catgut as to render it weak or brittle.  One of the best substances for the purpose is cumol, which boils at about 330° F.  The method is a little too complicated for office use.

Catgut may be sterilized by immersion in alcohol heated under pressure in order to obtain a high degree of temperature.  This requires special apparatus, and is not a method suitable for general office use.

Catgut sold in sealed glass tubes is usually prepared by one of the two methods last mentioned.  Catgut prepared in this manner costs from ten to twenty-five cents a piece.

Commercial catgut comes in coils of one hundred feet, costing in the sizes usually employed from fifty cents to one dollar a coil.

Chromic Catgut

As stated above, plain catgut disintegrates in the tissues within a few days.  Under certain circumstances this is a disadvantage – for example, in suturing the various fascial planes in order to cure a hernia, it is desirable that the sutures shall not give way until the granulation tissue becomes firm.  For such purposes, catgut is prepared to resist disintegration by soaking it in potassium bichromate or chromic acid for twenty-four to forty-eight hours.  A good method for office use is that of Elsberg, mentioned above, with the addition of one part of chromic acid to one thousand parts of the ammonium sulphate solution.

The longer the catgut remains in the solution of chromic acid or bichromate of potash, the harder it becomes, and the longer will it resist disintegration in the body.  Chromic catgut or chromatized catgut is sold as “ten day catgut,” “twenty day catgut,” etc.  These figures are not very reliable estimates, and should not be too implicitly depended upon.  If the catgut remains too long in the hardening solution, it will become practically indestructible in the tissues of the body.  Buried sutures of such material have often been removed months afterward without their showing the slightest change.

 Kangaroo and Other Animal Tendons

Kangaroo tendon was formerly employed a great deal for the deep sutures in hernia operations.  The tail tendon of the kangaroo naturally splits into round cords which make excellent sutures.  The fibers in the leg tendons have to be pulled apart mechanically, like the fibers in the tendons of the domestic animals.  This gives a rough thread of uncertain strength.  many of the kangaroo tendons sold at the present time have very little value.  Chromic catgut is gradually taking its place.

Non-Absorbable Sutures

Silk

Twisted or braided silk is by far the commonest material employed for sutures.  Some surgeons also employ it for ligatures on account of their fear of infection from imperfectly sterilized catgut.  Black silk is preferable to white for most sutures, as the stitches are more readily seen and removed.  Silk possesses the very great advantage of being easily boiled in water at the time of the operation.  Any good black sewing silk answers the purpose satisfactorily, although many surgeons prefer to buy specially prepared and sterilized silk sutures in sealed glass tubes, costing from fifteen to twenty-five cents each.

For tying large pedicles, floss silk is often employed.  This is a loosely twisted, very flexible, and strong thread, and answers the purpose remarkably well.  The practice of mass ligation, however, is falling into disuse, as it is now generally recognized that the blood-vessels should be ligated separately, and the wounds in the other tissues should be closed by suture with finer thread.

Silkworm Gut

This material, which is familiar to every fisherman, is obtained from the silkworm just before he spins his cocoon.  It is at the time in a viscid state, and is pulled out into a long string and allowed to dry.  This gives a hard, elastic smooth thread, almost like wire.  These threads can be obtained in bundles of one hundred of dealers in fishing tackle.  Such bundles cost from forty cents upward, according to the size and length of the individual threads.  They can be sterilized by boiling in water or by steam; or they can be obtained in sealed glass tubes, costing from fifteen to twenty=five cents each.  Silkworm gut is even less irritating in the tissues than silk, and is an excellent material to employ when deep sutures are required.

Horsehair

Black or brown hairs from the tail of a horse make excellent sutures for skin wounds.  They should be washed with soap and water, and then with alcohol.  When needed they are easily sterilized in boiling water or in steam.  They are not as strong as silk, but they are able to resist all the tension which any suture ought to have.  They can also be obtained ready sterilized, six in a tube, at twenty cents; or dry in bottles or envelopes at a considerably cheaper rate.

Cotton and Linen Thread

Although silk is generally used in preference to other manufactured threads, this is largely a matter of custom.  cotton or linen thread is easily sterilized by boiling, does not irritate the skin, and forms a perfectly satisfactory suturing material.  No one need hesitate to use either in an emergency, nor, for that matter, in his regular practice.  If a colored thread is used, it should have a fast dye, or else it should be boiled long enough to extract so much of the dye as is easily soluble.

Celluloid Thread

Thread dipped in celluloid is often employed in operations upon the stomach and intestine on account of its impervious character.  It is prepared in the following manner:  A gray linen thread is boiled in one per cent solution of carbonate of sodium, wrapped in sterile gauze, dried in hot air, and then dipped in a solution of celluloid which is heated in a hot air sterilizer.  I is dried and then placed in a sterile receptacle until wanted.

Silver Wire

Pure silver wire is used for suturing bones, and also by some operators for sutures of the cervix, perineum, harelip, etc.  The sizes usually employed are Nos. 24 or 30.  Such wire costs about two dollars and fifty cents an ounce.  It is also used in the manufacture of filigrees, employed in some operations for hernia.  Other kinds of wire, and notably an aluminum bronze, are employed a good deal in Germany, but have never obtained much popularity in this country.  Antiseptic powers are claimed for them by their advocates.

Suture Allergy vs Suture Reactivity

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

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)

Bioactive Sutures

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

H/T to MedGadget who’s post introduced me to “bioactive sutures.”  What a great idea by the Johns Hopkins biomedical engineering students! 

……have demonstrated a practical way to embed a patient’s own adult stem cells in the surgical thread that doctors use to repair serious orthopedic injuries such as ruptured tendons. The goal, the students said, is to enhance healing and reduce the likelihood of re-injury without changing the surgical procedure itself.

The project team of 10 undergraduates focused on Achilles tendon injuries which require repair in approximately 46,000 people in the United States every year.   The surgery may fail in as many as 20%.  Recovery can take up to a year even with successful surgery.  If this new suture speeds healing and lowers failure rates – what potential! 

At the site of the injury, the stem cells are expected to reduce inflammation and release growth factor proteins that speed up the healing, enhancing the prospects for a full recovery and reducing the likelihood of re-injury. The team’s preliminary experiments in an animal model have yielded promising results, indicating that the stem cells attached to the sutures can survive the surgical process and retain the ability to turn into replacement tissue, such as tendon or cartilage……………

As envisioned by the company and the students, a doctor would withdraw bone marrow containing stem cells from a patient’s hip while the patient was under anesthesia. The stem cells would then be embedded in the novel suture through a quick and easily performed proprietary process. The surgeon would then stitch together the ruptured Achilles tendon or other injury in the conventional manner but using the sutures embedded with stem cells.

Suture Allergies Revisited

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Over the last few months I have received several e-mails from patients with suture reactions, possibly allergic reactions. I say possibly because not being their treating physician I can't verify them, but by the descriptions they seem real. I reviewed this topic last year, but felt the need to revisit it. Hope you don't mind me sharing with you.

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).

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
• 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

Barbed Sutures

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

I am seeing more advertisements and a few articles in journals regarding barbed sutures. I find the concept interesting. The supposed benefits include:

• less time to close the incision as there is no tying
• multiple layers (subcutaneous and dermis) can be closed together with one continuous suture
• less suture "spitting" as no knots to be dissolved
• less or no strangulation of tissue as there are no knots tied
• no need for an assistant to "follow" the suture

The Barbed sutures are sutures with small projections that radiate outward from the center of the suture. For example, the suture may be made by cutting the surface of 2-0 polypropylene to create small projecting barbs, all angled in one direction and helicoidally arrayed around the length of the suture core. The core of the barbed suture is then equivalent to a 4-0 polypropylene suture. Barbed sutures come in both permanent ( polypropylene and nylon) and dissolvable (polydioxanone) forms.

While Barbed sutures offer the promise of minimally invasive facial suspension (ie Threadlift, Featherlift , etc), I am more interested in how they might be used in vertical scar mastopexy or abdominoplasty or other body contouring procedures. Also, the use in tendon repair (no strangulation of the tendon) is worth watching.

Here are some basic instructions found on the Quill SRS Website:

QuillTM SRS contains bidirectionally oriented barbs to anchor tissues and does not require knots to approximate opposing edges of a wound. Tying of knots with QuillTM SRS will damage the barbs and potentially reduce their effectiveness. For the bidirectional forces to be created and for the device to function properly, both sides of the QuillTM SRS must be engaged in the tissue. Additionally, when completing placement, an additional J-stitch or bite of tissue lateral to the end of the incision is required to lock the device in place.

Avoid contacting the QuillTM SRS with other materials (e.g. surgical gauze, drapes, etc.) in the surgical field to prevent ensnaring on the barbs. If the barbs catch, carefully pull the material in the opposite direction of the needle to disengage it from the barbs.

When using QuillTM SRS subcutaneously, the device should be placed as deeply as possible in order to minimize erythema and induration normally associated with absorption.

Care should be taken to avoid damage when handling. Avoid crushing or crimping the suture material with surgical instruments, such as needle holders and forceps. Do not pull the QuillTM SRS out of the package by the needles as this can cause the barbs to catch on one another. Do not attempt to remove memory in the polymer by running fingers down the suture material as this can damage the barbs.

I would think that some down sides to using barbed sutures might be:

• need to "never" redo a stitch placement as you can't "back" the suture out
• ability to "feel" the barb if placed to superficial
• can patient's "feel" the barb if to near the muscle layer?

I'd like to know more about these sutures. Has anyone used them?
APTOS Thread Website
Quill SRS Website
REFERENCES
Evaluation of a Novel Technique for Wound Closure Using a Barbed Suture; Plastic & Reconstructive Surgery. 117(6):1769-1780, May 2006; Murtha, Amy P. M.D.; Kaplan, Andrew L. M.D.; Paglia, Michael J. M.D., Ph.D.; Mills, Benjie B. M.D.; Feldstein, Michael L. Ph.D.; Ruff, Gregory L. M.D.
Evaluation of a Novel Technique for Wound Closure Using a Barbed Suture: Reply; Plastic & Reconstructive Surgery. 120(1):350, July 2007; Ruff, Gregory L. M.D.
Barbed Sutures: A Review of the Literature; Plastic & Reconstructive Surgery. 121(3):102e-108e, March 2008; Villa, Mark T. M.D.; White, Lucile E. M.D.; Alam, Murad M.D.; Yoo, Simon S. M.D.; Walton, Robert L. M.D.
Caveats for the use of suspension sutures; Aesthetic Plast. Surg. 28: 170, 2004; Hudson, D. A., and Fernandes, D. B.
Treating the Aging Neck; PSP Innovation in Aesthetic Medicine, November 2007; Malcolm D. Paul, MD, FACS
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