Wound care is a common issue in the ED. Certainly, not all wounds are created equal. We have discussed eyelid lacerations and tongue lacerations. We have also discussed my favorite wound closure technique: tissue adhesives. While tissue adhesives are pretty awesome, they aren’t appropriate for all scenarios. Sometimes you need sutures. I was taught that you use absorbable sutures to close deep layers and non-absorbable to close the surface. Pretty simple and made sense; however, removal of sutures is not always simple and sedating a child just to remove strings doesn’t seem to make much sense. Recently, there has been an evolving trend that challenges the myth that all skin closure is done with non-absorbable suture. Let us take a minute to digest a Morsel of information about Absorbable Sutures for primary wound closure.
- The primary purpose of sutures is to hold apposing tissues together to facilitate healing, while minimizing scar and complications.
- There is no single suture material that is suitable for all wounds. [Dennis, 2016]
- Choice of suture depends upon a number of factors:
- Wound tension (strength of suture)
- Depth and number of tissue layers involved
- Presence of edema
- Expected time of wound healing
- Inflammatory reactions from suture
- Ease of use
- Security of knot
Absorbable Sutures: Examples
- Absorbable suture = suture that undergoes degradation and absorption in tissue.
- Polyglactic 910 (ex, Vicryl) [Hochberg, 2009]
- Retains 65% of its tensile strength at 2 weeks; 40% at 3 weeks.
- Complete absorption occurs between 60 and 90 days.
- Very useful for completely buried sutures apposing deep tissues.
- Rapid Absorbing Coated Polyglactic 910 (ex, Vicryl Rapide) [Hochberg, 2009]
- Partially hydrolyzed and processed to speed up absorption.
- 50% tensile strength at 5 days; 0% at 2 weeks.
- Sutures can be absorbed in 10-14 days.
- Poliglecaprone (ex, Monocryl) [Hochberg, 2009]
- Retains ~40% of its tensile strength at 2 weeks.
- Absorption is in ~90-120 days.
- Has significant initial tensile strength, so closure can be done with a suture 1-2 sizes smaller than normal.
- Good for subcuticular closure.
- Gut [Hochberg, 2009]
- Made from twisted strands of purified collagen prepared from sheep or cattle small intestine.
- Comes in three varieties: Chromic, Plain, and Fast-Absorbing
- Chromic gut is tanned to decrease absorption rate. Absorption in 21 days.
- Plain gut is untreated. Absorption in 10-14 days.
- Fast-absorbing gut is head-treated to increase absorption rate. Absorption in 7 days.
- Fast-absorbing gut has less tensile strength than plain gut.
- Fast-absorbing gut is used primarily for epidermal suturing.
Absorbable Sutures: For Lacerations
- Controversy exists over using absorbable sutures for epidermal wound closure.
- Some avoid absorbable sutures due to “concerns” for increased scar formation, increased wound dehiscence, and increased wound infection.
- Others advocate for absorbable suture use, particularly in children, as it may avoid the challenges of having to remove sutures.
- There are several studies that demonstrate the utility and safety of using absorbable sutures, specifically in children. [Tejani, 2014; Luck, 2013; Luck, 2008; Karounis, 2004]
- Vicryl Rapide has been shown to be useful in closure of simple lacerations on the trunk and extremities. [Tejani, 2014]
- Fast-absorbing gut showed no significant clinical difference to non-absorbable suture for facial lacerations at 3 months. [Luck, 2008]
- Fast-absorbing gut did not have higher rates of wound infection or complications compared to non-absorbable. [Luck, 2008]
- Plain gut has also been found to be an acceptable alternative to non-absorbable suture for pediatric wound repair. [Karounis, 2004]
- So it would appear that the concerns about increased scar formation, wound dehiscence, and infection should not be as concerning as we may have been taught.
Absorbable Sutures: Proposed Strategy
- Always take care to anticipate the patient’s pain/anxiety to help avoid causing post-wound repair PTSD!
- Default to using absorbable sutures in children when sutures are required.
- Consider using Vicryl Rapide for extremities and trunk.
- Consider using Fast-Absorbing Gut for facial lacerations.
- If there is too much tension at the epidermal wound edges, consider deep layer closure.
- This may then allow for absorbable suture closure at the surface.
- Obviously, some wounds will still require non-absorbable sutures (ex, over joints, high tension).
- Still recommend removal of absorbable sutures at the appropriate time interval.
- This is particularly useful in areas that heal more rapidly than the suture dissolves (i.e., the face).
- Removing the suture may help to continue to minimize scar formation risk.
- If the child will not easily and calmly tolerate suture removal, the presence of the absorbable sutures allows for the suture removal procedure to be aborted.
- Simply trim down the sutures as much as allowed.
- Can recommend some gentle massage to help speed up the absorption process.