A wide variety of suture materials are available, all with variable handling characteristics, tissue reactivity, absorption characteristics, and costs. While much attention is paid to suture material, the needle may be as or more important than the suture material itself in promoting an ideal surgical outcome. Needles vary by manufacturer and even by suture material, and utilizing the most appropriate needle for the task is critical. Even the most accomplished surgeon will perform in a less-than-ideal fashion if their instruments or needle choices are flawed.

Most needles used for skin and soft tissue reconstruction are 3/8 circle in diameter, and most needles used for skin and soft tissue reconstructions are reverse cutting in nature (Figure 3-1). There are, however, important exceptions to this rule. For example, a semicircular P-2 needle may be used for narrow closures, such as those sometimes encountered on the nose, and a cutting needle, with the sharp edge on the inside of the curve, may be useful for nasal reconstruction where the thin atrophic dermis may be cut by the superficially coursing outside of the needle.

The two largest manufacturers of suture material used in cutaneous surgery are Ethicon and Covidien. While suture size is governed by USP guidelines (the larger the number of zeros, the smaller the suture), needle size and configuration is largely proprietary. Thus, the surgeon must be comfortable understanding the various needle sizes and configurations of the various manufacturers. Suture material packaging does include a cross-sectional image of the needle, permitting some comparison between companies. Of note, Covidien does not (except on its website) refer to any of its needles as reverse cutting; instead, they label cutting needles as conventional cutting and reverse cutting needles as cutting (Table 3-1). These distinctions are important when choosing suture, though many suture type and needle combinations are only available with a finite number of permutations. Since cutting and reverse cutting needles have a triangular tip, the orientation of the cutting end is indicated by whether the triangle on the box is pointing up (cutting) or down (reverse cutting).

The material used to make the needles themselves also varies considerably between manufacturers, as proprietary alloys are used to maximize strength and durability. While Ethicon and Covidien products are used most often in skin and soft tissue reconstruction, many other reputable companies manufacture suture material, and individual preferences may vary widely (Table 3-2).

Any monofilament suture, including absorbable sutures, may be used for transepidermal suture placement. Thus, utilizing a monofilament absorbable suture may permit the use of a single suture pack for both buried and epidermal sutures.

Many suture characteristics are commonly discussed, including handling, memory, pliability, knot security, tissue reactivity, and others. There are subtle differences between the handling characteristics of different suture materials, most modern options fall well within the realm of utility, so that while the handling of silk, for example, is clearly superior to the handling of nylon, even nylon handles very well. Similarly, certain materials, such as catgut, may be highly reactive, though the more frequently used formulations, such as chromic gut and fast-absorbing gut, do not lead to enough inflammation to make a marked clinical difference in most situations. For the most part, monofilament sutures lead to less tissue drag, and therefore are useful with running techniques, while braided sutures provide excellent handling and knot security, and are therefore useful for interrupted buried sutures. With improvements in materials, the distinction between outcomes now likely relates more to suturing technique than to choice in suture materials.

Vicryl (polyglactin 910)

Vicryl is one of the most frequently used suture materials in skin and soft tissue reconstruction. It is a braided, coated suture material that retains its strength for approximately 3 weeks and is completely absorbed in less than 3 months. It has excellent handling characteristics and only mild tissue reactivity. Recently a faster-absorbing variation, VicrylRapide, was developed, which loses its strength entirely in less than 2 weeks and may be seen as an alternative to fast-absorbing gut suture when suture removal is not desired. An antibacterial-coated variation is now also available in the market.

Polysorb (glycolide/lactide copolymer)

This is a braided absorbable suture, similar to Vicryl. It provides similar handling and knot security while ostensibly providing slightly improved initial tensile strength when compared with Vicryl. Its absorption characteristics are also similar to Vicryl. Velosorb Fast has also been developed as an alternative to VicrylRapide.

Monocryl (poliglecaprone)

Monocryl, often seen as a monofilament alternative to Vicryl, is another popular suture material choice. It is more expensive than Vicryl, has excellent handling characteristics for a monofilament suture, and loses its strength in less than 1 month, though complete absorption takes 3-4 months. As with Vicryl, an antibacterial option is also now available.

Maxon (polyglyconate)

Maxon is a long-lasting monofilament absorbable suture; while it loses some strength already after 3 weeks, it takes 6 months or more for the suture material to be entirely absorbed, making this a good choice when long-term strength retention may be helpful. It has good handling characteristics, though the slow absorption times should be taken into account if dyed suture material is used, as the suture may be visible if placed in a running subcuticular pattern.

Polydioxanone (PDS)

Polydioxanone I and II are very long lasting monofilament absorbable sutures. They are useful when long-term strength retention is critical. PDS II was developed as a better-handling alternative to PDS I, which was criticized for its less-than-ideal handling characteristics. It retains strength for an extended period of time, with 50% strength retention at 5 weeks, and may take more than 6 months to absorb.

Biosyn (glycomer 631)

Biosyn is another monofilament absorbable suture. It has very good handling characteristics and outstanding initial tensile strength. It retains its strength for at least 3 weeks and takes up to 4 months to absorb completely. If Biosyn is used for superficial closures, the undyed version may be preferable.

Caprosyn (polyglytone 6211)

Caprosyn is a fast-absorbing monofilament suture, often seen as an alternative to Monocryl. It absorbs completely in 8 weeks, while retaining tensile strength for 7-10 days postoperatively. It is therefore useful in low-tension closures, such as those on the face, where rapid suture material breakdown is an advantage.

Catgut

Plain gut is derived from bovine or sheep intestines, and therefore breaks down by enzymatic degradation, rather than the hydrolysis which breaks down synthetic absorbable sutures. Chromic gut is a longer-lasting version of gut, while fast-absorbing gut is heat treated to speed up absorption. On a practical level, fast-absorbing gut may be useful for closures when transepidermal sutures are desired for wound-edge apposition but where suture removal is impractical or inconvenient. Gut does lead to more tissue reactivity than other absorbable sutures and has a tendency towards breakage after multiple passes through tissue (Table 3-3).