The past few days have shown me some small pleasures of my practice. I spent about 20 minutes sewing together the hand and forehead of a sweet elderly lady who fell down while being evacuated from a nursing home fire. Her skin, like tissue, came together in fragile folds; my hands moved easily with the needle and thread thanks to so many years of practice, so many hundreds of feet of sutures placed. Although I must admit that my cataract-stricken right eye left my depth perception imperfect in a way that bonded me to her. (Sitting here, with no reading glasses, I can close my left eye and all I see is a hint of lines on the page, but no letters.)
My sweet little lady smiled at me, nervously, tentatively, but was comforted at the prospect of going back to her bed. Her son eased her fear with jokes, then took her home. Read more »
*This blog post was originally published at edwinleap.com*
In the comments, a question was posed from reader “Seattle Plastic Surgery on Lake Union” (an online handle that is as unwieldy as it is descriptive). He asks:
I would like to hear your opinion on a topic that is rapidly growing near and dear to my heart…the scenario is thus:
I’m on call, the local plastic surgeon, for the local ER. You are seeing a nice family with a child that has sustained a simple facial laceration. No fractures, no missing tissue, just a simple, linear, forhead laceration.
The Mom asks that a plastic surgeon be called to come in from home and close the wound. You reply that you are able to do the closure, the child is medically stable, and that a you are qualified to close the wound. The family presses you: call the plastic surgeon.
Can you tell me, from an ER doc’s standpoint- what is the most appropriate response from the on call plastic surgeon? Read more »
*This blog post was originally published at Movin' Meat*
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 their very 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.
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
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]
Allergies from Suture Material (September 7, 2007)
Suture Allergies Revisited (April 30, 2008)
Suture (June 7, 2007)
Basic Suture Techniques (June 8, 2007)
*This blog post was originally published at Suture for a Living*