It is common practice to have sutures from surgery or a laceration repair removed after 7 to 10 days, if one has stitches of the non-dissolveable type. But the main reason that external sutures are removed is to prevent a type of scarring known as tracking or railroad marks, not because the wound is actually healed very well. The outermost layer of the skin, known as the epithelium, bridges or joins back together quite quickly in a week or so. But the deeper layers of the wound have not joined back together by even three weeks after surgery, having about 10% of normal tissue strength. This is why plastic surgeons place deeper sutures on the underside of the skin which is where the real support in suture repair is created. These internal dissolveable sutures take months to break down, giving the wound plenty of time to knit together and develop more normal tissue strength.

The use of sutures is an absolute must for the closure of any type of incision in plastic surgery. Careful approximation of the wound edges and providing underlying layers of support by sutures are what makes the resultant scar from any elective plastic surgery procedure usually favorable and minimized. While the use of sutures  on the underside of the skin (dermis) or through the dermis (subcuticular) are integral to a nice closure and scar, they also are the source of frequent incisional problems that can be quite distressing to patients.

The use of buried sutures in wound closure is very convenient for patients as they are not seen nor require secondary removal. This is a great relief to most patients. When it comes to such operations as facelifts, breast lifts and reductions, tummy tucks and many other body contouring procedures, the amount of buried suture material can be considerable due to the length of incisions involved. While much of this suture material does indeed break down and is resorbed, this does not always occur. This is uniquely due to the superficial location (dermis) of the sutures. This suture location is prone to a common problem known as ‘spitting sutures’ or ‘spitters’. These appear like inflamed pimples or hot spots along the suture line weeks to months after surgery.

Patients understandably interpret these delayed eruptions along the incision line as an infection of their surgery. These developments are a frequent source of phone calls and concern to the plastic surgeon. While we would prefer not to see these minor suture problems they are inevitable at some level of occurrence for most patients. Understanding why they occur is helpful to putting their development in perspective.

While dissolveable sutures do eventually break down and go away, this is a process that takes time. How much time depends on the type of dissolveable material used. Most such materials today are polymers or various forms of plastic. In the days gone by, the material composition was ‘catgut’ or some form of synthetic or animal collagen. Dissolveable sutures today are mainly synthetic polymers because of their superior strength and handling properties. But they usually take longer to dissolve which is in the range of months up to a year after implantation.

But the time dissolveable sutures take to go away is affected by where they are placed. Sutures in the dermis will take longer to go away than if similarly placed in deeper tissues like muscle. But ‘spitting sutures’ are not primarily caused by this factor. Rather it is the very close location to the skin and the outer surface that can cause the body to react to them like a foreign body. The body reacts to the knots of the suture (a bigger mass of material than a straight line of sutures) through an inflammatory process and works to extrude or expel the stitch…long before the dissolveable process takes place.

This attempt by the body to expel dissolveable skin sutures creates a classic source of presentation. They appear weeks to months later at a time when the patient believes their incision is completely healed or nearly so. The most common time to see spitting sutures is between 3 and 8 weeks after surgery. It takes time for inflammation to develop and create the problem. They initially appear as a red or purple spots along the incision and may turn into a spot infection that looks like a pimple and may drain fluid or even pus. Squeezing on the ‘pimple’ will release the fluid and can even force the suture knot out. These are more small inflammatory problems and should not be confused with a more significant wound or surgical site infection.

The solution to the spitting suture problem is to remove the nidus or the cause, the suture itself. This is best done by the plastic surgeon as some rooting around or digging may be required to get it off. Despite how the area along the incision may look when it is extruding, this rarely causes any significant adverse scarring.   

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Today’s news was marked by the traumatic injury to President Obama while playing a pickup game of basketball. He was inadvertently elbowed in the mouth, resulting in a lip laceration. This type of sports injury, particularly in basketball, is not uncommon. The force of the elbow presses the lip against the solid bumper behind it known as the teeth. Between the elbow and the teeth, the lip has little chance being the less stout of the three. A laceration invariably results, splitting the pink vermilion on the outer lip. The lip laceration will usually extend inward on the inside of the lip because the mucosa of the lip lining is quite soft. The laceration may also cross the border of the vermilion outward onto the visible skin next to the lip.

While unfortunate, President Obama will go on and heal uneventfully. The lip will be swollen for a week or so but the lip will mend itself. What interested me most about this story, however, is what his press secretary said afterward. He described the lip repair as being done with ‘small monofilaments which took longer to do but will heal with less scar’, to paraphrase his comments.

He no doubt was specifically talking about the use of fine small sutures to meticulously put the lip back together. But what is a monofilament suture and why was it used? Monofilament sutures are made from a single strand of non-resorbable plastic material. This makes for a smooth slick strand of material of very small size. (calling it a thread would be inaccurate since a thread is a braided strand which is not a smooth surface) The benefits of a monofilament suture comes from this smooth surface. This makes it easier to pass the suture through the tissues with less trauma. Its smooth surface also makes it more resistant to harboring microorganisms and cause wound infection since there are no nucks and crannies for the bacteria to get into and multiply. The surface is simply too smooth. This smooth surface also makes them easier to remove as they slide out better.

Monofilament sutures are commonly used in plastic surgery of the face, whether it be laceration repair or for closure of elective incisions. The size of a suture is given in O sizes and is reflective of its thickness. In the face, small sizes of 5-0 (.1mm in diameter) or 6-0 (.07mms in diameter) monofilament sutures are used. Because of this small size, it is understandable why they must be more meticulously placed and take longer to do. These very small sutures can be left in a little longer than a week if necessary as the potential to leave visible tracks (holes were the sutures originally were) is not significant with such small diameter sutures.

The President’s monofilament lip sutures will likely be removed in 7 to 10 days. Will this injury leave him with a visible scar? There is no way to know for sure right now but the use of small monofilament sutures gives him the best chance to have the best outcome from this injury.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis Indiana

While suturing traumatic wounds and surgical incisions closed is a routinue part of every surgical specialty, doing so in plastic surgery is a near art form. One of the factors that differentiates plastic surgery technique is how the skin level is closed. Most commonly it is done using two different types of sutures, individual buried sutures in the dermis (the underside of the skin) and then a top layer placed either into the skin (subcuticular) or outside sutures. (interrupted or running)

This skin suturing method provides good strength during the healing process and a better-looking scar long-term. Despite these advantages, there are some very typical short-term issues that will occur in almost all patients with these types of sutures at this skin level. And the culprit is exactly what provides the advantages…buried dissolveable sutures.

While dissolveable sutures do go away with time, some longer than others based on their chemical composition, a different reaction can occur at the skin level. Most dissolveable sutures are tested and their resorption rates and characteristics studied at deeper tissue levels, usually muscle. The resorption process occurs through a combination of water absorption and a natural inflammatory and breakdown process. In deeper tissue levels, this process is never seen and it occurs uneventfully. In the skin, however, this process can often become unmasked and evident to the patient.

Sutures in the dermis of the skin can cause a localized inflammatory reaction known as a stitch abscess or ‘spitting suture’. This occurs because of the close proximity of the suture to the outer surface of the skin. As the body begins to react to the presence of the suture, a localized inflammatory reaction can develop. This inflammation can cause the suture to appear on the outside as redness and even the development of a small amount of pus. This occurs because there is little tissue between the suture and the outside. As the reaction occurs around the suture, the pressure builds due to the fluid collection until it either raises the overlying epithelium or actually breaks through. The closest analogy is like that of a pimple. They appears as red spots along the suture line and their appearance often develops at a classic time period between 3 and 6 weeks after surgery. (although they can appear much later)

These skin suture reactions can be very disturbing to patients for several reasons. First, they are unexpected and will make the patient think that something is wrong and their surgery site is infected. Over the years in my Indianapolis plastic surgery practice, I have gotten many calls about these problems.  Secondly, they occur at a time when patients understandably feel that they should be getting better and they are out of any ‘danger.’ And lastly because they affect the suture line, it is believed that the scar may end up worse.

These benign but disturbing localized suture reactions do not usually cause any long-term wound healing or scar issues. They are either self-resolving or can be easily cured by removal of the offending suture(s). Antibiotics are rarely needed to make them get better, suture removal is always curative. Some patients will have none, other just one or two, and rarely someone will have numerous suture extrusions. It is important for patents to realize that that stitch reactions are normal and are the result of skin suturing techniques and how the resorbable suture process naturally occurs.     

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

There are few, if any, plastic surgery procedures that do not require some form of skin closure with sutures. The methods that plastic surgeons use to close skin are somewhat different from many other surgical specialties. Given that the final appearance of the scar is of paramount importance, supporting the wound edges for a prolonged period of time from underneath is the key to achieving this aesthetic goal. This is known as dermal (intradermal) or under the skin suture techniques.

Because the sutures are placed under the skin, they usually are of the dissolving or resorbable type since removing them would be difficult. And while many of these sutures do dissolve and go away undetected, some do not and cause a reaction. Known as a ‘spitting suture’, they appear as a red or inflamed spots along the incision line weeks to months after surgery. Rarely, it may even happen a year or more later. Sometimes the suture erupts through the skin cleanly, other times it develops into a pimple-like abscess.

But placing sutures right under the skin, there is always the risk of a foreign body reaction. Since a suture is technically a foreign object, one’s body may react to it in an effort to expel it…long before the suture or stitch is designed to ever go away on its own. This is a unique phenomenon of being right under the skin.

The development of sutures and how they resorb is not really based on their use in skin. Most animal studies of the behavior of resorbable sutures is done on deeper tissues such as muscle which has a better blood supply and no risk of skin extrusion. By placing sutures in the skin, there is very little tissue between it and the skin surface should any reaction to it occur.

The appearance of a spitting suture or a suture granuloma or abscess can be confusing for many patients. They often feel that something is going wrong with their surgery or they feel they are developing an infection.  For some patients, they feel that they are allergic to the type of suture used. Because the incision can look so good for some time after surgery before these suture problems develop, patients understandably interpret them as a ‘developing problem’.

In reality, suture reactions are very common and will not occur for some time after surgery when actual healing starts to take place. They are not a sign of a wound infection and are a localized small nuisance, even if one develops several of them along the incision. The solution to them is to remove the underlying suture or knot as it will continue to fester until this is done. They can easily be picked out in the office. While they may make the incision look red and angry where they have erupted, they usually do not make the scar look worse once they have settled down and healed.

Such suture reactions are particularly common in plastic surgery procedures which involve long incisions where a lot of sutures are needed. Cosmetic body operations such as tummy tucks, body and thigh lifts, and breast lifts and reductions are particularly prone to these suture problems. Such suture problems are more more uncommon in facial procedures.      

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis