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. Â 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.
Indianapolis, Indiana