Whether it is the closure of a surgical incision or that of a laceration repair, a well-aligned wound approximation is the hallmark of a plastic surgeon. The best scar outcomes can only come from a beautifully closed wound. While good wound closure is not always a guarantee of a great scar result, poorly repaired tissue edges are a certainty to have a poor scar afterwards.
No matter how a wound is closed, it requires suture materials to do so. One of the classic plastic surgery suture techniques is that of the subcuticular or intradermal wound closure. While not exclusively done by plastic surgeons, it is more widely used by plastic surgery than any other surgical specialty. The other common method used in skin closure by plastic surgeons are interrupted buried dermal sutures. Usually they are done in combination for the dual effect of strength and gross approximation (interrupted dermal sutures) and meticulous skin closure. (subcuticular suture)
While these skin repair techniques provide excellent skin edge approximation and avoids undesired suture track marks, it does leave a fair amount of suture material at the most superficial layer of the tissues. While most of the suture material used for these closure techniques is resorbable, this does not mean that they always go away without causing some disturbing complications.
One of the most vexing wound problems from the incision line after surgery is the extruding suture/abscess. It is confusing for patients because of when it develops. Often not occurring for weeks to months after surgery, patients assume that they have an infection or a deeper wound problem. Patients understandably assume that wound healing is linear, meaning each day the wound appearance should continue to get better, but it isn’t. When an apparent well healed incision line develops an opening, drainage or a spot abscess weeks after surgery, patients are confused as to why it has occurred.
The spitting or extruding suture is a direct result of the intradermal and/or subcuticular wound closure techniques and is the ‘dark side’ to their use. They occur due to a combination of factors which includes the volume of suture material in the most superficial layer of the skin, the partial devascularization of the wound edges (with the subcuticular method) and the body’s inflammatory response to their materials and their degradation. In essence, the body thinks the sutures are foreign materials and an inflammatory response develops which is how they eventually resorb.
If the sutures were deep in the tissues this bodily reaction would never pose a problem. But in the skin, a small pocket of fluid around the knotted suture develops (which may progress to a small abscess like a pimple or pyogenic granuloma) and it begins to show through the suture line. A ‘hot spot’ will develop which will usually erupt through the skin and drain. Because the resorption time of all sutures used for these wound closure methods takes often six months or longer, the body’s inflammatory response occurs far quicker than the suture’s ability to resorb. When these suture extrusions involve a subcuticular stitch, it can act as a wick spreading the infection a great distance along the wound closure line.
Treatment of extruding sutures and their abscesses ultimately requires that the suture be removed, or the problem will continue to fester. In some cases, the suture extrudes innocuously many months later without any inflammatory reaction. This can be harder to appreciate because many of these suture materials are colorless and the only sign is a small opening along the incision line.
The most likely problems with extruding sutures is on long incisions from body contouring procedures. Tummy tucks, breast reductions, thigh lifts and arm lifts, all which involve extensive wound closures, are the most common procedures where these types of suture reactions are most likely to be seen. Why some patients get none, experience just a few and others have large number of extruding sutures in these wound closures is not clear.
Dr. Barry Eppley
Indianapolis, Indiana