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CHAPTER 8

Instruments, Suture
Materials, and Closure
Choices
Key Practice Points
nn Lacerations

and wounds can be managed with a few well-chosen


instruments: needle holders, tissue forceps, and scissors.
nn Each instrument requires special handling (described in this chapter) to
close lacerations and repair wounds correctly.
nn Proper instrument technique reduces tissue damage and excessive
scar formation.
nn There two basic suture types: absorbable for deep, subcutaneous
closure and nonabsorbable for superficial skin closure.
nn In recent years, however, absorbable sutures with rapid absorbing
properties have been used for superficial skin closures.
nn Studies have shown that there are no cosmetic differences between
absorbable and nonabsorbable superficial skin closures.
nn Older suture types, such as silk, cause greater tissue reaction than do
newer synthetic materials.
nn Reverse cutting needles are atraumatic and are recommended more
highly than older, tapered needles.

It is not necessary to have large numbers of instruments and suture materials for emergency wound care. Wounds and lacerations can be managed with three or four well-chosen instruments and a few wound closure products. Although the type of instruments
remains relatively constant, each wound has differing requirements for wound closure
materials. Absorbable and nonabsorbable sutures and a variety of wound tapes, staples,
and tissue adhesives can be selected according to the specific patient problem. The following are guidelines for the selection of suture materials and the choice and proper
handling of instruments. Tapes, staples, and adhesives are discussed in Chapter 14.

BASIC INSTRUMENTS AND HANDLING


Most wounds can be cared for with the following set of instruments: needle holders, tissue forceps, and suture scissors. For more complex wounds that may require revision or
dbridement, iris (tissue) scissors, hemostats, a knife handle, and appropriate knife blades
might be required. A bewildering array of instruments is currently available through the
major suppliers of surgical instruments, but only the types and configurations of instruments necessary to manage wounds and lacerations are discussed here. Also, numerous
disposable instrument sets meet the needs of many emergency wound care problems.
82
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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

Needle Holders

Because most lacerations are closed with relatively small suture materials, the needle
holder need not be bulky or large. A 412-inch needle holder can accommodate most
curved suture needles. Occasionally, large needles are used, and a 6-inch needle holder
is necessary.

Technique for Handling Needle Holder

Just as important as the choice of needle holder is the technique used for holding and
arming it with the needle. Figure 8-1 shows the right way and the wrong way to hold
the instrument during introduction of the needle into tissue for routine emergency

Correct

Incorrect

Figure 8-1. Technique for properly holding the needle holder. A, The correct way allows for proper needle

entry into the skin. B, The incorrect waythe finger holes are not used when introducing the needle holder
into the skin.

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

Figure 8-2. Technique for arming a needle holder. The needle is held approximately one third of the way from

the swage and is grasped at the tip of the needle holder. The angle of the needle to the holder is exactly 90 degrees.

l aceration closure. The rings are used only to clamp and unclamp the jaws by closing
and releasing the locking mechanism. When introducing the needle into the skin, better
precision can be gained by grasping the needle holder close to the jaws in the manner
illustrated. This precision is particularly important when closing lacerations on the face.
The needle holder is armed with the needle by closing the tip of the jaws onto the
body of the needle (Fig. 8-2). If the needle is pushed farther back into the jaws of the
instrument, the curve is flattened, significantly weakening the needle and making it susceptible to breakage. The needle itself is grasped at right angles, approximately one third
of the way down the body shaft from the end to which the suture is attached (the swage).

Forceps

Grasping and controlling tissue with forceps during skin closure is essential to proper
suture placement. Whenever force is applied to skin or other tissues, however, inadvertent damage to cells can occur if an improper instrument or technique is used. Forceps
still are widely used and are safe when proper technique is applied. The currently recommended forceps are 434-inch forceps with small teeth. Teeth decrease the need to apply
excessive force to grasp and secure tissue. The use of forceps without teeth is discouraged,
because the flat surface of the jaws of the forceps tends to crush tissue more easily.

Technique for Handling Forceps

When handling tissue, the jaws of the forceps are never closed on skin itself. The epidermis and dermis are avoided in favor of the superficial fascia (subcutaneous tissue).
By grasping superficial fascia gently, the wound edge is stabilized for needle placement
and inadvertent damage to the dermis is avoided (Fig. 8-3). Forceps also can serve as a
surrogate skin hook as illustrated. The needle entry point can be immobilized and supported without closing the jaws.
Figure 8-4 illustrates the correct and incorrect methods for grasping forceps. The
pencil grasp technique allows for better control of the forceps and tends to diminish
the amount of force delivered to the tissue.

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

A Correct

B Incorrect

C Correct
Figure 8-3. The correct and incorrect methods for grasping tissue with a forceps. A, The correct way is

to grasp the tissue by the superficial fascia (subcutaneous tissue). B, The incorrect way to grasp tissue is by
crushing the dermis and epidermis between the jaws of the forceps. C, Forceps can be used as a skin hook to
retract or stabilize the wound edge for exploration or suture needle placement.

Scissors

Standard 6-inch, single blunt-tip, double-sharp suture scissors are most useful for cutting sutures, adhesive tape, sponges, and other dressing materials. Because of their size
and bulk, these scissors are durable and practical. Curved and straight, 4-inch iris, or
tissue, scissors are used to assist in dbridement and wound revision. These scissors
are extremely sharp and provide excellent precision in cutting tissue for whatever task.
They are delicate, however, and are not recommended for cutting sutures. Occasionally,
when small sutures have been used in the face area, iris scissors can be used for suture
removal.

Technique for Scissor Tip Control

Whenever scissor tip control is essential, for example, when cutting close to the
knots of deep or dermal closures with absorbable sutures, the technique illustrated
in Figure 8-5 is recommended. The tips of the scissors are brought gently down to
the knot. Just before cutting, the tips are rotated slightly to avoid cutting the knot
itself.

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

Correct

Incorrect

Figure 8-4. The correct and incorrect ways of holding the forceps manually. A, The forceps is held in the
pencil grasp fashion as the correct technique. B, The incorrect technique is to grasp the forceps.

Hemostats

Hemostats have three functions in emergency wound care. Originally, hemostats


were designed to clamp small blood vessels for hemorrhage control. Another use is
to grasp and secure superficial fascia during undermining and dbriding wounds.
Finally, this instrument is an excellent tool for exposing, exploring, and visualizing
the deeper areas of a wound. Two types of hemostats are commonly used in wound
care. For general use, the standard hemostat is recommended. Finer work in small
wounds is often best served by the 5-inch curved mosquito hemostat with fine serrated jaws.

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

Figure 8-5. Proper technique for tip control for scissors.

Figure 8-6. Examples of retractable no. 11 and no. 15 scalpels. Top, no. 11 in retracted position; middle, no.
11 in open position; bottom, no. 15 in open position.

Knife Handles and Blades

The choice of scalpels can be limited to three blade configurations, no. 10, no. 15, and
no. 11. For safety, the retractable scalpel is recommended (Fig. 8-6). The no. 10 blade is
not usually needed in emergency wound care but occasionally is helpful for larger excisions during wound revision. Commonly used and quite versatile is the no. 15 blade,
which is small and well suited for precise dbridement and wound revision. This blade
is also preferred for foreign-body excision and the intricate work necessary around eyes,
lips, ears, and fingertips. The no. 11 blade is configured ideally for incision and drainage
of superficial abscesses. It also can be used to help remove small sutures such as might
be placed in the face.

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TABLE 8-1
Absorbable
Suture
Materials

Absorbable Suture Materials


Structure

Tissue
Reaction

Tensile
Strength

HalfLife
(Days)

Gut

Natural

++++

++

5-7

For mucosal closures, rarely


used

Rapid absorbing
gut

Natural

+++

++

7-10

Skin closure (face), mucosa

Chromic gut

Natural

++++

++

10-14

For oral mucosa, perineal,


and scrotal closures; can be
annoying to patients because of
stiffness

Polyglycolic acid
(Dexon)

Braided

++

+++

25

For subcutaneous closure;


coated version easier to use but
requires more knots (Dexon
Plus)

Polyglactin 910
(Vicryl)

Braided

++

++++

28

For subcutaneous closure; do


not use dyed suture on face

Polyglactin
910 (irradiated,
Vicryl Rapide)

Braided

++

+++

5-7

Scalp, mucosa, child hand


andface

Polyglyconate
(Maxon)

Monofilament

+++++

28-36

For subcutaneous closure; less


reactive and stronger than polyglycolic acid and polyglactin 910

Poliglecaprone
25 (Monocryl)

Monofilament

++++

7-10

Deep (subcutaneous) closures

Polydioxanone
closures (PDS)

Monofilament

++++

36-53

For subcutaneous that need


high degree of security; stiffer
and more difficult to handle
than polyglycolic acid or
polyglyconate

Uses and Comments

SUTURE MATERIALS
Several criteria must be met before a particular suture can be used to close a laceration.
A good suture must have appropriate tensile strength to resist breakage, good knot
security to prevent unraveling, pliability and workability in handling, low tissue reactivity, and the ability to resist bacterial infection. Currently, there are two main classes
of suture materials: absorbable and nonabsorbable. Tables 8-1 and 8-2 summarize the
characteristics of suture types. In general, absorbable sutures are placed deep for closure of dead space in large wounds or to reduce closure tension. Nonabsorbable sutures
are used most commonly for percutaneous or skin closure. However, there has been a
growing trend toward using alternatives for skin, superficial closure (including staples),
wound adhesives (see Chapter 14), and absorbable sutures. Table 8-3 lists recommendations for suture and closure materials by anatomic site.
Absorbable sutures have been traditionally used for deep closures to close dead
space and to lessen tension of the superficial skin sutures. Numerous studies have demonstrated that absorbable sutures have a cosmetic outcome equal to nonabsorbable
sutures when used to close superficial skin layers.1-6 Vicryl Rapide has been effective in

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices


TABLE 8-2

Nonabsorbable Suture Materials


Tissue
Reaction

Tensile
Strength

Knot
Security

++++

++

++++

Easy to handle but has increased


potential for infection

Monofilament

++

+++

++

Commonly used in skin closure


but high degree of memory;
requires several throws for
secure closure

Polypropylene (Prolene)

Monofilament

++++

High degree of memory,


lowtissue adhesion; good for
subcuticular pull-out technique

Dacron
(Mersilene)

Braided

+++

++

++++

Easy to handle, good knot


security; similar to silk but less
risk to tissue for inflammation
and infection

Polybutester
(Novafil)

Monofilament

++++

++++

Excellent handling, strength,


and security; expands and
contracts with changes in tissue
edema

Material

Structure

Silk

Braided

Nylon
(Ethilon,
Dermalon)

Uses and Comments

closing scalp incisions when compared with nonabsorbable sutures.3 Patients expressed
considerable satisfaction with not having to have stitches removed. Fast-absorbing gut
and Vicryl Rapide has been successfully used to close adult facial lacerations.2,5 Much of
the experience with absorbable suture superficial skin closure has been in children.4,6,7
The cosmetic differences between absorbable and nonabsorbable sutures were not significant. One study did show a difference at 6 weeks, but the difference disappeared by
6 months.1 At 1 month, some Vicryl-sutured wounds, particularly on the hand, were
more erythematous compared with nylon-sutured wounds. By 6 months the erythema
had disappeared, and the wounds could not be distinguished from one another. An
important characteristic of sutures of any type is that they cause suture marks if left in
the skin longer than 10 to 14 days. If absorbable sutures on the face have not fallen out
by 7 days, the patient or parent can be instructed to gently rub them off with a moistened sponge or cloth.

Absorbable Suture Materials


Polyglactin 910 (Vicryl, Vicryl Rapide)

Polyglactin 910 is a braided synthetic polymer used for deep closures. It has similar
dry tensile strength compared with polyglycolic acid (Dexon) but maintains in vivo
function and strength somewhat longer. However, polyglycolic acid has greater knot
security. Polyglactin 910 can be modified by irradiation (Vicryl Rapide), which greatly
increases its tissue absorption.8 Its half-life is only 5 to 7 days, and the sutures fall off
in 10 to 14 days. This quality makes Vicryl Rapide ideal for closure of oral mucosa,
face, scalp, scrotal skin, and perineum. The suture can be placed, and because of rapid
absorption, no return visit is necessary for removal.

Polyglycolic Acid (PGA) (Dexon, Dexon II)

PGA is a synthetic, braided polymer. When compared with plain or chromic catgut,
PGA is much less reactive and is experimentally better able to resist infection from

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TABLE 8-3

Wound Closure Type per Anatomic Site

Anatomic
Site

Layer

Closure Type

Alternatives

Scalp

Deepa
Skin

4-0 Polyglactin 910b


Staples

4-0 Polyglycolic acidc


5-0 Vicryl Rapide
4-0 Nylon, polypropylene

Face

Deep
Skin

5-0 Polyglactin 910


6-0 Nylond
Wound adhesive
(pediatrics)f

5-0 Polyglycolic acid


6-0 Polypropylenee
5-0 Fast-absorbing gut, Vicryl
Rapide

Ears

Skin

6-0 Nylon

6-0 Polypropylene

Lip

Muscle/subcutaneous

5-0 Polyglactin 910

5-0 Polyglycolic acid

Skin

6-0 Nylon

6-0 Polypropylene, Vicryl Rapide

Intraoral

Mucosa

5-0 Chromic gut

4-0 Polyglactin 910

Tongue

Mucosa

4-0 Chromic gut

4-0 Polyglycolic acid

Eyelid

Skin

6-0 Nylon

6-0 Polypropylene

Neck

Deep

5-0 Polyglactin 910

5-0 Polyglycolic acid

Skin

5-0 Nylon

5-0 Polypropylene

Deep

4-0 Polyglactin 910

4-0 Polyglycolic acid

Skin

4-0 Nylon

4-0 Polypropylene, staplesg

Deep

4-0 Polyglactin 910

4-0 Polyglycolic acid

Skin

4-0 Nylon

4-0 Polypropylene

Hand

Skin

5-0 Nylon

5-0 Polypropylene, Vicryl Rapide


(pediatrics)

Leg

Deep

3-0 Polyglactin 910

3-0 Polyglycolic acid

Skin

4-0 Nylon

4-0 Polypropylene

Trunk
Arm/forearm

Staplesg
Foot

Skin

5-0 Nylon

5-0 Polypropylene

Penis

Skin

5-0 Nylon

5-0 Polypropylene

Scrotum

Skin

5-0 Chromic gut

5-0 Polyglactin 910

Introitus

Labia majora

5-0 Nylon

5-0 Polypropylene

Labia minora

5-0 Chromic gut

5-0 Polyglactin 910

Vagina

5-0 Chromic gut

5-0 Polyglactin 910

aSubcutaneous

layer.
910 (Vicryl).
acid (Dexon).
dNylon (Ethilon, Dermalon).
ePolypropylene (Prolene).
fChildren.
gAvoid weight-bearing surfaces.
bPolyglactin

cPolyglycolic

c ontaminating bacteria.9 PGA has excellent knot security and maintains at least 50%
of its tensile strength for 25 days.10 The main drawback of PGA is that it has a high
friction coefficient and binds and snags when wet. For this reason, some experience
is required to pass this material properly through tissues and to seat the throws during knotting. The manufacturer has modified PGA (Dexon Plus) by coating it with

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

oloxamer 188, an agent that significantly reduces the friction and drag through tisp
sues. Although handling has become easier with this modification, more throws (four
to six) are required to prevent knot slippage than for plain PGA (three to four). The
main uses of PGA are for deep closures of superficial fascia (subcutaneous tissue) in
wounds and ligature of small bleeding vessels to effect hemostasis.

Gut (Plain, Chromic, Fast-Absorbing)

An older and less commonly used absorbable suture material is gut. Gut is an organic
material manufactured from sheep intestines. A newer form of this suture is gut treated
with chromium trioxide (chromic gut) to retard absorption in tissues; however, its holding security is only 14 days. Compared with PGA, plain gut and chromic gut appear
to have inferior tensile strength and wound security.11,12 Because of its relatively rapid
absorption, the main use of chromic gut is to close lacerations within the oral mucosa,
perineum, and scrotal skin. Wounds within the oral cavity tend to heal rapidly and do
not require prolonged suture support. Chromic gut is absorbed more rapidly than PGA
on the oral mucosa and does not require suture removal.13 Fast-absorbing gut is heat
treated also to create more rapid absorption than chromic gut. Fast-absorbing gut is
useful for wounds that only need 5 to 7 days of holding, such as intraoral mucosa. It
also can be used as superficial skin closures in children when suture removal is problematic.

Polyglyconate (Maxon) and Polydioxanone (PDS)

These are two monofilament absorbable suture materials that have some advantages
over PGA and polyglactin 910. The main advantage of these suture materials is that
they maintain their invivo tensile strength longer than PGA and the other absorbable
suture materials.10,14 They also appear to have greater knot security and lower friction
coefficients. Polyglyconate is less stiff and easier to handle than polydioxanone. Because
they are monofilaments, they enjoy the theoretical advantage of creating a lower potential for infection.

Poliglecaprone (Monocryl)

A newer, effective absorbable suture is poliglecaprone (Monocryl).15 This suture material has high initial tensile strength and low tissue reactivity. It has excellent handling
characteristics, with low friction and good knot security. Another intriguing finding is
that Monocryl causes less hypertrophic scar formation compared with Vicryl Rapide.16
Monocryl is a monofilament, whereas Vicryl Rapide is multifilament, and this difference might account for the reduced scar formation. With many patients with this tendency, it is important know that there is a suture material with a lower potential for
hypertrophic scar formation. Even though Monocryl is an absorbable suture, it has
been recommended for superficial skin closure of surgical incisions in numerous anatomic sites such as face, eyes, ears, neck, abdomen, and other sites.15 It is also being used
in emergency settings.

Nonabsorbable Suture Materials


Nylon (Ethilon, Dermalon)

Of all the nonabsorbable suture materials, monofilament nylon (Ethilon, Dermalon) is


used most commonly for superficial closure of skin (see Table 8-2). The monofilament
configuration makes it minimally tissue reactive and makes it able to resist infection
from experimental wound contamination compared with braided suture material.10
Nylon has tensile strength that ensures wound security. The main disadvantage of nylon
is the difficulty in achieving good knot security. Because monofilaments have greater

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

memory (the tendency to return to their packaged shape) than braided sutures, they
tend to unravel if not tied correctly. At least four to five carefully fashioned throws or
knots are required to achieve a secure final knot.

Polypropylene (Prolene)

The polymer polypropylene (Prolene) is another nonabsorbable monofilament. Polypropylene appears to be stronger than nylon and has better overall wound security.12 It
is also less reactive and is able to resist infection at least as well as nylon.10 It has greater
memory than nylon, however, and is more difficult to manage. The main uses of polypropylene are for percutaneous and subcuticular pull-out closures.

Polybutester (Novafil)

Another monofilament suture material is polybutester (Novafil).17 Polybutester appears


to be stronger than other monofilaments. This material does not have significant memory, nor does it maintain its packaging shape the way nylon and polypropylene do. For
this reason, it is reported to be easier to work with, and it has greater knot security.
A unique feature of polybutester is that it has the capacity to adapt or stretch with
increasing wound edema. When the edema subsides, polybutester resumes its original
shape. Compared with nylon, this suture material has a lower risk of causing hypertrophic scarring.18 The ability to adapt to the swelling and changing configuration of a
healing wound is credited for this reduction in risk.
Less commonly used for minor wound care problems are braided, nonabsorbable
suture materials, including cotton, silk, braided nylon, and multifilament Dacron.
Until the advent of synthetic fibers, silk was the mainstay of wound closure. It is the
most workable of sutures and has excellent knot security. The usefulness and popularity of silk have declined, however, because of its propensity to cause tissue reactivity
and infection.10,12 Research has shown that, similar to silk, the braided synthetics have
a greater tendency to cause wound infection when exposed to contaminating bacteria.10,19 These materials have excellent workability and knot security, however. Because
of the properties just mentioned, braided sutures are useful on the face, where maximal
control and precision are needed. The earlier removal time for facial sutures and the
natural resistance of the face to infection make the chances of developing inflammation and infection almost negligible.

NEEDLE TYPES
Similar to instruments and suture materials, a bewildering array of needles is manufactured for wound closure. Most wound closures can be accomplished, however, with a few
needles. Curved needles have two basic configurations: tapered and cutting (Fig.8-7).
For wound and laceration care, the cutting needle is used almost exclusively. Needles
that now are commonly referred to as cutting needles are reverse cutting needles. The
needle is made in such a way that the outer edge is sharp so as to allow for smooth and
atraumatic penetration of the skin, and the inner portion is flattened so that the needle
puncture wound is not inadvertently enlarged when the suture is passed through the
hole and the knot is tied.
Needles come in two grades: cuticular and plastic. These grades differ significantly
in their usefulness for wound care. Cuticular needles are less expensive but are noticeably less sharp than plastic-grade needles. The increased sharpness of plastic needles allows the operator better to control entry and passage of the needle through
tissues. Plastic needles also are less traumatic. Although they are more expensive,
these needles are recommended for emergency wound and laceration repair. There
is a bewildering number of code designations for needles. Cuticular needles can be

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CHAPTER 8 Instruments, Suture Materials, and Closure Choices

Swedge
Point
Body

Shank

Figure 8-7. Basic needle configurations: The standard round, tapered needle (left); the reverse cutting
needle (right). The sharp edge is on the convex portion of the needle.

r ecognized by the letters C (cuticular) or FS (for skin). Plastic-grade needle codes usually start with theletter P.

References

1. Shetty PC, Dicksheet S, Scalea TM: Emergency department repair of hand lacerations using absorbable
vicryl sutures, J Emerg Med 15:673674, 1997.
2. Parell GJ, Becker GD: Comparison of absorbable with nonabsorbable sutures in closure of facial skin
wounds, Arch Facial Plast Surg 5:488490, 2003.
3. Missori P, Polli FM, Fontana E, etal: Closure of skin or scalp with absorbable sutures, Plast Recon Surg
112:924925, 2003.
4. Luck RP, Flood R, Eyal D, etal: Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations, Pediatr Emerg Care 24:137142, 2008.
5. Holger JS, Wandersee SC, Hale DB: Cosmetic outcomes of facial lacerations repaired with tissue-adhesive,
absorbable, and nonabsorbable sutures, Am J Emerg Med 22:254257, 2003.
6. Karounis H, Gouin S, Eisman H, etal: A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon
sutures, Acad Emerg Med 11:730735, 2004.
7. Collin TW, Blyth K, Hodgkinson PD: Cleft lip repair without suture removal, J Plast Reconstr Aesthet Surg
62:11611165, 2009.
8. Tandon SC, Kelly J, Turtle M, Irwin ST: Irradiated polyglactin 910: a new synthetic absorbable suture, J R
Coll Surg Edinb 40:185187, 1995.
9. Bourne RB, Bitar H, Andreae PR: In vivo comparison of four absorbable sutures: Vicryl, Dexon Plus,
Maxon, and PDS, Can J Surg 31:4345, 1988.
10. Edlich R, Panek PH, Rodeheaver GT, etal: Physical and chemical configuration of sutures in the development of surgical infection, Ann Surg 177:679687, 1973.
11. Howes E: Strength studies of polyglycolic acid versus catgut sutures of the same size, Surg Gynecol Obstet
137:1520, 1973.
12. Swanson N, Tromovitch T: Suture materials, 1980s: properties, uses, and abuses, Int J Dermatol 21:373378,
1982.
13. Holt G, Holt J: Suture materials and techniques, Ear Nose Throat J 60:2330, 1981.
14. Rodeheaver GT, Powell TA, Thacker TJ, etal: Mechanical performance of monofilament synthetic absorbable sutures, Am J Surg 154:544547, 1987.

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15. Hochberg J, Meyer KM, Marion MD: Suture choice and other methods of skin closure, Surg Clin North Am
89:627641, 2009.
16. Niessen FB, Spauwen PH, Kon M: The role of suture material in hypertrophic scar formation: Monocryl
vs. Vicryl-Rapide, Ann Plast Surg 39:254260, 1997.
17. Bernstein G: Polybutester suture, J Dermatol Surg 14:615616, 1988.
18. Trimbos JB, Smeets M, Verdel M, Hermans J: Cosmetic result of lower midline laparotomy wounds: polybutester and nylon skin suture in a randomized clinical trial, Obstet Gynecol 82:390393, 1993.
19. Alexander J, Kaplan J, Altemeier W: Role of suture materials in the development of wound infection, Ann Surg
165:192199, 1967.

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