Overview
Definition:
Suture selection in pediatrics involves choosing between absorbable and nonabsorbable materials based on the tissue type, location, duration of wound support required, and patient-specific factors like age and potential for allergic reactions
optimal selection ensures effective wound healing, minimizes complications, and achieves superior cosmetic outcomes.
Clinical Significance:
Appropriate suture selection in pediatric patients is critical for preventing wound dehiscence, infection, and excessive scarring
Considerations unique to pediatrics, such as growth potential, patient compliance with follow-up, and the need for atraumatic handling, necessitate a tailored approach compared to adult wound closure.
Types Of Sutures:
Absorbable sutures degrade naturally in the body over time, varying in absorption rates (e.g., Polyglycolic acid (PGA), Polylactic acid (PLA), Monocryl, Vicryl, Catgut)
Nonabsorbable sutures retain their tensile strength indefinitely and require removal or remain permanently in situ (e.g., Nylon, Prolene, Silk, Stainless Steel).
Factors Influencing Selection
Tissue Type And Strength:
Tissues with high tension (e.g., fascia) may require stronger, longer-lasting support, potentially favoring nonabsorbable or slowly absorbable sutures
Tissues with rapid healing (e.g., mucosa) can utilize faster-absorbing materials
Dermal layers require sutures that can be removed or are fine and absorbable to minimize scarring.
Required Duration Of Support:
The length of time tensile strength is needed dictates suture choice
Superficial wounds might only need a few days of support (fast-absorbing), while deeper or fascial closures might require weeks to months (slowly absorbing or nonabsorbable).
Infection Risk:
In contaminated or infected wounds, monofilament, non-absorbable sutures are often preferred as they are less prone to harbor bacteria, though their removal is crucial
Absorbable sutures in infected fields can act as a nidus for ongoing infection.
Cosmetic Outcome:
For cosmetically sensitive areas like the face, fine, monofilament, absorbable sutures are often used in the dermis, or nonabsorbable sutures are removed promptly to minimize track marks and scarring
Subcuticular sutures, often absorbable, offer excellent cosmetic results.
Patient Age And Compliance:
Younger children may be less compliant with suture removal appointments, making absorbable sutures or sutures that can be removed easily a practical choice
The need for general anesthesia for suture removal in uncooperative children is also a consideration.
Suture Selection By Location Pediatrics
Scalp:
For superficial scalp lacerations, fast-absorbing or slowly absorbing sutures like Vicryl or Monocryl in the dermis, with interrupted nonabsorbable sutures (nylon) for the skin if long-term support is needed, or absorbable sutures for subgaleal closure
Scalp lacerations often heal well, and fine sutures minimize scarring.
Face:
Delicate facial tissues necessitate fine, absorbable sutures (e.g., Vicryl, Monocryl) for dermal closure and sometimes subcuticular closure to achieve the best cosmetic results
Nonabsorbable sutures (e.g., Nylon) for skin closure are typically removed within 3-5 days to prevent track marks
Consider cosmetic sutures.
Trunk And Limbs:
For deeper wounds on the trunk and limbs, absorbable sutures (e.g., Vicryl) are commonly used for fascial and subcutaneous layers
Skin closure can be achieved with absorbable sutures (e.g., Monocryl subcuticular) for cosmesis or interrupted nonabsorbable sutures (e.g., Nylon) which require removal
Suture strength for fascial closure is paramount.
Perianal And Genital Areas:
These areas have excellent blood supply and rapid healing potential
Fast-absorbing sutures (e.g., Monocryl, Vicryl) are ideal for mucosal and submucosal closure
Nonabsorbable sutures are generally avoided due to patient discomfort and risk of irritation
if used, they must be removed quickly.
Intraoral Mucosa:
The oral mucosa heals rapidly
Absorbable sutures, particularly Vicryl or Monocryl with their shorter absorption times, are preferred
They do not require removal and minimize the risk of the child chewing or swallowing them, or causing oral trauma during removal attempts.
Absorbable Sutures In Pediatrics
Common Types And Uses:
Polyglycolic acid (PGA) and Polyglactin 910 (Vicryl) are braided and provide good knot security, used for soft tissue approximation and ligation
Monocryl is a monofilament, softer, and used for skin and subcutaneous closure where rapid wound healing is expected
Chromic and gut sutures are also available but less commonly used in favor of synthetics.
Absorption Rates And Implications:
Fast-absorbing sutures (e.g., Monocryl, ~57 days) are suitable for tissues that heal quickly
Medium-term absorbable sutures (e.g., Vicryl, ~70-90 days) provide longer support
The rate of absorption can be influenced by tissue type, patient metabolism, and infection
In pediatric patients, predictable absorption is key for comfort and avoiding long-term foreign body reactions.
Advantages:
No need for removal, reducing patient discomfort and need for follow-up visits
can lead to better cosmetic outcomes by avoiding stitch marks
useful in locations where removal is difficult or impossible (e.g., intraoral).
Disadvantages:
Initial reduced tensile strength as they begin to degrade
potential for tissue reaction or inflammation during absorption
not suitable for all tissues requiring prolonged support
can be more expensive than some nonabsorbable options.
Nonabsorbable Sutures In Pediatrics
Common Types And Uses:
Nylon (Ethilon) and Prolene (Polypropylene) are monofilaments ideal for skin closure where prompt removal is planned, or in situations where long-term tensile strength is critical (e.g., abdominal wall closure, though absorbable sutures are often preferred in pediatrics unless specific concerns exist)
Silk is a braided natural fiber, often used for skin or internal ligation but can cause more tissue reaction.
Handling And Advantages:
Nonabsorbable sutures maintain their tensile strength indefinitely, offering permanent support if left in situ
Monofilaments are smooth and pass easily through tissue, causing less drag
They are generally less reactive than braided sutures.
Disadvantages And Considerations:
Require removal, which can be challenging in uncooperative children, potentially necessitating sedation or anesthesia
Can act as a nidus for infection if retained
Silk sutures can cause significant inflammation and are prone to bacterial colonization
Permanent sutures are generally avoided in pediatric skin closure due to cosmetic concerns and risk of infection.
Removal Schedule:
Facial sutures typically removed in 3-5 days
Trunk and limb sutures 7-14 days, depending on tension and location
Prompt removal minimizes track marks and infection risk.
Key Points
Exam Focus:
Understand the principles of absorbable vs
nonabsorbable sutures, with specific examples and applications in pediatric surgical scenarios
Differentiate suture properties (material, structure, absorption rate) and link them to anatomical locations and tissue types in children.
Clinical Pearls:
Always consider the cosmetic outcome in pediatric patients, especially on the face and exposed areas
Prioritize atraumatic technique and smallest effective suture size
In young children, default to absorbable sutures for skin closure when possible to avoid removal difficulties.
Common Mistakes:
Using nonabsorbable sutures in the oral mucosa
failing to remove skin sutures promptly leading to scarring
selecting sutures with inadequate tensile strength for high-tension areas
not considering patient age and compliance for suture removal.