As ophthalmologists, we learn and become proficient in the use of 10-0 nylon on the delicate and small organ that our careers focus around, but what do we use in the periocular area in cases of surgery and trauma? This article will discuss the use of sutures beyond the eyeball.
First, the basics: Effective wound closure is key in both surgery and trauma. If closure is not complete, the wound edges can separate, providing a potential pathway for bacterial contamination leading to infection, scarring and low patient satisfaction. Eversion of the skin edges with the appropriate sutures is paramount.
Ethicon, a division of Johnson & Johnson, manufactures most of the sutures we use. As we know, sutures come in different sizes, are attached to various needle sizes, shapes and curves, and can be absorbable or non-absorbable.
Needle types: Needles should be chosen so that they are sharp enough to penetrate the given tissues with minimal resistance. They should be thin enough without sacrificing durability.
There are various needle curves to choose from ranging from straight to compound curves. The curve must be chosen depending on the tissues that are being sewn. If sewing deep tissues, a more curved needle often is beneficial (P-2 half circle). On the skin surface, a less curved needle, such as a 3/8 circle is helpful (P-1 or P-6). Cutting or reverse cutting needles are best for the skin so the needle glides through the tissues without undue pressure, resistance or trauma. When throwing sutures through lamellar bites of the tarsus or sclera, a spatulated needle offering a ¼ circle soft bend that is flat on the undersurface and unlikely to penetrate the given tissue such as the S-24 or S-14 is beneficial.
Suture materials come in absorbable and non-absorbable, braided or monofilament. In general, deep, tension-bearing sutures should be absorbable and superficial skin closure should be done with non-absorbable sutures, provided they can be removed in a week. Braided sutures may have more tissue memory, but can put a wound at higher risk for infection or inflammation. If using an absorbable suture, keep in mind the absorption time and base your choice on how long you would like the suture to stay intact.
Below is a summary of the various suture types and properties, including approximate strength retention and absorption profile:
Absorbable:
Non-Absorbable:
- Nylon – monofilament or braided
- Merselene – braided
- Prolene - monofilament
- Silk - braided
In general, when suturing the eyelid proper, a 7-0 suture is sufficient. Above the brow and on the cheek involves thicker skin and can be sewn with 6-0 suture. Deep, tension-bearing sutures, such as in the forehead or cheek area are best sewn with 5-0 vicryl sutures. In cases where some adhesion of the tissue is desired, for instance in eyelid rotation procedures, a chromic gut suture may be ideal.
In a child, suture removal may not be worth a trip back to the OR and will rarely be tolerated in clinic. In these instances, either an absorbable suture can be used or, if general anesthesia for the repair is not desired or reasonable, tissue adhesives can be used.
Dermabond:
This tissue adhesive is a sterile, liquid topical made of a monomeric formulation (2-octylcyanoacrylate) plus a colorant D & C Violet #2. It can be used in cases where suturing may not be ideal such as with children.
Dermabond is provided in a single use applicator and can provide up to 7 days of wound holding strength. It seals in 90 seconds to 3 minutes. In vitro, Dermabond has show antimicrobial action against both gram negative and gram positive bacteria for at least 72 hours.
Staples:
Believe it or not, staples can be used in ophthalmology. When performing a brow lift, either temporal, pretrichial, endoscopic or coronal, staples can be used as an alternative to sutures to close the wound behind the hairline.
Proximate Plus MD Skin Stapler
This is a low cost skin stapler that permits multi-directional release. The stapler is a sterile, single-use instrument that delivers rectangular, stainless steel staples for routine wound closure. The device has an alignment indicator to aid in precision and symmetry of placement, and the staples have a dry film coating for easy extraction. The staples are removed using the Squeeze-Handle Staple Extractor seen below, which can be used for all models of Ethicon skin staplers.
There is a lot of variation amongst surgeons with respect to what sutures to use when and where. Learning the general properties and variations available for use is helpful when making your own decision.
Keep in mind the type of tissue you are repairing and the length of time you would like the suture to hold the tissues together when choosing your particular suture and needle.