S05E92 Demystifying Spitting Sutures: Causes, Prevention, and Solutions in Plastic Surgery

Ever wondered why some sutures seem to surface through your skin post-surgery? Tune in as hosts Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic unravel the mystery of spitting sutures, a common concern in plastic surgery. 

You’ll learn why absorbable sutures sometimes make an unwelcome appearance on your skin and discover that this phenomenon is typically a normal part of the healing process—not a cause for alarm. Our experts will break down the factors at play, from the type of suture used to individual patient reactions and surgical techniques, dispelling myths and providing much-needed reassurance.

But we don't stop at just understanding the problem—our episode is packed with practical solutions and cutting-edge strategies to minimize spitting sutures. Find out why transitioning from Vicryl to PDS and Monocryl can make a world of difference in patient outcomes. 

We delve into the pros and cons of various sutures, share innovative techniques for tummy tuck closures, and discuss the benefits of glue and newer devices for reducing incision line tension. Plus, we offer essential post-operative care tips to help you manage any suture-related issues effectively at home. Don't miss this episode if you want to ease your concerns and arm yourself with knowledge about spitting sutures.

@3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery 

S05E92 Demystifying Spitting Sutures: Causes, Prevention, and Solutions in Plastic Surgery

TRANSCRIPT

[00:00:00] Dr. Sam Jejurikar: welcome everyone to another episode of Three Plastic Surgeons and a Fourth. I'm Dr. Sam Jejurikar in Dallas, Texas, and I'm joined as always by Dr. Sal Pacella, who's joining us from La Jolla, California, who can be found at at San Diego Plastic Surgeon. Dr. Sam Rhee from Bergen County, New Jersey, who's found at at Bergen Cosmetic, and Larry Tong aka LT from Toronto, Canada, who can be found at Yorkville Plastic Surgery.

Plastic surgery, plastic surgeon,

[00:00:38] Dr. Lawrence Tong: Plastic surgery.

[00:00:39] Dr. Sam Jejurikar: surgery. Okay, kind of right the first time. Today we're going to talk about a topic that we find excruciatingly boring, but we get asked about all the time by our patients. And that is little wound healing complications, aka spitting sutures. I think patients will find this to be a very practical episode, but before we get into the meat of it, LT, you want to read the disclaimer?

[00:01:01] Dr. Lawrence Tong: Sure thing. This show is not a substitute for professional medical advice, diagnosis or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstance, situation and medical judgment after appropriate discussion. Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice because of something on this show.

[00:01:27] Dr. Sam Jejurikar: Great. Well, um, have you guys ever run across spitting sutures in your practice? Spitting sutures. And how often do you?

[00:01:35] Dr. Lawrence Tong: I've never seen it in my life.

[00:01:42] Dr. Sam Jejurikar: What? Well, hey, Dr. Pacella, why don't you tell our audience what a spitting suture is?

[00:01:48] Dr. Salvatore Pacella: Okay, so, um, the human body just doesn't magically heal, right? We have to put sutures in there, or stitches, in order to approximate tissue. And, you know, let's say we're sewing up an abdomen. There's a couple different layers that we have to sew up, and some of them are buried. So sutures in general on the inside that are underneath the skin, We try to use something called absorbable sutures, which, uh, dissolve over time.

But sometimes the knots of those sutures work their way up to the surface, and hence a spinning suture. And this could be anything from a small little, uh, annoying little poke in the skin that has to be just gently plucked out, to a full fledged infection of the suture knot, which causes obviously a lot of, uh, anxiety to the surgeon and patient. So, hence the spitting suture. And

[00:02:42] Dr. Sam Jejurikar: And, uh, and I will say that, uh, you know, the inspiration for this topic actually came from a patient of mine who is an avid listener of our podcast. He said that in, uh, in a closed plastic surgery chat room that she is actually in, This is a huge topic of conversation because patients just don't know how to deal with this.

So, um, Dr. Rhee, if a patient comes to you and they have a spitting suture, do you view this to be A major problem, a minor problem, a nuisance. Do you consider it to be an allergic reaction? Like, what's your general approach to it?

[00:03:14] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: I mean, all kidding aside, it's pretty common. And, uh, it, there are a couple of reasons why we encounter spitting sutures. Maybe, uh, more, uh, you know, it's not uncommon in patients. And the first reason is, is as Sal said, we're trying to pull this tissue together. So we're using these sutures to gather this, the, uh, open tissue.

tissue to pull it together to keep tension off of the skin, which allows the scar to heal really nicely. Now when Sal talked about absorbable sutures, there are, um, and I remember this from medical school because we had this like Ethicon. I don't know if you guys had a suture manual and it kind of broke down sutures into different classes.

And as Sal said, there's absorbable and non absorbable sutures and absorbable sutures are the ones that break down within the body. Okay. And there are different kinds. There's a Vykrl, which is one of the most common, which is a, uh, Um, a polymer of, uh, lactic acid or, or sometimes glycolic acid. And, uh, those are some of the most common absorbable sutures that we use.

There are some other ones like, uh, gut and so forth, or, or PDO, which are other, um, They're formulated differently, but I would say most of the absorbable sutures we use are vicryl type sutures. And the reason why, and, and the reason why we use them is because they're very easy to use. It's kind of a braided suture, it's easy to stitch with, it holds a good knot, um.

But, uh, these sutures can, as Sal say, uh, said, as they break down, they can, they cause naturally a tissue reaction. That's how the tissue breaks it down. And sometimes they can work their way up to the surface, and if they do, you can see them, they can break through. And, um, you know, you're trying to put just enough suture to hold the tissue nicely together without any.

Any tension, but you don't want to put so many that you might get a lot of these spinning sutures. So a lot of this is just surgical experience. It also depends on the location and, and the type of suture you're using, the, the person, the, the specific patient. So depending on all of these different factors, you may, you may get some spitting sutures.

So I wouldn't really call it a problem per se, but it is something that patients do get concerned about when they see.

[00:05:38] Dr. Salvatore Pacella: you know, the thing is too, um, you know, what a lot of patients say, uh, many times is they're told by their doctor, um, you shouldn't use a vicryl suture or you shouldn't use a PDS suture. I'm allergic, right? I'm allergic to those. What do you guys think about that when, when patients say that to you?

[00:05:57] Dr. Sam Jejurikar: Yeah, it's, it's not an allergy. Um, you know, as Sam sort of alluded to, you know, when you have a suture material, it doesn't disappear because it magically dissolves. It, it goes away because the body has an inflammatory reaction that's around it. And sometimes in the process of this inflammatory reaction of, of, you know, getting rid of this biomaterial that's.

In the patient instead, it gets pushed out to the surface instead of being dissolved. So it's not an allergic reaction. I will, you know, I don't actually use vicryl sutures. Um, I tend to use more monofilament sutures, but I still have plenty of issues with, with spinning sutures. But I think the closer it is to the skin surface, the number of knots that it has, certain biological factors about the patient can make it more likely, uh, What do you think, Larry?

Do you think it's an allergic reaction?

[00:06:47] Dr. Lawrence Tong: No, I don't, I don't think it's an allergic reaction at all. I think it's exactly what you said, that there's a inflammatory response, and it could be. Causes this redness, uh, potentially around the site. So patients may easily mistake that for, um, allergy. I think if the, you know, if the stitches just sticking out through the skin and the, and the patient feels it, that's, that's not a big deal.

Then the next step beyond that, where it's, you know, a little bit more. More of an issue is if you get, um, an infection on top of that. So, because the stitch may be sticking through the skin, um, and there's bacteria on the skin. Sometimes the bacteria can get onto the stitch and then sort of migrate its way down into the incision a little bit.

And then you might get what's called a stitch abscess, which is basically a bit of pus around the stitch. And you know, Still, that's, that's not a big deal. You wouldn't want to leave it unchecked, but generally, if I have a patient who has that, I'll have them come in. I'll take a look at it and, uh, you know, just, um, open it up.

So to drain a little bit, it's just basically like a very small pimple. You just pop it and if the stitches there, maybe snip it out. And, uh, once it's cleared, um, it'll heal. Um, that's, that's part of the reason why it's important for, you know, patients to have good hygiene after they had the surgery to keep, you know, the area, uh, clean, because if, if there are stitches that are sticking out, then your, uh, risk of, um, getting a, a small infection will be decreased if you keep things generally nice and clean.

But, um, no, not, um, Not an allergic reaction, just some minor irritation in general, which can lead to something a little bit more, but in general, still not a, not a big problem. But patient reassurance is, is important because, um, I'll get, I'll get back to you Calls or emails, uh, with patients very concerned, they think that the wound is going to fall apart or something like that.

So it's very important to, you know, um, reassure patients and educate them and see them promptly and deal with it.

[00:08:53] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: Let me ask you guys, what, what types of sutures do you prefer to use? So I know Sam, you just said you like using monofilament. I use a combination. I'll, for deep tissue closure, I'll, I'll usually use a vicryl or braided type of absorbable suture. And then for subcuticular or skin type stuff, I'll use, um, sometimes, um, a, um, What do you call it?

Um, yeah, like a monofilament, but sometimes it has, uh, whatever is it? Blanking on it. Hooks? What do you call it? Uh, yeah, barb sutures. And, uh, I, I, I use a lot of barb sutures. Um, uh, I try to run the fewest number of layers I can, but it really depends on the location and the amount of tension that is at the site.

If it's really tight, sometimes I'll have to do a lot of interrupted and then I'll run some monofilament on top of it. Um, what do you guys like doing for, for your cases?

[00:09:52] Dr. Salvatore Pacella: So, um. So first off, I would say, you know, early on in residency, we used a lot of Vicryl and the whole reason for using Vicryl is it's a braided suture and it holds the knot much better. Very strong suture, but I found in practice, those are notorious for spitting, notorious for getting infected. So I, I tried to switch this over to PDS.

And so what I would use is, so PDS is a little bit longer acting. It's a monofilament, meaning it's smooth. But those also still spit quite a bit. So, so now what I do is I try to do a, a very strategic closure if I'm doing, say, a tummy tuck. So I'll do very deep, uh, layers of PDS. So the idea is that if they're an inch or two underneath the skin, that hopefully they won't spit.

And then there is a layer that's just below the skin called the deep dermal layer. I'll oftentimes use a PDS for that. And I'll leave the edges of it hanging out through the skin. Then I'll use on the direct undersurface of the skin, so called the Subcuticular layer, I'll use a monocryl and I'll also leave that hanging and then I'll tie the PDS to the monocryl so there's one knot, knot hanging out on one side, another knot hanging on the other side and I can just cut that in a couple weeks without any major problem.

To me, that avoids any knots close to the skin if possible and I found that to be very helpful and consistent.

[00:11:18] Dr. Sam Jejurikar: Hey, uh, Pacella, would you mind explaining the differences and how long those sutures last in the body?

[00:11:25] Dr. Salvatore Pacella: Um, yes, so, um, so Monocryl is a suture that is very short lived. It, uh, uh, my understanding is it's anywhere from 21 to 6, 21 days, 6 weeks, something like that, right? So, it's something we want to use close to the skin that's going to absorb, um, very quickly. Vicryl, um, correct me if I'm wrong, lasts about 90 days, right?

Is that your understanding? Okay. Yeah, so Vicryl is relatively short lived but longer than Monocryl. So, the idea is you use it underneath the skin at a little bit deeper level. PDS is a longer acting suture, lasts quite a bit longer. anywhere from three months to six months and can be around for a bit of time.

And so it's really kind of a structurally permanent suture for, for many, many, many months. And that's why I like it because it holds the tension off of a lot of repairs.

[00:12:21] Dr. Sam Jejurikar: And, and it seems as though, and tell me if you guys disagree with what I'm saying, but as you're getting more superficial with your sutures, you're picking, um, you're picking suture

[00:12:30] Dr. Salvatore Pacella: More absorbent, quicker.

[00:12:32] Dr. Sam Jejurikar: that goes away quicker.

[00:12:34] Dr. Salvatore Pacella: Yes.

[00:12:35] Dr. Sam Jejurikar: Right. You know, when I first started in practice in Dallas, one of my partners who was a really well known plastic surgeon, and this is an older way that surgeons would do it, would do their deep thermals using clear nylon sutures.

Nylon for the viewers is a permanent suture. And so spitting sutures could happen over a period of time of years and years and years. Like I've got one of his patients who, um, You know, he retired more than 10 years ago. Um, I've got one of his patients who still has spitting sutures 20, 25 years after the fact.

Most of the spitting sutures that we see, it's a matter of the first few months after surgery, and then, and then it goes away. Larry, did you want to talk about how you closed the scan or was it fairly similar with these other guys we are doing?

[00:13:16] Dr. Lawrence Tong: Yeah, fairly similar. I, I tend to use a braided suture for the, the deeper layers. Like, for example, if we're doing a tummy tuck for the, the scarpus layer, I'll typically use something like a bicol. Then as I go up a bit to the deep dermal layer, it'll be. Something like monocryl, and then I'll just follow, uh, finish off with a monocryl layer.

I think that, um, using Vicryl closer to the surface of the skin is, um, a little bit higher risk for, uh, Infections if you get a spinning stitch because it's a braided material. So for the viewers, um, the, the braided, uh, stitches, um, tend to act like a, sort of like a wick. And so, um, I try to avoid using the, uh, vicral sutures closer to the surface.

But, um, yeah, very similar to what you guys, uh, described as the closure, multi-layer closure, and then using more of a monofilament type, uh, stitch. Uh, near the surface,

[00:14:15] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: Do you guys use glue?

[00:14:17] Dr. Sam Jejurikar: I

[00:14:18] Dr. Lawrence Tong: I don't use glue.

[00:14:20] Dr. Salvatore Pacella: I, I do, um, but not in the sense of using. I like the device known as Prinio, so it's got tape and glue. Um, I feel that that takes off a lot of tension off of the incision line, um, pretty well. So I tend to use that in longer incisions.

[00:14:40] Dr. Sam Jejurikar: I, you know, I, I, I think the way I do it is so similar to the way you guys are doing it, that the subtle differences are kind of irrelevant for the purpose of this conversation. But what I think would be useful for listeners is this, the reason why they're talking about it in their closed chat rooms is they apparently don't have surgeons that are guiding them through this process.

Larry, you said, if you have this issue, someone's coming to your office and you're clipping the stitch, you're getting them directed on local wound care. But what are some tips you guys might have for patients? who are at home maybe a great distance away from their surgeon and are trying to take care of this themselves.

If they get a suture abscess, should they go to the emergency department? Are there at home tips that you have for people? Anything that you can do to try to help people through this?

[00:15:25] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: I mean, I think Larry had a good point about post procedure hygiene and incision care. Like, it is very helpful to keep those areas clean. And I've had some patients who were, even though we have very clear instructions sometimes, it is, yeah, they're either misinformed or someone tells them something different.

Um, I don't know. And, and instead of, you know, sort of following, Uh, with cleaning those areas and, and sort of changing dressings and so forth, uh, if you do have, as Larry said, like, um, a suture abscess and it gets secondarily infected, um, that can be a little bit problematic, especially, um, I mean, I haven't really experienced that that often, but I have seen it.

Um, and, you know, sometimes you just, you do have to go to, um, the emergency room for something that may develop into something worse. Um, I think for me, um, oftentimes, uh, I will communicate pretty closely with my patients. They'll send me pictures, um, and we can sort of get through whatever it is that, that they need.

But local care. of the site, keeping it really, um, aseptic and clean can be, can be super helpful.

[00:16:48] Dr. Sam Jejurikar: I mean, do you find it?

[00:16:49] Dr. Lawrence Tong: Do you guys ever, um. If a patient doesn't want to come in, they, they, you know, for whatever reason, they're busy, um, sometimes I even tell them, you know, if they're comfortable and they just want to, um, like, sort of, um, pop it like, like a pimple that often takes care of it and I'll call in an antibiotic for them and then have them check back with me.

That's, you know, you can't do that with everybody. The patient has to feel comfortable, uh, with doing that. And, um, I think that that is something that I've done before. And it, it hasn't had any, uh, problems with it. So, if a patient doesn't want to come in, just. For something relatively minor like that, I've advised patients to, um, to do that if they're comfortable with it.

[00:17:37] Dr. Sam Jejurikar: Yeah. I mean, I think, um, you know, Sam, you had sort of mentioned that occasionally they might need to go to an ER or a higher level of care. I think we would all pretty rare occurrence. I mean, most of the time. 99 plus percent of the time, this is relatively easy. I think the principles that I try to impress upon people, because many of them don't come in for this, they either live a great distance or they're just busy, is if there's any way they can get the foreign material out, like, if they see a stitch that's actually coming out with it, if they can trim it flush with the skin, that would be great.

I don't usually have them go digging into the area. Two, it's really common for the, for the, um, for the spitting suture to kind of present with a little drop or two of pus. Like that's usually the way it always presents. And it doesn't mean they have a rip roaring infection that necessarily needs antibiotics.

Three, you know, I think trying to get that biomaterial, you know, getting that suture material out of there is helpful if at all possible. I'll do something for, you know, for a few days afterwards, we'll all have them use a little half strength peroxide. Peroxide's great because it, um, It kind of non selectively dissolves everything in the wound.

Um, I have them dilute it though, just so it doesn't dissolve all the healing tissue as well. And then, um, I'll help them do that for three days, use some antibiotic ointment and, you know, and typically they heal up okay with that, even if they don't come in. I don't know. Pacella, do you have anything, uh, anything you want to add to that?

[00:19:03] Dr. Salvatore Pacella: No, I think, um, you know, if there's, if there's a suture coming out, we oftentimes advise patients to, um, you know, take a little piece of the, take a little tweezer, a little forcep. You can try to pull at it. The, the idea is to get that foreign body material out of there. And so I think once that's gone and once an infection goes away, you know, warm compresses, I think, help quite a bit.

Um, So it's, it's just a lot easier to deal with. Um, so I, I don't think it's a major problem I've seen in my practice. And, and we do, we do a lot of teaching, uh, I should say to, uh, to help with this beforehand. So we don't, hopefully our patients are not super surprised.

[00:19:43] Dr. Lawrence Tong: Yeah, I think one point that's important, um, to impress upon patients also is that you don't want to have like a bunch of little suture abscesses because each time you have a little infection like that, that can affect the patient. The way the scar ultimately looks, basically more inflammation can lead to more scar tissue, which can lead to a scar that doesn't look as, um, as hidden or as, you know, um, uh, good looking as, as it could be.

So, um, if, if you tell them to keep it clean, uh, because it can also affect how they heal and ultimately how, how the scar looks, I think. That improves their compliance with that.

[00:20:25] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: Routinely? Prescriber?

[00:20:29] Dr. Lawrence Tong: you mean like, um, as a routine for, you know, after surgery, do I, um, prescribe? Yeah, I usually, I usually give them about five days of, um, antibiotics for most cases, uh, that I do. I, I don't think. That the science is necessarily, um, all on board with that, but to some extent, I think that patients actually expect that.

And I don't know if there's some sort of, um, um, you know, implied standard of care, uh, with that. So, I just usually do it. I that's that's how I did it when I trained and I just continue with that.

[00:21:12] Dr. Sam Jejurikar: Yeah, I do the same thing because there's no data to support any of us doing that. But we all do it because everybody else does it. And if we don't and our patient gets an infection, it looks as though we did something negligent. But I don't think any of us actually believe it makes a difference in a routine, in a routine case. Right? I mean, do you agree with that, Sam?

[00:21:33] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: I routinely do post op antibiotics, um, and I don't know if it prevents anything or not, but I certainly feel like I would get More of an accusatory look for my patients if they had a lot of spitting sutures and they weren't on antibiotics for the first couple days after their procedure.

[00:21:54] Dr. Sam Jejurikar: Well, I think we've largely exhausted this topic, but I think before we finish, maybe we can all take a turn and summarize what a spitting suture means to them in three sentences or less, starting with Pacella. Go.

[00:22:13] Dr. Salvatore Pacella: A, a minor, a minor annoyance.

[00:22:18] Dr. Sam Jejurikar: Yep. LT.

[00:22:20] Dr. Lawrence Tong: You want three sentences or a word? Three words.

[00:22:23] Dr. Sam Jejurikar: Three sentences or less, or less.

[00:22:25] Dr. Lawrence Tong: All right.

[00:22:26] Dr. Sam Jejurikar: think

[00:22:27] Dr. Lawrence Tong: Uh, no big deal.

[00:22:32] Dr. Sam Jejurikar: Dr. Rhee.

[00:22:34] riverside_sam_rhee_raw-synced-video-cfr_monday_may 27 8pm e_0001: I would say understandable if patients get concerned. As surgeons, we, right, don't consider them to be significant, but reassurance is always, always helpful.

[00:22:50] Dr. Sam Jejurikar: And I think I would say really common, a nuisance, not a major problem. Alright guys, it's been thrilling. Um, this is a 20 minutes I will never forget.

And uh, with that, to our viewers, thanks for watching as always. Later