materials for wound closure

3/23/2015 Materials for Wound Closure

http://emedicine.medscape.com/article/1127693-overview#aw2aab6b4 1/11

MaterialsforWoundClosure

Author:EllenStolleSatteson,MDChiefEditor:DirkMElston,MDmore...

Updated:Feb13,2015

WoundHealingandClosure

Woundscanhealbysecondintention,ortheycanbeclosedbyavarietyofmethods.Althoughtheskilland

techniqueofthesurgeonareimportant,soisthechoiceofwoundclosurematerials.Thepurposeofthesematerials

istomaintainwoundclosureuntilawoundisstrongenoughtowithstanddailytensileforcesandtoenhancewound

healingwhenthewoundismostvulnerable.

Inordertofullyappreciatetheessentialsofawoundclosure,itisfirstimportanttounderstandtheprocessofwound

healing.Healingoccursin4stageshemostasis,inflammation,proliferation,andremodeling.

Thehemostasisphasebeginsimmediatelyafterinjury.Whilesomeauthorsconsiderthisprocesspartofthe

inflammatorystage,itshouldberecognizedthatintheprocessofhemostasis,theformationoffibrinand

degranulationofplateletssetsthestageforthesubsequentstages.Theinflammationstagebeginsshortlyafter

injury.Inthisstage,mobilizationofthecomponentsoftheimmunesystemremovedamagedtissueandbacteria

fromthewound.Theproliferativestageisthetissueformationstageinwhichreepithelialization,angiogenesis,and

fibroblastproliferationandmigrationpredominate.Duringthefinalstage,theextracellularmatrix,whichiscomposed

offibronectin,hyaluronicacid,proteoglycans,andtypeIIIcollagen,isdepositedandconstantlyalteredwiththefinal

accumulationofmaturetypeIcollagen.Thisstagemayoccurforaslongas612monthsafterwounding.

Woundstrengthgraduallyincreasesthroughoutthehealingprocess,reachingabout20%ofthepreinjurystrengthat

3weeks.Postinjuryskinstrengthultimatelyonlyreaches7080%ofthatofnormalskin.Thecomponentsofthe

phaseswoundhealingaredepictedintheimagebelow.

Woundhealingphases.ImagecourtesyofMikaelHggstrm,MedicalgalleryofMikaelHggstrm2014,WikimediaCommons.

AlsoseeSuturingTechniquesandSurgicalDressings.

SutureCharacteristics

Thechoiceofaparticularsuturematerialshouldbebasedonthepatient,wound,tissuecharacteristics,suture

characteristics,andanatomiclocation.Asurgeon'sselectionmaynotbespecificallybasedonscientificdata,but

ratheronthepreferencesthatheorshelearnedfrommentorsand/orintraining.

Understandingthevariouscharacteristicsofavailablesuturematerialsisimportanttomakeaneducatedselection.

Noonesuturepossessesalldesirablecharacteristics.Theoptimalsutureshouldbeeasytohandleandhavehigh

tensilestrengthandknotsecurity.Anytissuereactionshouldbeminimal,andthematerialshouldresistinfectionand

havegoodelasticityandplasticitytoaccommodatewoundswelling.Alowcostispreferred.Althoughsomeofthe

newermaterialsavailablehavemanyoftheseproperties,noonematerialisidealandcompromisesmustbemade.

Sutureneedlesaredepictedintheimagesbelow.

Anatomyofaneedle.

Commonlyusedsutureneedlescrosssectionsoftheneedleshownatthepoint,body,andswage.Aisataperneedle,Bisa

conventionalcuttingneedle,andCisareversecuttingneedle.



Interactionbetweentheneedleholderandsutureneedle.Aisaneedleholderofappropriatesizefortheneedle.Bisaneedle

holderthatistoolargefortheneedle.Pressureappliedbytheneedleholderleadstoinadvertentstraighteningofthesuture

needle.Cisaneedleholderthatistoosmallfortheneedle.Theneedlerotatesaroundthelongaxisoftheneedleholder.

Thephysicalcharacteristicsofasuturematerialdetermineitsutilitythesecharacteristicsincludeconfiguration,

diameter,capillarityandfluidabsorption,tensilestrength,knotstrength,elasticity,plasticity,andmemory.

Configuration

Theconfigurationofasutureisbasedonthenumberofstrandsofmaterialusedtofabricateit.Asuturecanbe

monofilament(ie,singlestranded)ormultifilament(ie,multistranded).Multifilamentoussuturesaretwistedor

braided.

Sizes

UnitedStatesPharmacopeia(USP)sizesarestandardizedandrelatedtoaspecificdiameterrange(inmillimeters)

thatisnecessarytoproduceacertaintensilestrength.Thesediameterrangesvarywiththedifferentcategoriesof

suturematerial.Thesecategoriesincludenaturalmaterials,syntheticabsorbablematerials,andsynthetic

nonabsorbablematerials.Sizesareexpressedwithzeroes,suchas30,40,50,and60morezeroesindicatea

smallersize.

Tensilestrength

Thetensilestrengthofamaterialisthemaximalstressthatitcanwithstandbeforebreaking.Therateatwhicha

suturelosesitstensilestrengthovertimeisnotthesameasitsabsorptionandvariesamongsuturematerials.The

implantationandtyingofasuturedecreasesitstensilestrength.Dry,unused,absorbablesutureloses413%ofits

initialstrengthafterbeingsoakedinsodiumchloridesolutionfor24hours.Knottedsutureshavetwothirdsthe

strengthofunknottedsutures.Inselectingsuturematerial,thetensilestrengthofasuturedoesnotneedtoexceed

thatofthetissueitissecuring.

Knots

Theknotistheweakestportionofthesuture.Itsstrengthisdefinedbytheforcenecessarytocauseslippage.The2

mostcommonlyusedtypesofknotsinsurgeryareflatsquareknotsandslidingknots.Flatsquareknotsare

consideredmoresecurethanslidingknots,whereasslidingknotsallowforatighterknotwhentighterapproximation

oftissueisrequired.Asurgeonsknotisasquareknotinwhichtwoknotthrowsareperformedpriortotighteningthe

knot.Althoughthisinitialthrowaddsnostrengthtotheknot,itdecreasesthetendencyofthewoundtoseparateas

thesutureistied.

Numerousstudieshaveevaluatedtheoptimalnumberofknotthrowstolimituntyingwithoutexcessivebulk,which

mayleadtosutureexposure.Whiletheseresultsvarybasedonthetypeofsutureandknottyingtechniqueused,

mostconcludedthatfourorfivethrowsareoptimalforsuturesusedindermalclosures.

Barbs

Theuseofbarbedsuturesallowsclosureofawoundwithouttheuseofknots.Barbsaremadebyplacinglinear

nicksalongthesutureandpermitthesuturetobepulledinonlyonedirection.Bothunidirectionalandbidirectional

barbedsuturesareavailableinseveralabsorbableandnonabsorbablematerials,includingVLoc(Covidien

Mansfield,Mass)andQuill(AngiotechVancouver,BritishColumbia).Byeliminatingtheweakpointofaknot,barbed

suturesshould,intheory,provideastrongerrepair.Afewanimalstudieshaveshownthatbarbedsutureclosures

provideincreasedtensilestrengthcomparedwithsimilarnonbarbedsuturingtechniquesincertainsituations.Ina

multicenterrandomizedcontrolledtrial,barbedsutureswerealsofoundtoenablesignificantlyfasterdermalclosures

comparedwithtraditionalsmoothsutureclosure.[1]

Plasticityandelasticity

Plasticityistheabilityofthesuturetoretainitsnewformandlengthafterstretching.Plasticityallowsasutureto

accommodatewoundswelling,therebydecreasingtheriskofstrangulatedtissueandcrosshatchmarks.Asswelling

subsides,however,thesutureretainsitsnewsizeandmaynotcontinuetoadequatelyapproximatethewound

edges.

Elasticityistheabilityofasuturetoregainitsoriginalformandlengthafterstretching.Aftertheswellingofawound

recedes,thesuturereturnstoitsoriginallengthandkeepsthewoundwellapproximated.Mostsuturesareelastic

fewareplastic.

Memoryistheabilityofasuturetoreturntoitsoriginalshapeafterdeformationbytying.Memoryisrelatedto

plasticityandelasticity.Sutureswithahighdegreeofmemory,particularlymonofilamentsutures,arestiffand

difficulttohandleandmaybemorepronetoknotlooseninganduntying.

Handlingcharacteristics

Handlingcharacteristicsofsuturematerialsaredefinedbypliabilityandcoefficientoffriction.Pliabilityreferstothe

easewithwhichasuturecanbebent.Thecoefficientoffrictionisameasureoftheslipperinessofthesuture.

Sutureswithahighcoefficientoffriction,generallybraidedsutures,aremoredifficulttopassthroughtissue,thereby

causingagreaterdegreeoftissueinjuryduringplacementandremoval.However,thesesuturesaremorepliable,

beingeasiertohandleandmanipulatefortyingknots.

Tissuereaction

Differentsuturematerialsproducevaryingdegreesoftissuereaction,specificallyinflammation.Significant

inflammationreducestheresistancetoinfectionanddelaystheonsetofwoundhealing.Thetypeofmaterialand

sizeofthesuturearethoughttobethemajorfactorscontributingtothisreaction.Naturalmaterialsareabsorbedby

proteolysis,whichcausesaprominentinflammatoryresponse,whilesyntheticmaterialsareabsorbedbyhydrolysis,

whichproducesaminimalreaction.



Braidedsutureshaveahighdegreeofcapillarity,whichiscorrelatedwithatendencytoabsorbandretainbothfluidandbacteria.Thesematerialsareassociatedwithgreaterreactivityandmaypromoteinfectionifbacterialcontaminationoccursduringorshortlyaftersurgery.Smitetal[2]histologicallyevaluatedtissuereactivitytodifferentsuturematerials(ie,silk,plainandchromiccatgut,polyester,nylon,Vicryl,Maxon,Prolene)inrats7daysaftersurgery.Interestingly,thestudydidnotrevealanysignificantdifferencesintissuereactions.Thisfindingsuggeststhatsurgicaltraumamayhaveagreaterinfluenceonreactivitythanthesuturematerial.

Theamountofsutureplacedinawound,particularlywithrespecttotheknotvolume,affectsinflammation.Thesuturesizecontributesmoretoknotvolumethanthenumberofthrows.Thevolumeofsquareknotsislessthanthatofslidingknots,andknotsofmonofilamentsuturesaresmallerthanthoseofbraidedsutures.

Allergicreactionstosuturematerialsarerareandhavebeenspecificallyassociatedwithchromicgut.Chromicacidsmayprovokeareactioninindividualswhoaresensitivetochromate.

Antibacterialproperties

Antimicrobialpropertiesintrinsictothesutureandtheadditionofanextrinsicantimicrobialcoatinghavelongbeentheorizedaswaysofreducingsurgicalsiteinfections(SSIs)bydecreasingbacterialadherencetothesuture,butsuchproductshaveonlymorerecentlybecomeavailableonthemarket.

Currentlyavailableproductsusetriclosan(CoatedVicrylPlusAntibacterialEthiconandMonocrylPlusAntibacterialEthicon).ThisantimicrobialbiocidehasbeenshowntoreduceinvitrosuturecolonizationwithbothmethicillinsensitiveandmethicillinresistantStaphylococcusaureusandStaphylococcusepidermidis.[3]Ametaanalysisof15randomizedcontrolledtrialsincludingatotalof4800patientsestimatedarelativerisk0.67(95%confidenceinterval[CI],0.540.84P=.00053)withanoveralllowerfrequencyofSSIsinpatientsinwhichtriclosancoatedsuturewasusedcomparedwiththoseinwhichnoncoatedsuturewasused.

Otherantimicrobialsuturecoatingssuchaspoly[(aminoethylmethacrylate)co(butylmethacrylate)](PAMBM)havebeenshowntoprovidebacteriocidalactivityagainstSaureuscomparedwiththebacteriostaticpropertyoftriclosaninvitro[4]however,suchproductshavenotbeentestedinvivoandare,therefore,notyetavailablecommercially.

Forexcellentpatienteducationresources,seeeMedicineHealth'spatienteducationarticleSutureCare.

SutureMaterialsSuturesareclassifiedasabsorbableornonabsorbable,naturalorsynthetic,andbraidedormonofilament.Numerouscompaniesmanufacturesutureshowever,Ethicon,Syneture(UnitedStatesSurgical/DavisandGecksuturedivisionofTycoHealthcare),andLook(SurgicalSpecialtiesCorporation)manufacturemostofthesuturesusedinwoundclosure.Mostsuturesareavailableinstandard18and27inchlengths.Severalmanufacturers(eg,Delasco,Look)providesuturesin8,9,and10inchlengths.Theseshortersuturesarelessexpensiveandareusedprimarilyforbiopsywoundsorsmallwoundclosures.

Absorbablesuturematerials

Absorbablesuturesaredefinedbythelossofmostoftheirtensilestrengthwithin60daysafterplacement.Theyareusedprimarilyasburiedsuturestoclosethedermisandsubcutaneoustissueandreducewoundtension.Theonlynaturalabsorbablesutureavailableissurgicalgutorcatgut.Syntheticbraidedmaterialsincludepolyglycolicacid(DexonSyneture)andPolyglactin910(VicrylEthicon).Monofilamentousformsincludepolydioxanone(PDSEthicon),polytrimethylenecarbonate(MaxonSyneture),poliglecaprone(MonocrylEthicon),Glycomer631(BiosynSyneture),andPolyglytone6211(CaprosynSyneture).

Table1.CharacteristicsofAbsorbableSutures(OpenTableinanewwindow)

Property Gut PolyglycolicAcid

Polyglactin Polydioxanone PolytrimethyleneCarbonate

Poliglecaprone

Handling Fair Fairgood Good Poor Good ExcellentKnotsecurity

Poor Fairgood Fair Poor Good Good

Tensilestrength

Low

Proteolysisby6090d,

unpredictable

High

Hydrolysisby90120d

High

Hydrolysisby6090d

Moderate

Hydrolysisby

180210d

High

Hydrolysisby180210d

High

Hydrolysisby90120d

Coefficientoffriction

High High Medium Low Low Low

Memory Low Low Low High Low LowTissuereactivity

High Lowmoderate

Lowmoderate Low Low Low

Uses Mucosaltissues,

Buried BuriedVicrylRapide(Ethicon)in

Buriedinwounds

Buriedinwoundsrequiringlong

Buried



vesselligation

woundsrequiringshorttermdermalsupport

requiringlongtermdermalsupport

termdermalsupport

Other Lowelasticity

Beige,violet,orgreen

Lowelasticity

Clearorviolet

Clearorviolet Clearorgreen Highelasticity

Clear

Surgicalgut

Surgicalgutorcatgutwasthefirstabsorbablesuturematerialavailable.Despiteitsname,catguthasneverbeenmadefromcatintestines.Itisactuallymadebytwistedfiberformedfromthecollagenoftheintestinesofsheep,cattle,orgoats.Surgicalgutispackagedinalcoholtopreventitfromdryingandbreaking.The3formsavailableareplain,chromic,andfastabsorbing(Ethicon).Plaingutelicitsamarkedinflammatoryreactionintissueandmaintainsitstensilestrengthforonly710daysafterimplantation.Generally,itiscompletelyabsorbedby70dayshowever,lossofstrengthandabsorptionvarygreatly.

Chromicgutisplainguttreatedwithchromiumsaltstoslowabsorptionanddecreasetissuereactivitybycrosslinkingthecollagen.Itstensilestrengthismaintainedforaslongas1021days,andcompleteabsorptiondoesnotoccuruntilatleastday90.Plainandchromicguthavedecreaseduseinmodernsurgeryowingtothedevelopmentofsyntheticsuturesthatarehydrolyzedandthereforelessinflammatory.Thismaterialisusedintheclosureofmucosalsurfacesorasligaturesforbloodvessels,amongotheruses.

Fastabsorbinggutisplainguttreatedwithheattofacilitatemorerapidabsorption.Itwasdesignedforpercutaneoussuturingandmaintainsitstensilestrengthforonly57days.Itiscompletelyabsorbedwithin24weeks.Fastabsorbinggutisusefulforthepercutaneousclosureoffacialwoundsunderlowtensionandforsecuringbothsplitandfullthicknessskingrafts.

Polyglycolicacid

Polyglycolicacid(DexonSSyneture)wasintroducedin1970asthefirstsyntheticabsorbablesuture.Ithashightensilestrength,witharetentionof60%atday7,35%atday14,andonly5%atday28.Polyglycolicacidiscompletelyhydrolyzedby90120days.Thisbraidedsutureisuncoatedandmultifilamentoustherefore,ithasgoodhandlingandknotsecurityproperties.However,itshighcoefficientoffrictionresultsinsignificanttissuedrag.Tominimizethisdrag,apolycaprolatecoatedformisavailable(DexonIISyneture).Thisformslidesreadilythroughtissueandiseasytotiehowever,4throwsarerecommendedtoensuresecureknots.Thetissuereactivityassociatedwiththismaterialisrelativelylow,butthemultifilamentnaturemaypotentiateinfection.Polyglycolicacidisavailableasaclearorgreensuture.

Afastabsorbingpolyglycolicacidsuture(PolysynFASurgicalSpecialties)isavailablethatmaintainstensilestrengthfor710daysandiscompletelyhydrolyzedby42days.Thissutureisusefulinwoundsrequiringshorttermdermalsupport.

Polyglactin

Introducedin1974,polyglactinwasthesecondsyntheticabsorbablesuturematerialavailable.Likepolyglycolicacid,polyglactinisbraidedandhassimilarhandlingandknotsecurityproperties.Polyglactin910(VicrylEthicon)iscoatedwithPolyglactin370,whichfacilitatesknottyingandreducestissuedraghowever,thiscoatingalsoreducesknotsecurityandmayrequiretheuseofextrathrows.

Theinitialtensilestrengthofpolyglactinisslightlygreaterthanthatofpolyglycolicacidandisabsorbedmorequickly.Polyglactinretains60%ofitstensilestrengthatday14afterimplantationandonly8%ofitsoriginalstrengthatday28.Itiscompletelyhydrolyzedby6090days.Tissuereactivitywithpolyglactinislow,lessthanthatofpolyglycolicacid.Bothofthesesuturematerialsmaybetransepidermallyeliminatedifburiedtoosuperficiallyinthedermis.Althoughusedprimarilyasaburiedsuture,polyglactinhasbeenusedforpercutaneousclosureswithoutadverseoutcomesandwithresultantcostsavings.Polyglactinisavailableasaclearorvioletsuture.

TwoadditionalPolyglactin910sutureshavebeendevelopedbyEthicon.VicrylRapideisPolyglactin910thathasbeenionizedwithgammaraystospeeditsabsorption.Thisproductisusefulasaburiedsutureinawoundrequiringlimiteddermalsupportitiscompletelyabsorbedin35days.Thenewestmaterialisanantibacterialsuture(CoatedVicrylPlusAntibacterialEthicon).Theantibacterialagentusedtocoatthesutureistriclosan.[5]Biocompatibilityandimplantationstudieshaveshownthistobenoncytotoxicandnonirritating.HandlingandwoundhealingcharacteristicsandabsorptionprofilearecomparabletotheoriginalPolyglactin910material.

Fordetal[3]showedthatfewerpediatricpatientstreatedwiththeantibacterialsuturehadpainonpostoperativeday1whencomparedwiththosetreatedwiththeoriginalPolyglactin910suture(68%vs89%).BothinvitroandinvivostudieshavedemonstratedthatantibacterialPolyglactin910sutureinhibitsbacterialcolonizationwithbothmethicillinsensitiveandmethicillinresistantStaphylococcusaureusandStaphylococcusepidermidis.Thissuturemaybeusefulinwoundsatincreasedriskofinfection.

Polydioxanone

Asyntheticmonofilamentabsorbablesuture,polydioxanone(PDSEthicon)wasfirstavailablein1982.Althoughitsinitialtensilestrengthislowerthanthatofthe2syntheticbraidedsuturesmentionedabove,itretainsitsstrengthlonger.Atday14afterimplantation,ithas74%residualinitialstrengthatday28,58%andatweek6,41%.Completehydrolysisoccursby180210days.Polydioxanoneisstiffandhaspoorhandlingandknottyingproperties.Knotsecurityislikewiselowandrequiresanadditionalthrow.[6,7]AnewerproductthathasreplacedtheoriginalproductisPDSII(Ethicon),whichhasimprovedhandlingcapabilities.



Asamonofilamentsuture,polydioxanonecausesminimaltissuereaction.Itisusefulincontaminatedwoundsorwoundsinlocationsatgreaterriskforinfection.Polydioxanoneisalsousefulasaburiedsutureinwoundsthatrequireprolongeddermalsupport.Dermalsupportofawoundmayreducethespreadingofscars.ElliotandMahaffey[8]demonstratedthata16%reductioninthespreadingofscarscanbeaccomplishedbyusingdermalsupportfor3weeks.Theyfurthershoweda38%reductioninspreadwiththeuseofdermalsupportfor6months.Polydioxanoneisavailableasaclearorvioletsuture.Polydioxanoneismoreexpensivethanpolyglycolicacidorpolyglactin.

Polytrimethylenecarbonate

Polytrimethylenecarbonateorpolyglyconate(MaxonSyneture)wasintroducedin1985asanothersyntheticmonofilamentabsorbablesuture.Ithasahighinitialtensilestrength(greaterthanthatofpolydioxanone),anditretains81%ofitsstrengthatday14,59%atday28,and30%atweek6.Itiscompletelyhydrolyzedby180210days.Polytrimethylenecarbonateiseasiertohandleandhasgreaterknotsecuritythanpolydioxanone,polyglactin,orpolyglycolicacid.Itstissuereactivityiscomparabletothatofpolydioxanone,itsusesarethesame,anditscostislower.Polytrimethylenecarbonateisavailableasaclearorgreensuture.

Poliglecaprone

Poliglecaprone(MonocrylEthicon)isasyntheticabsorbablematerialintroducedin1993.Poliglecaproneisverypliabledespiteitsmonofilamentnature,and,asaresult,itshandlingandknotstrengthareexcellent.Amongallabsorbablemonofilamentsutures,poliglecapronehasthehighesttensilestrengthhowever,only2030%ofitsstrengthisretainedatday14afterimplantation.Completehydrolysisoccursby90120days.Poliglecaproneismostusefulasaburiedsutureinwoundsinwhichprolongeddermalsupportisnotessential.Similartoothermonofilamentsutures,poliglecapronehasminimaltissuedragandreactivity.Itisavailableasaclearmaterial.Thecostofpoliglecaproneiscomparabletothatofpolydioxanone.

Anantibacterialformofpoliglecaproneisnowavailable(MonocrylPlusAntibacterialEthicon).Theantibacterialagentistriclosan,whichhasbeenshowntoinhibitcolonizationofthesuturebymethicillinsensitiveandmethicillinresistantSaureusandSepidermidis,Escherichiacoli,andKlebsiellapneumoniae,evenafterdirectinvivochallengewithbacteria.Thetensilestrengthandabsorptionprofilearesimilartothatofuntreatedpoliglecaprone.

Other

Amonofilamentsyntheticpolyester,Glycomer631(BiosynSyneture),isanotherabsorbablesuture.Rodeheaveretal[9]comparedittoPolyglactin910andfoundittohavegreatertensilestrength4weeksafterimplantation.Thehandlingcharacteristicsandknotsecuritywerealsosuperior.Tissuedragandriskofbacterialinfectionwerelower,likelyaresultofthemonofilamentconstruction.Glycomer631retains75%ofitstensilestrengthatday14and40%atday21.Absorptioniscompletebetween90and110days.Thissutureisavailableundyedorinviolet.

OneofthenewestsyntheticabsorbablesuturesisPolyglytone6211(CaprosynSyneture),whichisarapidlydegradedmonofilamentpolyester.Polyglytone6211hasgreatertensilestrength,lowertissuereactivity,andimprovedhandlingcharacteristicscomparedwithchromicgutsuture.Itsgreatestadvantage,however,isitsrapidrateofabsorption.Itprovidessecurewoundapproximationfor10days,andalltensilestrengthislostbyday21.Itiscompletelyhydrolyzedin56days.Polyglytone6211isavailableundyedorinviolet.

Nonabsorbablesuturematerial

Nonabsorbablesuturesaredefinedbytheirresistancetodegradationbylivingtissues.Theyaremostusefulinpercutaneousclosures.Surgicalsteel,silk,cotton,andlinenarenaturalmaterials.Syntheticnonabsorbablemonofilamentsuturesaremostcommonlyusedincutaneousproceduresandincludenylon,polypropylene,andpolybutester.Syntheticnonabsorbablebraidedsuturescomposedofnylonandpolyesterareusedinfrequentlyindermatologicsurgery.

Table2.NonabsorbableSutureCharacteristics(OpenTableinanewwindow)

Properties Silk Nylon,Monofilament

Nylon,Multifilament

Polyester Polypropylene Polybutester

Handling Excellent Poor Fairgood Good Poor GoodKnotsecurity

Excellent Poor Fairgood Good Poor Fairgood

Tensilestrength

Low High High High Moderate High

Coefficientoffriction

High Low High High Verylow Verylow

Memory Low High Medium Medium High LowTissuereactivity

High Low Moderate Lowmoderate

Low Low

Uses Mucosaltissues,conjunctivaorintertriginouszonestoelevateorretracttissues

Percutaneousburiedifprolongeddermalsupportisneeded

Minimaluseindermatologicsurgery

Minimaluseindermatologicsurgery

Percutaneousburiedifprolongeddermalsupportisneededrunningsubcuticularclosures

Percutaneousrunningsubcuticularclosures

Other Black Black,green,orclear

Greenorclear

Highplasticity

Blueorclear

Highelasticity

Blueorclear



Silk

Silkwasfirstwidelyusedasasuturematerialinthe1890s.Itisabraidedmaterialformedfromtheproteinfibers

producedbysilkwormlarvae.Althoughsilkisconsideredanonabsorbablematerial,itisgraduallydegradedintissue

over2years.Silkhasexcellenthandlingandknottyingpropertiesandisthestandardtowhichallothersuture

materialsarecompared.Itsknotsecurityishigh,tensilestrengthlow,andtissuereactivityhigh.Sutureremovalcan

bedifficultandpainfulbecausethebraidedmaterialbecomesinfiltratedwithcellsandencrustedwithdebriswhile

implantedintheskin.

Silkisasoft,pliablesuturematerialthatiscomfortableforpatientsandunlikelytotearthroughevendelicatetissues.

Asaresult,itisagoodchoiceforuseinmucosaltissuesorintertriginousareas.Silkalsoisusefulasatemporary

suturetoelevateorretracttissuesforimprovedvisibilityduringsurgery.Itisavailableinblack.

Nylon

Introducedin1940,nylonwasthefirstsyntheticsutureavailable,anditisthemostcommonlyusednonabsorbable

materialinwoundclosure.Itisavailableinbothmonofilamentousandbraidedforms.Nylonhasahightensile

strength,and,althoughitisclassifiedasnonabsorbable,itlosestensilestrengthwhenburiedintissue.Braided

formsretainnotensilestrengthafterbeingintissuefor6months,whereasmonofilamentousformsretainasmuchas

twothirdsoftheiroriginalstrengthafter11years.Monofilamentnylonisstifftherefore,handlingandtyingare

difficultandknotsecurityislow.Thesuturealsomaycuteasilythroughthintissue.

Braidedformshavebetterhandlingpropertiesbutgreatertissuereactivityandcost.Theyareusedinfrequentlyin

woundclosure.Monofilamentnylonisrelativelyinexpensiveandavailableasblack,green,orclear.Althoughits

greatestuseisasapercutaneoussuture,becauseofitslowtissuereactivity,nylon(clear)canbeusedasaburied

sutureinsituationsinwhichprolongeddermalsupportisnecessary.

Polyester

Polyesterisabraidedsyntheticsuturewithusessimilartothoseofbraidednylon.Ithashightensilestrength,with

goodhandling,goodknotsecurity,andrelativelylowtissuereactivity.Polyesterisavailableinacoatedformthat

decreasestissuedrag.Itisapliable,softsuturesimilartosilkandcanbeusedinmucosaltissuesorintertriginous

areas.Additionalsuturetensilestrengthcanbeachievedwhenpolyesterisbraidedorblendedwithothersynthetic

fiberssuchaspolyethyleneinproductslikeEthibond(Ethicon)andMersilene(Ethicon).Thesesutures,however,are

costlyandinfrequentlyusedforskinclosurebutinsteadondeeptissuessuchastendonorfascia.

Polypropylene

Polypropylene(Prolene,Ethicon)isamonofilamentsyntheticsuturethatwasintroducedin1962.Itstensilestrength

islowerthanthatoftheothersyntheticnonabsorbablesutures.Itshandling,tying,andknotsecurityarepoorasa

resultofitsstiffnatureandhighmemory.Anadditionalthrowisneededforadequateknotsecurity.Amethodto

improvesecurityistheuseofthermocauterytofusetheknotsortransformtheendsintosmallbeads.Tissue

reactivityisextremelylowforpolypropylene,and,unlikenylon,gradualabsorptiondoesnotoccurifitisburiedin

tissue.Asaresult,polypropyleneisanexcellentchoiceforaburiedsutureforlongtermdermalsupport.

Polypropylenehasalowcoefficientoffrictionandeasilyslidesthroughtissuethischaracteristicmakesitthesuture

ofchoiceforarunningsubcuticularclosure.Itisaplasticsuturethataccommodatestissueswellingtherefore,the

likelihoodofitcuttingthroughthetissueandcausingcrosshatchingislessthanthatofothermaterials.However,as

swellingofawoundresolves,sutureremainsloose,andthisloosenessmayaffectwoundapproximation.The

plasticityofpolypropylenemayactuallyimproveknotsecurityinsomecasestheknotistightenedasthesutureis

stretchedduringwoundswelling.Polypropyleneismoreexpensivethannylonandisavailableasaclearorblue

suture.

Polybutester

Thenewestmonofilamentnonabsorbablesyntheticsutureispolybutester(NovafilSyneture).Thissuturecombines

manyofthedesirablecharacteristicsofpolypropyleneandpolyester.Polybutesterhasahightensilestrengthwith

goodhandlingqualities.Itsmemoryislowerthanthatofpolypropylene,andtherefore,itsknotsaremoresecure.

Polybutesterisnotaplasticsuture,butithasuniqueelasticpropertiesthatallowittooptimallyrespondtowound

edema.Likepolypropylene,polybutesterhasalowcoefficientoffrictionandisanexcellentchoiceforarunning

subcuticularclosure.Polybutesterisavailableasaclearorbluesuture.Itscostiscomparabletothatof

polypropylene.

AlsoseetheMedscapearticleSuturingTechniques.

NeedlesNeedlesarenecessaryfortheplacementofsuturematerialinawound.Needlesshouldbemadeofhighquality

stainlesssteel,sharpenoughtopenetratetissuewithminimaltrauma,rigidenoughtoresistbending,andmalleable

enoughtobendbeforebreaking.Thesharpnessoftheneedleisdeterminedbythemethodofsharpening.Hand

honedorelectrohonedneedlesaresharperthanthoseprocessedbymachinegrinding.Sharperneedlespassmore

easilythroughtissueandcreatelesstraumatothewound.Theyareidealforfinecosmeticwork.Thecostofneedles

isbasedonthequalityofthestainlesssteelandtheirsharpness.Inchoosinganeedleforcutaneoussurgery,the

followingshouldbeconsidered:tissuethickness,tissuetype,location,needforcosmesis,suturesize,andcost.

Needlestructure

Thestructureofaneedleincludes3standardportions:theshankoreye,thebody,andthepoint.Theshankisthe

portionoftheneedlethatisattachedtothesuture.Swagedneedlesarepreferredinwoundclosure.Theyhavea

hollowshankintowhichthemanufacturerhassecuredthesuture.Thisportion,theswage,isboththethickestand

weakestpartoftheneedle.

Thebodyistheportionoftheneedlebetweentheproximalendofthepointandthecontourchangeatthebeginning



oftheswage.Inwoundclosure,thebodyisusuallycurved.Thecurvatureisbasedonafractionofthearcofacircle3/8circleand1/2circlecurvaturesaremostoftenused.Thechoiceofaparticularneedlelength,width,andcurvaturedependsonthesizeanddepthofthewoundandthethicknessandtypeoftissuetobesutured.Forexample,indeep,narrow,orconfinedspaces,1/2circleneedlesareeasiertohandle.Thecrosssectionalshapeofthebodycanberound,triangular,oval,rectangular,ortrapezoidal.Thebodymayberibbedtoimprovetheholder'sgripontheneedle.

Themainfunctionsofthebodyaretointeractwiththeneedleholderandtotransmitpenetratingforcetothepoint.Theneedleholdershouldbeplacedapproximatelyonethirdthedistancefromtheshanktothetipofthepoint.Holdingtheneedleovertheshankmaycauseittobendorbreak.

Thepointistheportionoftheneedlefromthetiptotheendofthetaperatthemaximumdiameterofthebody.Fourtypesofneedlepointsareavailable:round,conventionalcutting,reversecutting,andspatulated.Aroundpointistaperedandhasnocuttingedgesitpassesthroughtissuebystretchingit.Thisneedleisusedforsuturingsoft,elastictissues(eg,fascia,muscle)butnotskin.

Conventionalcuttingandreversecuttingneedlesaremostcommonlyusedinwoundclosure.Theypassthroughtissuebycuttingapathratherthanstretchingthetissue.Bothhavetriangularshapesand3cuttingedges.Twoofthecuttingedgesareonopposingsidesoftheneedle.Theconventionalcuttingneedlehasitsthirdcuttingedgeontheinnercurvatureoftheneedleandhasatendencytocutthroughtissueifupwardpressureisexerted.Thereversecuttingneedlehasitsthirdcuttingedgeontheoutercurvature.Thisneedleislesslikelytotearthroughtissueduringsuturingandismoreoftenusedforskinclosure.

Spatulaneedlepointsareflatand4to6sidedwithcuttingedgesfacilitatingsuperiorcontrolandpreventingaccidentalperforationwhensuturingdelicatetissue.Theyaremostcommonlyusedinophthalmologicsurgeryandnailbedrepairs.Finally,anewquadsidedneedlewithdiamondgeometry(DermaglideLook)isavailable,anditisdesignedtominimizetissuetraumabyretainingitssharpnesslonger.

Inadditiontothemorecommonlyusedcurvedneedles,straightneedlesarealsoavailable.Thesearetypicallyusedineasilyaccessibletissuewherethereisadequatespacetomaneuverthemorecumbersomestraightdesign.Keithneedles(Medline)arestraightneedleswithathreadableeye,muchliketraditionalfabricsewingneedles.

Needleselection

Theselectionofneedlesisconfusingbecausemanufacturersusevaryingdesignationsforsimilarneedles(seeTable3).Ethiconneedles,forexample,includeFS(forskin),PS(forplasticskin),P(forprecisionpoint),andPC(forprecisioncosmetic)types.SynetureneedlesincludePorPC(plastic/cosmetic),C(cutaneous)andDX(DermaXpremiumxcutting).Look(SurgicalSpecialties)makesneedlescomparabletothosemadebytheabovemanufacturers.

TheFSandCtypesarelarge,reversecuttingneedlesandaretheleastsharpandexpensive.Theyareusefulintheburiedandpercutaneousclosureofwoundsonthescalp,trunk,andextremitiesinwhichcosmesisisnotcrucial.ThePSneedleissimilartotheFSneedleinsizeandconfiguration,butitissharperandbetterforcosmeticproceduresinareaswheretheskinisthickerandtougher.ThePneedlesarealsoreversecutting,buttheyaresharperandsmallerthanthePSneedletherefore,theyareanexcellentchoiceforuseinthin,delicatetissueswhencosmesisisimportant.

ThePCneedlesareconventionalcuttingneedles,buttheyhavealong,narrow,andverysharptipthatislesslikelytotearthroughtissue.Asaresult,theycauseverylittletissuetraumaduringsuturing.PCneedlesareidealforfine,detailedwork.

Table3.Needles(OpenTableinanewwindow)

NeedleStyle ManufacturerEthicon Look Syneture

11mm,3/8circle,reversecutting P1 C1 P1013mm,3/8circle,reversecutting P3 C3 P1313mm,3/8circle,conventionalcutting PC1 CP1 PC1019mm,3/8circle,reversecutting PS2 PC31 P1219mm,3/8circle,reversecutting FS2 C6 C13

StaplesStaplesareformedfromhighqualitystainlesssteelandareavailableinregularandwidesizes.Staplesarecomposedof(1)acrossmemberthatlaysonthesurfaceoftheskinperpendiculartothewound,(2)legsthatareverticallyplacedintheskin,and(3)tipsthatsecurethestapleparalleltothecrossmember.Staplesarerelativelyeasytoplaceandmayshortentheclosuretimeby7080%.Theprimaryutilityofstaplesisintheclosureofwoundsunderhightensiononthetrunk,extremities,andscalp.Theyarealsousedtosecuresplitthicknessskingrafts.Theyarenotusedindelicatetissuesorwoundsinfinelycontouredareas,overbonyprominences,orinhighlymobileareas.

Severalstudieshavebeenconductedtocomparetheuseofstaplesandnylonsuturesonthetrunk,head,andnecktheserevealedcomparablecosmeticresults.Advantagesofstaplesincluderapidspeedofclosure,adecreasedriskofinfection,improvedwoundeversion,andminimaltissuereactivity.Disadvantagesincludetheneedforasecondoperatortoevertandreapproximateskinedgesduringstapleplacement,greaterriskofcrosshatchmarking,andlessprecisewoundapproximation.Thecostisusuallymorethanthatofsuturematerial.

Inskinclosure,thestaplersusedaredisposableandloadedwith535staples,dependingonthemanufacturer.Theyarelightweightandhavehandlesthatareeasytogripandcontrol.Thewidthandheightofthestaplesvarywiththemanufacturer.Mostregularstaplesare46mmwideand3.54mmhigh.Widestaplesforuseinthickerskinare6.57.5mmwideand45mmhigh.



Forstapleplacement,thestaplerisgentlyheldonthesurfaceoftheskin,perpendiculartothewound,andthe

handleissqueezed,plungingthestapleintotheskintoformanincompleterectangle.Thedepthofpenetrationis

basedonthepressureexertedonthestapleragainsttheskin.Todisengagethestaple,thehandleisreleased.Ifthe

staplerhasanejectorspringrelease,itisliftedverticallyofftheskin.Ifnot,thestaplermustbemovedanteriorlyor

posteriorly.

Thecorrectplacementofstaplesiscriticaltoavoidcomplicationssuchastissuestrangulationandcrosshatch

marking.Staplesshouldbeinsertedat45or60angles.Asawoundswells,astapleplacedatanacuteangle

rotatesintoaverticalposition,leavingaspacebetweenthecrossmemberandtheskinsurfacetoaccommodate

swelling.Ifplacedata90angle,thestaplecannotmoveandislikelytostrangulatethetissueduringswelling.

StaplersthatareusedwidelyinskinclosureincludeAppose(Autosuture,UnitedStatesSurgical)andProximate

(Ethicon).AuniquestapleristheMultifirePremiumstapler(Autosuture),whichisdisposablebutcanbereloadedfor

continueduseonthesamepatient.ThePreciseMultiShotcricketskinstapler(3M)isasmallerskinstapler

designedformoredelicatetissueclosuresorfortackingskingraftsinplace.

Recently,theINSORBstaplingdevice(IncisiveSurgicalIncPlymouth,Minn)wasintroduced,providinga

subcuticularabsorbableskinstaplingoption.RandomizedcontrolledtrialscomparingINSORBwithtraditionalsuture

closurehaveshownshorterclosuretimesandbetterskinedgeeversionwithINSORM,withnosignificantdifference

inscarappearancescores4monthspostoperatively.[10]

Surgicalstaplesaredepictedintheimagebelow.

Surgicalstaplesingroinafteringuinalherniaoperation.ImagecourtesyofWikimediaCommons.

Staplesareremovedpainlesslybyusingaspecializedsetofextractors.

TapesTapesarestripsofmicroporousnonocclusivematerial(eg,paper,plastic,rayonfabric)backedbyathinfilmof

acrylicpolymeradhesive.Theyareusefulasanadjuncttoorasubstituteforotherwoundclosurematerials.

Althoughtheyareusedmostoftentoreinforceawoundaftertheremovalofsuturesorstaples,theycanalsobe

usedaloneforwoundsthataresmall,nonexudative,andunderminimaltension.

Theadvantagesoftapesincludeeaseofuse,comforttothepatient,andavoidanceoftissuestrangulation,infection,

andcrosshatchmarks.Followupvisitsforremovalarenotnecessary.Allergicreactiontotheadhesiveis

uncommon.Disadvantagesincludelimitedwoundeversion,imprecisewoundedgeapproximation,andinconsistent

adhesion.Tapeshavelittleusefulnessinhairyorhighlymobileareas.Moisture,soap,andwoundexudatedecrease

thedurationoftapeadhesion.

Tomaximizeadhesion,theuseofaliquidadhesiveisessential.Mastisol(FerndaleLaboratories)andtinctureof

benzoinareavailableforthispurposeMastisolhassuperioradhesivestrength.Afterthewoundisgrossly

reapproximated,theareashouldbedegreasedwithalcohol,acetone,oradhesiveremover,andtheliquidadhesive

shouldbeappliedoverthewoundedgesandtheentireareatowhichthetapeswillbeplaced.Oncetheadhesive

hasdriedtoatackyfeel,stripsoftapesshouldbeplacedperpendicularlyacrossthewoundwithoutoverlappingone

another.Additionaltapesshouldnotbeusedparalleltothewoundtoreinforcethetapeedgesbecausethis

applicationdecreasesadherence.Tapesthatarekeptdryandcleanmayremainadherentforupto12weeks.

Zempskyetal[11]

comparedthecosmeticoutcomesoffaciallacerationsclosedwithSteriStripSkinClosures(3M)or

Dermabondtissueadhesive(Ethicon)in97patients.Atshorttermfollowup,morecomplicationswerenotedinthe

tissueadhesivegroup(7)thaninthetapegroup(1).Longtermfollowuprevealednocosmeticdifference.Tape

closureofsimplefaciallacerationsmaybeausefullowcostalternativetotissueadhesivesandsutures.

Tapesareavailableindifferentwidths(eg,oneeighthinch,quarterinch,halfinch)andcolors(eg,white,clear,flesh

toned).CommonlyavailableproductsincludeSteriStripSkinClosures(3M),CoverStripII(Beiersdorf),andProxi

StripSkinClosures(Ethicon).

TissueAdhesivesCyanoacrylatesforuseinsurgeryhavebeenavailableinCanadaandEuropefor20years,butproductssuitablefor

useinskinclosureintheUnitedStateshavenotbecomeavailableuntilrecently.Octylcyanoacrylate(Dermabond

Ethicon)andNbutyl2cyanoacrylate(IndermilSyneture)polymerizeinanexothermicreactiononcontactwithfluidtoforma3dimensional,strong,flexiblebond,withusescomparabletothoseof50monofilamentnylon.Bothare

availableinsingleusevials/ampules.

OctylcyanoacrylateandNbutyl2cyanoacrylateareusefulfortheclosureofsimplelacerationsinchildrenanduncooperativepatients.Theyarealsousefulfortheclosureofincisionsundercastsorincasesinwhichfollowupis

difficult.Theyarenotforuseinareasthatarehighlymobileorsubjecttofriction(eg,overjoints,hands,feet).Both

cyanoacrylatesarequickandeasytoapply,requiringonlyonetenthtoonefourthofthetimerequiredforsuture

placement.Theymayalsobeusedtoreinforceincisionsclosedwithsutureorstaples,astheyprovidean

antimicrobialandwaterproofcoating,butrepeatedwashingremovestheadhesiveinafewdays.Thecosmetic

outcomeisgood,andnopostoperativevisitisrequiredforremoval.

Despitethefactthattheiruseonthehandsisdiscouraged,Sinhaetal[12]

randomized50patientsundergoinghand



surgerytowoundclosurewithsuturesorNbutyl2cyanoacrylate.Fivewounddehiscencesoccurred3inthecyanoacrylategroupand2inthesuturegroup.ThestudydemonstratedthatNbutyl2cyanoacrylatemaybeaseffectiveassuturingforcutaneousclosureinhandsurgery.

AnotherstudycomparedtheeffectivenessofNbutyl2cyanoacrylate(NBCA)andtraditionalsuturesfortensionfreeinguinalhernialsurgery.Atotalof110patientswithprimaryunilateralinguinalherniawereassignedrandomlytoeitherNBCAadhesiveortraditionalsuture.Resultsshowednoherniarecurrenceorwoundinfectionineithergroup.Inthesettingoftensionfreeinguinalherniawounds,NBCAiscomparabletotraditionalsutureclosure.[13]

Thecostperunitofcyanoacrylateishigherthanthatofcomparablesutureshowever,Osmondetal[14]performedacostanalysis,comparingtheuseofsuturestotissueadhesivesinanemergencydepartment.Theyaccountedforallequipment,healthcareworkertime,andlossofincomeforfollowupvisitsandfoundthattheuseofthetissueadhesivewasoverallcosteffective.

Theuseofcyanoacrylatesrequiresthatthewoundbecompletelyreapproximatedbeforeitsapplication.Infullthicknesswoundclosure,alayerofburiedsuturesisgenerallyrequiredpriortotheapplicationoftheadhesive.Iftheadhesiveseepsintothewoundbed,healingisimpaired.

Beforeapplication,theskinmustbedefattedwithalcoholoracetone.Octylcyanoacrylateisappliedinathinlayerovertheentirewoundandextending510mmbeyondthewoundedge.Theformationofthebondproducesheatthatthepatientcanfeel.Oncethelayerisdried(1030seconds),asecondlayerisapplied.Threeto4layersarenecessary.Nbutyl2cyanoacrylaterequiresonlyasingleapplicationbydropletthatsetsin30secondsandrequiresnodirectcontactwiththewound.Noadditionalbandagingisrequired,andthepatientisadvisedtonotperformwoundcareathome.By714days,mostoftheadhesivesloughswiththeepidermis,andtheremaindermayberemovedwithsoapandwaterorpetroleumjelly.Achiseltipapplicatorisavailablefortheoctylcyanoacrylatevialtoimproveapplication.AnaccessorycannulatipcanbeobtainedforusewiththeNbutyl2cyanoacrylateampuleforthesamereason.

Inadditiontotheirindicationforuseasasurgicaladhesive,bothcyanoacrylatesareapprovedbytheUSFoodandDrugAdministrationforuseasabarrieragainstcommonbacterialmicrobes,includingcertainstaphylococci,pseudomonads,andEcoli.

Anoverthecounterformulationofoctylcyanoacrylate,LiquidBandage(Johnson&Johnson),wasintroducedasanocclusivedressingforminorlacerationsandabrasions.MartnGarcaetal[15]studiedthisasadressingoversuturedfacialexcisionsandfoundittobeaconvenientandeconomicalalternativetodailydressingchanges.

NewDirectionsThebondingofwoundsusinglaserenergy,knownaslaserwelding,hasbeenusedonalimitedbasisasanalternativetotraditionalwoundclosure.Comparedwithpreviouslymentionedclosurematerials,laserweldingisfaster,watertight,andavoidsaforeignbodyreaction.However,collateralthermalinjuryhaspreventeditsregularclinicaluse.Tominimizethisinjury,lasersolderingwasintroduced.Thisprocessinvolvestheapplicationofabiologic"solder"(eg,bovineserumalbumin)priortotemperaturecontrolledlaserwelding.[16]

AnimalstudiesperformedbySimhonetal[17]andBroshetal[18]demonstratedfasterreepithelialization,reducedscarwidth,reduceddermalinflammation,andhigherlongtermtensilestrengthinlasersolderedincisionscomparedwithsuturedincisions.AclinicalstudybyKirschetal[19]examinedlasersolderingforhypospadiasrepair.Operativetimesandcomplicationrateswerereducedcomparedwithstandardsuturing.Additionalstudiesarenecessarytodeterminethepracticaluseoflasersolderingindermatologicsurgery.

Newconceptsinskinsubstitutesincludebioengineeredproducts,polymers(polyNacetylglucosamine)withbioactiveproperties,and,geneticallymodifiedtissueengineeredskinwithvariousgrowthfactors.[20,21,22]

ContributorInformationandDisclosuresAuthorEllenStolleSatteson,MDDepartmentofPlasticandReconstructiveSurgery,WakeForestUniversitySchoolofMedicine

Disclosure:Nothingtodisclose.

Coauthor(s)JosephAMolnar,MD,PhD,FACSMedicalDirector,WoundCareCenter,AssociateDirectorofBurnUnit,Professor,DepartmentofPlasticandReconstructiveSurgeryandRegenerativeMedicine,WakeForestUniversitySchoolofMedicine

JosephAMolnar,MD,PhD,FACSisamemberofthefollowingmedicalsocieties:AmericanAssociationofPlasticSurgeons,AmericanBurnAssociation,AmericanCollegeofSurgeons,AmericanMedicalAssociation,AmericanSocietyforParenteralandEnteralNutrition,AmericanSocietyofPlasticSurgeons,NorthCarolinaMedicalSociety,PeripheralNerveSociety,UnderseaandHyperbaricMedicalSociety,andWoundHealingSociety

Disclosure:ClinicalCellCultureGrant/researchfundsCoinvestigatorIntegraLifeSciencesHonorariaSpeakingandteachingHealogicsHonorariaBoardmembershipAnikaTherapeuticsHonorariaConsultingFoodMattersHonorariaConsulting

SpecialtyEditorBoardDesireeRatner,MDDirector,ComprehensiveSkinCancerCenter,ContinuumCancerCentersofNewYorkDirectorofDermatologicSurgery,BethIsraelMedicalCenterandStLuke'sandRooseveltHospitalsProfessorofClinicalDermatology,ColumbiaUniversityCollegeofPhysiciansandSurgeons

DesireeRatner,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology,AmericanCollegeofMohsMicrographicSurgeryandCutaneousOncology,AmericanMedicalAssociation,AmericanSocietyforDermatologicSurgery,andPhiBetaKappa




DavidFButler,MDSectionChiefofDermatology,CentralTexasVeteransHealthcareSystemProfessorofDermatology,TexasA&MUniversityCollegeofMedicineFoundingChair,DepartmentofDermatology,ScottandWhiteClinic

DavidFButler,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyofDermatology,AmericanMedicalAssociation,AmericanSocietyforDermatologicSurgery,AmericanSocietyforMOHSSurgery,AssociationofMilitaryDermatologists,andPhiBetaKappa


JeffreyPCallen,MDProfessorofMedicine(Dermatology),Chief,DivisionofDermatology,UniversityofLouisvilleSchoolofMedicine

JeffreyPCallen,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyofDermatology,AmericanCollegeofPhysicians,andAmericanCollegeofRheumatology

Disclosure:UpToDateHonorariaauthor/editorJAMADermatologyHonorariaAssociateeditorandintermittentauthorElsevierRoyaltyBookauthor/editorStockholdingsinvarioustrustaccountsincludesomepharmaceuticalcompaniesanddevicemakersIdonotcontroltheseaccounts,buthavedirectedourmanagerstodivestpharmaceuticalstocksasisfiscallyprudentIinheritedthesetrustaccountsXOMAHonorariaConsulting

GlenHCrawford,MDAssistantClinicalProfessor,DepartmentofDermatology,UniversityofPennsylvaniaSchoolofMedicineChief,DivisionofDermatology,ThePennsylvaniaHospital

GlenHCrawford,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyofDermatology,AmericanMedicalAssociation,PhiBetaKappa,andSocietyofUSAFFlightSurgeons

Disclosure:AbvieHonorariaSpeakingandteaching

ChiefEditorDirkMElston,MDDirector,AckermanAcademyofDermatopathology,NewYork

DirkMElston,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofDermatology


AdditionalContributorsMargaretTerhune,MDPrivatePractice,RichmondDermatologyandLaserSpecialists

MargaretTerhune,MD,isamemberofthefollowingmedicalsocieties:PhiBetaKappa


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