The use of sutures is an absolute must for the closure of any type of incision in plastic surgery. Careful approximation of the wound edges and providing underlying layers of support by sutures are what makes the resultant scar from any elective plastic surgery procedure usually favorable and minimized. While the use of sutures on the underside of the skin (dermis) or through the dermis (subcuticular) are integral to a nice closure and scar, they also are the source of frequent incisional problems that can be quite distressing to patients.
The use of buried sutures in wound closure is very convenient for patients as they are not seen nor require secondary removal. This is a great relief to most patients. When it comes to such operations as facelifts, breast lifts and reductions, tummy tucks and many other body contouring procedures, the amount of buried suture material can be considerable due to the length of incisions involved. While much of this suture material does indeed break down and is resorbed, this does not always occur. This is uniquely due to the superficial location (dermis) of the sutures. This suture location is prone to a common problem known as ‘spitting sutures’ or ‘spitters’. These appear like inflamed pimples or hot spots along the suture line weeks to months after surgery.
Patients understandably interpret these delayed eruptions along the incision line as an infection of their surgery. These developments are a frequent source of phone calls and concern to the plastic surgeon. While we would prefer not to see these minor suture problems they are inevitable at some level of occurrence for most patients. Understanding why they occur is helpful to putting their development in perspective.
While dissolveable sutures do eventually break down and go away, this is a process that takes time. How much time depends on the type of dissolveable material used. Most such materials today are polymers or various forms of plastic. In the days gone by, the material composition was ‘catgut’ or some form of synthetic or animal collagen. Dissolveable sutures today are mainly synthetic polymers because of their superior strength and handling properties. But they usually take longer to dissolve which is in the range of months up to a year after implantation.
But the time dissolveable sutures take to go away is affected by where they are placed. Sutures in the dermis will take longer to go away than if similarly placed in deeper tissues like muscle. But ‘spitting sutures’ are not primarily caused by this factor. Rather it is the very close location to the skin and the outer surface that can cause the body to react to them like a foreign body. The body reacts to the knots of the suture (a bigger mass of material than a straight line of sutures) through an inflammatory process and works to extrude or expel the stitch…long before the dissolveable process takes place.
This attempt by the body to expel dissolveable skin sutures creates a classic source of presentation. They appear weeks to months later at a time when the patient believes their incision is completely healed or nearly so. The most common time to see spitting sutures is between 3 and 8 weeks after surgery. It takes time for inflammation to develop and create the problem. They initially appear as a red or purple spots along the incision and may turn into a spot infection that looks like a pimple and may drain fluid or even pus. Squeezing on the ‘pimple’ will release the fluid and can even force the suture knot out. These are more small inflammatory problems and should not be confused with a more significant wound or surgical site infection.
The solution to the spitting suture problem is to remove the nidus or the cause, the suture itself. This is best done by the plastic surgeon as some rooting around or digging may be required to get it off. Despite how the area along the incision may look when it is extruding, this rarely causes any significant adverse scarring.
Dr. Barry Eppley