PLASTIC SURGERY…for Neurosurgeons

Dr. Joel Aronowitz

5 min readMay 21, 2024

Dr. Joel Aronowitz

CSMC Div. Plastic Surgery

Sutures are as old as creation.

“And they knew they were naked and SEWED fig leaves to cover themselves”

Genesis

A Brief Suture History

· 30,000 BC Neolithic eyed needles

· 3,500 BC Edwin Smith Papyrus

· 210 AD Galen sewed gladiators w/gut

· 1887 sterile sutures introduced

· 1920 Merson invents the Swage

Classification of Sutures

Absorbable vs. Permanent

Natural vs. Synthetic
Tensile strength loss over time

Braided vs. Monofilament

BRAIDED VS MONOFILAMENT SUTURE

BRAIDED

Handling better
Knots more secure
Softer
No snitching, Clinching
Infection risk hi, 10,000X less bact innoculum
Freq spitting

MONOFILAMENT

Lower infection risk
Snitches easily
Stiffer
Less spitting

ABSORBABLE VS NON-ABSORBABLE

ABSORBABLE

No retained foreign body
No late suture reaction
Risk of premature tensile strength failure
Elicits cellular response, ie wbc

NON-ABSORBABLE

Permanent strength
Useful anatomic marker
Min inflamm response, monofil., relatively inert
Long term FB effects, esp braided sutures
Poor handling may cause loss of strength, eg instrument grasping, over stretch etc.

Absorption of Non-Permanent Sutures

Absorbable suture strength vs time

Absorbable suture strength loss

Vicryl and Vicryl rapide, coated (polyglactin)

3 wks

2. Monocryl (poliglecaprone)

2 wks

3. PDS (polydioanone)

4 wks

4. Gut; fast and chromic (collagen)

1 wk

Natural material: Enzymatic Absorption w/ WBC response

Synthetic material: Hydrolysis with less WBC response

TYPES of ABSORBABLE SUTURE

MONOFILAMENT

Monocryl (plus)
PDS (plus)
Gut - Plain, fast, chromic
Dyed vs Undyed
Barbed (Stratafix)

BRAIDED

Vicryl
Vicryl rapide
Dyed vs undyed

TYPES of NONABSORBABLE SUTURE

MONOFILAMENT

Ethilon (nylon)
Prolene (polypropylene)
Pronova (blue)
Steel

BRAIDED

Nurolon (nylon)
Mersilene (polyethylene)
Ethibond (polyprop. green)
Silk

SURGICAL NEEDLES

TAPER

Useful for vessels, delicate tissues, prone to propagating a tear
Dull easily

CUTTING

Many cutting tips
Needle creates a small laceration in tissue
Spatulated, Straight

SURGICAL NEEDLES

Needle Point Type

TAPER POINT
TAPERCUT
TAPERCUT CARDIO
PRIME CONVENTIONAL CUTTING
PRIME REVERSE CUTTING
REVERSE CUTTING
BLUNT POINT
BLUNT POINT ETHIGUARD
TROCAR ,(straight)
CUTTING EDGE PRIME CONVENTIONAL
CUTTING EDGE PRIME REVERSE
CUTTING EDGE REVERSE
CUTTING EDGE SPATULA REVERSE
LIGAPAK Reel
NO NEEDLE
EYED (FREE) NEEDLES

WHAT SUTURE TO USE

SKIN of SCALP

3–0 Prolene simple or vert.mattress as needed to evert
Staples
3–0 Monocryl Subcuticular
Prineo System and Dermabond rare cases

SUBCUTANEOUS FAT LAYER and GALEA

3–0 Monocryl buried in adipose
2–0 Monocryl in Galea
6–0 Prolene in face (forehead, brow, preauricular)

SOME TISSUE HANDLING TIPS

Envision surgical tissue handling on a histologic level.
Avoid crushing tissue, avoid excess or prolonged stretch
Respect the cutaneous blood supply, cauterize judiciously
Radiated tissue is anoxic on a cellular level due to obliterative arteritis, thus radiation injury worsens over time. Surgeon Beware!
Place sutures evenly, without xs tension
Minimize FB present in wound and hardware profile on overlying skin flap

SOME (extracranial) SURGICAL TECHNIQUE TIPS

Recognize and use old scars if possible, no signif. blood supply across the old scar. Keep Nitrobid close by…
Err on side of larger flap design, not smaller.
Protect scalp flap in long cases, keep moist, avoid excess tension in retraction, allow 5 min restoration of blood flow if flap is ischemic for >6 hrs.
Undermine scalp at subperiosteal level to recruit laxity if needed. OK to undermine forehead to sup orbit and nasal root, cheek to zygoma, and occiput to nape of neck if SO, ST, Occip vessels are preserved.

Skin Anatomy

Suture Technique

WHEN TO REMOVE SUTURES

Suture scars result from epithelialization of suture tract, ie sutures in too long, or strangulation of tissue within suture loop, suture pulled too tight or excess po swelling.