How to be sure all sutures are removed when they are covered with granulation tissue?

Removing Sutures Covered by Granulation Tissue

To ensure all sutures are removed when covered by granulation tissue, thorough debridement of the granulation tissue using a degranulation bur is strongly recommended before attempting suture removal. 1

Assessment and Preparation

• Carefully examine the wound for:

  • Signs of infection (redness, warmth, swelling, purulence)
  • Indications of wound dehiscence
  • Extent of granulation tissue coverage

• Use aseptic non-touch technique (ANTT) for the procedure 2

  • Prepare sterile field
  • Use appropriate personal protective equipment
  • Follow local policy for wound management

Step-by-Step Approach

1. Initial Debridement

   • Use a degranulation bur to thoroughly remove all granulation tissue 1
   • This is critical as granulation tissue can completely obscure sutures
   • Ensure complete visualization of the wound bed

2. Wound Irrigation

   • Rinse the area with sterile solution or L-PRF exudate (if available) 1
   • This helps clear debris and improve visualization

3. Careful Examination

   • Use good lighting and magnification if necessary
   • Systematically inspect the entire wound bed for any visible or partially visible sutures
   • Pay special attention to wound edges and corners where sutures may be hidden

4. Suture Removal Technique

   • Once identified, grasp the suture with forceps and gently lift
   • Cut the suture at skin level on one side
   • Pull the entire suture out in one piece using the forceps
   • Ensure the entire suture is removed, not just visible portions

Special Considerations

For Persistent Granulation Tissue

• Be aware that persistent granulation tissue may indicate underlying foreign material (sutures) 3
• In cases of persistent granulation tissue despite treatment, suspect hidden sutures
• Consider that actinomycosis can be associated with persistent granulation tissue and suture material 3

When Granulation Tissue Obscures Visualization

• If granulation tissue is extensive and visualization remains poor despite initial debridement:
  • Consider using Negative Pressure Wound Therapy (NPWT) to manage the wound and promote better visualization 1
  • A wound contact layer (e.g., non-adherent silicon layer) should be placed between NPWT wound filler and wound bed to prevent damage during dressing changes 1

For Difficult Cases

• If outpatient removal attempts are unsuccessful or causing significant discomfort:
  • Consider surgical intervention in the operating room for complete suture removal 3
  • This may be necessary when granulation tissue is extensive or when sutures are deeply embedded

Potential Complications

• Incomplete suture removal can lead to:

  • Persistent inflammation
  • Delayed healing
  • Infection
  • Formation of suture granulomas
  • Potential need for additional procedures

• Excessive debridement risks:

  • Damage to healthy tissue
  • Bleeding
  • Increased pain
  • Delayed healing

Follow-up Care

• Monitor the wound for:

  • Resolution of granulation tissue
  • Signs of infection
  • Complete healing
  • Recurrence of granulation tissue (which may indicate remaining suture material)

• If symptoms persist despite apparent complete suture removal, consider antibiotic therapy only if infection is confirmed, as antibiotics alone may not resolve the issue if foreign material remains 3