Is it common to miss sutures during removal?

Missing Sutures During Removal

Yes, it is common to miss sutures during removal, particularly in areas with poor visibility, when using buried sutures, or when sutures are covered by granulation tissue or new skin growth. 1

Factors Contributing to Missed Sutures

• Suture Visibility Issues:

  • Buried or subcutaneous sutures are particularly challenging to identify and remove completely
  • New skin growth can cover sutures if removal is delayed beyond the optimal window (7-10 days)
  • Granulation tissue formation can obscure sutures

• Anatomical Considerations:

  • Sutures in areas with complex anatomy or poor visibility are more likely to be missed
  • Wound edges with irregular contours increase difficulty in identifying all suture points

• Suture Material Factors:

  • Transparent or skin-colored sutures are harder to visualize
  • Braided sutures may fragment during removal attempts
  • Small gauge sutures are more difficult to identify

Clinical Implications of Missed Sutures

• Granulation Tissue Formation: Retained sutures can act as foreign bodies, stimulating granulation tissue formation 2

• Infection Risk: Missed sutures can serve as a nidus for infection, particularly when using braided materials

• Persistent Symptoms: Patients may experience ongoing discomfort, intermittent discharge, or spotting due to retained suture material 2

• Delayed Healing: Wound healing may be impaired by persistent inflammation around retained suture material

Prevention Strategies

• Systematic Approach: Count sutures placed and removed to ensure all are accounted for

• Adequate Lighting: Use proper illumination and magnification when needed

• Documentation: Record the number and type of sutures placed during the procedure

• Consider Alternative Closure Methods:

  • Absorbable subcuticular sutures do not require removal and maintain 50-75% tensile strength after one week 1
  • Subcuticular continuous sutures have lower rates of wound dehiscence and surgical site infections compared to interrupted sutures 1

Management of Missed Sutures

• Thorough Examination: If symptoms persist after suture removal, carefully examine the wound for retained material

• Complete Removal: When retained sutures are identified, complete removal is necessary to resolve symptoms 2

• Surgical Intervention: In rare cases where office-based removal is unsuccessful, surgical intervention in the operating room may be necessary 2

• Antibiotic Therapy: Consider antibiotics only if signs of infection are present; antibiotics alone may not resolve symptoms if sutures remain 2

Timing of Suture Removal

• The optimal window for removing non-absorbable transcutaneous sutures is typically 7-10 days after placement 1, 3

• Delayed removal increases the risk of "railroad track" scarring and tissue overgrowth that may obscure sutures 1

• High-risk patients (diabetes, immunosuppression, corticosteroid use) may require longer retention of sutures 1

Remember that complete suture removal is essential for optimal wound healing and to prevent complications. When in doubt about whether all sutures have been removed, a careful re-examination of the wound is warranted.