What are the consequences and management options if suture removal is only partially successful and leaves remaining parts in the skin?

Retained Suture Material: Consequences and Management

If suture removal is only partially successful with material remaining in the skin, the primary risks are infection and foreign body reaction, though most retained suture fragments are well-tolerated if they are subcutaneous and not causing symptoms.

Immediate Consequences of Retained Suture Material

Infection Risk

• Retained non-absorbable sutures increase the risk of surgical site infection, particularly when they remain close to the skin surface or are exposed to the external environment 1
• The infection risk is higher when sutures are left in place too long, as noted in head and neck surgery guidelines 2
• Suture abscesses can develop around retained material, presenting as localized inflammation, pus formation, and drainage 1

Foreign Body Reaction

• Retained suture material can trigger tissue response or foreign body reaction leading to infection and its sequelae 3
• "Spitting sutures" may occur where the body attempts to extrude the foreign material through the skin 1
• Chronic inflammation around the retained material can persist for weeks to months 3

Wound Complications

• Superficial wound dehiscence risk increases if sutures are removed too early or incompletely, particularly in areas of tension 2
• Retained transcutaneous (through-skin) sutures pose higher risk than deeply buried subcutaneous sutures 4
• Granulation tissue may form around retained suture material, potentially enlarging the wound tract 1

Management Algorithm

Assessment Phase

• Examine the wound for signs of infection: erythema, warmth, purulent drainage, increased pain, or systemic signs (fever, elevated WBC) 1
• Determine the location and depth of retained suture material (superficial vs. deep subcutaneous) 5
• Assess wound healing status and whether the wound edges are adequately approximated 6

Decision-Making Based on Clinical Presentation

If the wound shows signs of infection:

• Remove all accessible retained suture material immediately 1
• Obtain Gram stain and culture of any purulent drainage 1
• Initiate antibiotic therapy active against Staphylococcus aureus (including MRSA coverage if risk factors present) 1
• Consider clindamycin, doxycycline, or trimethoprim-sulfamethoxazole for empiric MRSA coverage 1

If the wound is healing well without infection:

• Deeply buried subcutaneous sutures can be left in place if they are non-absorbable but not causing symptoms 3
• Superficial or partially exposed sutures should be removed to prevent future infection 2
• Monitor closely for development of suture abscess or spitting sutures over the following 2-4 weeks 1

If suture material is creating umbilical depression or tension:

• Incise the subcutaneous tissue around the suture and bury it deeper to prevent infection risk, as demonstrated in vascular closure device cases 5
• Re-approximate the dermis with absorbable sutures if needed 5

Prevention of Complications

Timing Considerations

• Non-absorbable sutures should be removed at 7-9 days for most surgical wounds to prevent complications 1, 2
• Removing sutures at the recommended time prevents new skin growth from covering the sutures and reduces scarring 6
• Delayed removal beyond recommended timeframes increases infection risk and makes removal more difficult 2, 6

Material Selection for Future Cases

• Consider using absorbable subcuticular sutures to eliminate the need for removal and reduce wound dehiscence risk (RR 0.08; 95% CI 0.02 to 0.35) 1
• Absorbable sutures (4-0 poliglecaprone or polyglactin) retain 50-75% tensile strength after 1 week, providing extended wound support 1
• Triclosan-coated sutures significantly reduce SSI prevalence compared to non-coated sutures 1

Common Pitfalls to Avoid

• Do not leave superficial or exposed suture material hoping it will "work itself out" - this significantly increases infection risk 2
• Avoid attempting needle aspiration of any abscess that forms around retained sutures; incision and drainage is required 1
• Do not pack wounds after removing infected sutures and draining abscesses, as this causes more pain without improving healing 1
• Ensure adequate follow-up for patients with retained deep sutures to monitor for delayed complications 6