What is the best course of action for a patient who had an excision and failed to return for suture removal until two weeks later, with no visible sutures?

Management of Non-Visible Sutures After Delayed Follow-Up

When sutures are not visible at two weeks post-excision (one week beyond the intended removal date), they have most likely either spontaneously fallen out, become buried beneath re-epithelialized tissue, or were absorbable sutures that have begun degrading—in all cases, careful wound examination for retained suture material and assessment of healing adequacy takes priority over attempting removal.

Initial Wound Assessment

Before attempting any intervention, perform a thorough examination of the surgical site:

• Inspect for buried sutures: Look for small punctate marks, suture track marks, or subtle elevations along the wound line that indicate sutures beneath re-epithelialized skin 1
• Assess wound healing: Check for well-approximated wound edges without tension, absence of erythema, warmth, purulent drainage, or signs of infection 1
• Evaluate for dehiscence: Examine for any separation of wound edges or gaping that would indicate inadequate healing 1
• Palpate the wound: Gently feel along the incision line for firm nodules or "railroad track" irregularities suggesting retained suture material 2

Most Likely Scenarios at Two Weeks

Scenario 1: Sutures Spontaneously Fell Out (Most Common)

• Non-absorbable sutures typically loosen and fall out naturally between 10-14 days, especially on the face where removal is normally scheduled at 5-7 days 2
• If the wound appears well-healed with no visible suture material and no palpable foreign body, no intervention is needed 1
• Document the healed wound and provide standard post-removal wound care instructions 1

Scenario 2: Sutures Buried Under Re-Epithelialized Skin

If you suspect retained sutures beneath healed epithelium:

• Do not blindly probe or cut into healed tissue, as this risks wound dehiscence and infection 1
• Use magnification (loupes or dermatoscope) to identify suture entry/exit points 2
• If suture ends are barely visible, grasp with fine forceps and gently pull to assess if removal is feasible 1
• For completely buried non-absorbable sutures causing no symptoms: observe rather than re-open healed tissue 3
• If causing symptoms (spitting sutures, inflammation, palpable nodules): consider referral to the original surgeon or dermatology for evaluation 4

Scenario 3: Absorbable Sutures Were Used

• Absorbable sutures (poliglecaprone, polyglactin) retain 50-75% tensile strength at one week and gradually dissolve 3, 5
• At two weeks, these sutures may be partially degraded and not visible externally 3
• No removal is necessary—document that absorbable sutures were likely used and provide routine wound care 5

When Active Intervention IS Indicated

Only attempt suture removal if:

• Visible suture material remains with accessible ends that can be grasped 1
• Signs of suture reaction: erythema, induration, or "spitting" sutures pushing through skin 3
• Palpable suture causing symptoms: pain, foreign body sensation, or cosmetic concern 4

Technique for Removing Partially Visible Sutures

1. Clean the area with antiseptic solution 1
2. Use fine-tipped forceps to grasp the visible suture knot or end 1
3. Gently lift the suture away from skin while cutting the suture below the skin surface with fine scissors 1
4. Pull the suture through in one smooth motion to avoid breaking it 1
5. Inspect to ensure the entire suture was removed 1

Post-Assessment Care Regardless of Findings

• Keep the area clean and dry for continued healing 1, 5
• Consider applying new steri-strips if any tension remains across the wound, particularly in high-tension areas, for an additional 3-5 days 1
• Avoid excessive tension on the wound during activities 1
• Monitor for delayed complications: infection, dehiscence, or widening of the scar over the next 2-4 weeks 1, 2

Critical Pitfalls to Avoid

• Never re-open healed epithelium to search for buried sutures unless there is clear clinical indication (infection, abscess, persistent symptoms) 4
• Do not assume absence of visible sutures means complete healing—the wound at two weeks is still gaining tensile strength and remains at risk for dehiscence with trauma 3
• Avoid aggressive probing of the wound, which can introduce infection or disrupt healing 1
• Do not dismiss patient concerns about retained suture material—palpable foreign bodies may require imaging or surgical exploration if symptomatic 4

Documentation and Follow-Up

Document your findings clearly:

• Whether sutures were visualized or not 1
• Wound healing status (well-approximated, no erythema, no drainage) 1
• Whether any intervention was performed 1
• Instructions provided to patient regarding wound care and warning signs 1

Schedule follow-up only if: wound shows signs of infection, dehiscence, or patient reports symptoms suggesting retained suture material 1, 2