How can I determine if a hole in a surgical scar is caused by a spitting stitch?

Determining if a Hole in a Surgical Scar is from a Spitting Stitch

A hole in a surgical scar is most likely from a spitting stitch if you observe suture material protruding through the skin surface or palpate a firm nodule beneath the opening, typically occurring weeks to months after surgery when buried absorbable sutures work their way to the surface. 1

Clinical Presentation of Spitting Sutures

• Spitting sutures present as small openings in the healed incision with visible suture material emerging through the skin, often accompanied by localized inflammation, drainage, or a small raised bump at the site 1
• The phenomenon typically occurs 14% of the time at 6 weeks post-surgery and decreases to 1% by 6 months, making the timing of hole appearance a useful diagnostic clue 2
• Patients may report a foreign body sensation, localized tenderness, or intermittent drainage from the opening before the suture becomes visible 1

Key Distinguishing Features

• Spitting sutures are characterized by the presence of suture material (either visible at the surface or palpable as a firm nodule just beneath the opening), which differentiates them from simple wound dehiscence or infection 1
• The opening is typically small (1-3mm), well-circumscribed, and located directly over the original suture line, rather than between suture points 1
• Granulation tissue or a small granuloma may surround the opening, appearing as pink, friable tissue that bleeds easily when touched 2

Associated Complications to Rule Out

• Abscess formation occurs in only 1% of cases at 6 weeks and presents with more extensive erythema, warmth, fluctuance, and purulent drainage rather than the isolated small opening of a spitting suture 2
• Granulomas occur in 11% of cases at 6 weeks and appear as firm, raised nodules that may or may not have a central opening with visible suture material 2
• Monitor for signs of deeper infection including fever, red streaks extending from the wound, increasing pain after the initial healing period, or foul-smelling discharge, which suggest complications beyond simple suture spitting 3

Risk Factors That Increase Likelihood

• Multifilament (braided) sutures have higher spitting rates than monofilament sutures because their interstices harbor bacteria and provoke greater inflammatory response 4
• Superficially placed deep sutures (closer to the skin surface) are more prone to spitting, as noted in surgical outcome studies where surgeons placing sutures more superficially experienced higher complication rates 2
• Wounds closed with excessive numbers of deep sutures or with sutures that incorporate fat or muscle tissue rather than aponeurosis alone show increased spitting rates 4, 2

Management Algorithm

• If suture material is visible or easily palpable, grasp it with sterile forceps and gently extract the exposed portion after cleansing the area with antiseptic 1
• If a firm nodule is present without visible suture, monitor for 1-2 weeks as the suture will often work its way to the surface and become accessible for removal 1
• Apply topical antibiotic ointment and cover with a clean dressing after suture removal to promote healing of the small opening 1
• Refer for surgical consultation if the opening fails to heal after suture removal, if signs of abscess develop, or if multiple spitting sites occur, as this may require formal exploration and removal of remaining buried sutures 1

Common Pitfalls to Avoid

• Do not assume all post-surgical holes are spitting sutures—dehiscence from inadequate wound support presents as separation of wound edges rather than a small isolated opening 4
• Avoid aggressive probing or manipulation of the opening if suture material is not readily visible, as this can introduce infection or create a larger defect 1
• Do not ignore persistent drainage or enlarging openings, as these may indicate abscess formation requiring incision and drainage rather than simple suture removal 2