Can a Spitting Stitch Cause a Hole in a Surgical Scar Without Retained Foreign Body?
Yes, a spitting suture can create a full-thickness defect in a surgical scar even after the suture material has been completely expelled or removed. The tissue disruption occurs during the inflammatory process of suture extrusion, and the resulting sinus tract or defect may persist as a permanent hole in the scar tissue.
Mechanism of Defect Formation
When buried sutures migrate toward the skin surface ("spit"), they create an inflammatory tract through the dermis and epidermis that serves as a pathway for suture extrusion 1.
This inflammatory process causes tissue destruction along the tract, and once the suture material exits or is removed, the epithelialized sinus tract may remain as a permanent defect 1.
The defect represents a full-thickness disruption of the scar tissue where the suture cut through during migration, not simply superficial irritation 2.
Why the Hole Persists After Suture Removal
The epithelialized tract created during suture migration does not spontaneously close in many cases because the surrounding tissue has been permanently disrupted and scarred 1.
Unlike acute wounds that heal by primary intention, these chronic tracts behave more like fistulous communications that require active intervention to close 2.
The absence of retained suture material does not guarantee tract closure—the structural defect in the tissue architecture remains 1.
Risk Factors for Spitting Sutures Creating Defects
Multifilament (braided) sutures have significantly higher rates of spitting and subsequent defect formation compared to monofilament sutures because bacteria colonize the interstices, triggering prolonged inflammation 2.
Superficial suture placement in the dermis rather than deeper fascial layers increases the likelihood of migration to the surface and defect creation 3.
Contaminated surgical fields or wounds with higher bacterial loads promote inflammatory reactions that drive suture extrusion through tissue 2.
Rapidly absorbable sutures paradoxically can cause spitting when they lose tensile strength before adequate healing, leading to tissue disruption as the weakened material fragments and migrates 3.
Clinical Presentation
The defect typically appears as a small punctate opening in the scar, often 1-3 mm in diameter, which may drain serous fluid or small amounts of purulent material 1.
Patients report a firm nodule or "bump" under the scar that eventually opens to the surface, with or without visible suture material extruding 1.
The hole may persist for weeks to months after the suture has been removed or expelled, and does not close spontaneously in many cases 1.
Management Algorithm
If suture material is visible: Grasp the exposed suture with forceps and remove it completely by gentle traction, then irrigate the tract with sterile saline 2, 1.
If no suture is visible but a defect persists: Probe gently with a sterile cotton-tipped applicator to assess tract depth and rule out retained suture fragments 1.
For persistent defects after suture removal: Allow 2-4 weeks for spontaneous closure with daily cleansing and topical antibiotic ointment 1.
For defects that fail to close: Consider excision of the epithelialized tract and primary closure with monofilament suture, or allow healing by secondary intention if the defect is small (<3 mm) 1.
Prevention Strategies
Use monofilament absorbable sutures (4-0 poliglecaprone or polyglactin) for buried dermal closure rather than braided materials to minimize spitting risk 3, 4.
Place deep sutures in the appropriate tissue plane—limit closure to fascia/aponeurosis and avoid incorporating fat or superficial dermis 2.
Consider triclosan-coated sutures in contaminated or high-risk wounds, as they reduce inflammatory complications (OR 0.72; 95% CI 0.59-0.88) 2, 3.
Avoid rapidly absorbable sutures for deep closure, as premature loss of tensile strength leads to tissue disruption and suture migration 3.
Critical Pitfalls to Avoid
Do not assume that absence of visible suture material means no defect will form—the tissue damage from migration creates permanent structural changes 1.
Never probe aggressively or attempt to "dig out" suspected retained suture, as this causes additional tissue trauma and enlarges the defect 1.
Avoid using multifilament sutures for buried dermal closure in any wound, as the interstices harbor bacteria and dramatically increase spitting rates 2, 3.
Do not close a spitting suture defect primarily until all inflammation has resolved and you have confirmed no retained suture material remains, as premature closure leads to abscess formation 2, 1.