Spitting Sutures After Deep Plane Face Lift
Suture extrusion after deep plane facelift is primarily caused by superficial suture placement, foreign body reaction to suture material, or infection, and should be managed by removing the exposed suture material with sterile technique, treating any associated infection with antibiotics if present, and allowing the wound to heal by secondary intention.
Causes of Suture Extrusion
The primary mechanisms leading to spitting sutures include:
Superficial suture placement: When sutures are placed too close to the skin surface or in areas of tension, they are more likely to migrate through the tissue and extrude 1, 2.
Foreign body reaction: Absorbable suture materials can trigger inflammatory responses and granuloma formation, particularly with materials like Vicryl (polyglactin), leading to tissue rejection and suture extrusion 3.
Infection: Bacterial contamination can cause localized inflammation and tissue breakdown around sutures, facilitating their migration to the surface 1, 2.
Technical factors: Excessive tension on sutures, improper knot placement, or using suture material that is too heavy for the tissue layer increases extrusion risk 1, 2.
Clinical Presentation
Patients typically present 3-8 weeks postoperatively with:
- Visible suture material protruding through the skin 1, 3
- Localized erythema and inflammation 2
- Small granulomas or papules at the extrusion site 3
- Possible purulent drainage if infection is present 2
- Skin dimpling or contour irregularities near the extrusion site 1
Treatment Algorithm
Immediate Management
Remove the exposed suture material using the following approach:
- Cleanse the area with antiseptic solution 1
- Use sterile forceps and scissors to grasp and cut the visible suture 1
- Gently extract the suture without excessive tissue trauma 1
- If resistance is encountered, do not force removal—allow more time for tissue breakdown 3
Assessment for Infection
Evaluate for signs of infection including:
- Purulent drainage, erythema extending beyond 2 cm, warmth, or tenderness 2
- If infection is present (occurs in approximately 6-11% of cases), initiate antibiotic therapy with amoxicillin/clavulanic acid 1g three times daily for 7-10 days 4, 2
- Alternative regimen: levofloxacin 400mg twice daily for patients with penicillin allergy 4
Management of Granulomas
- Small granulomas often resolve spontaneously after suture removal 3
- Persistent granulomas may require excision with removal of surrounding granulomatous tissue 3
- Wounds typically heal without further complications once foreign material is removed 3
Follow-up Care
- Monitor the site weekly until complete healing occurs 1
- Expect healing within 2-4 weeks after suture removal 1, 3
- Watch for recurrent extrusion of deeper suture material 3
Common Pitfalls and Prevention
Avoid these technical errors that increase extrusion risk:
- Placing deep sutures too superficially in the subcutaneous layer 1, 2
- Using barbed sutures in superficial planes where they are more prone to migration 1, 2
- Creating excessive tension on closure, which increases inflammatory response 2
- Combining multiple biomaterials (e.g., absorbable sutures with tissue adhesives) may increase reaction rates, though the mechanism is unclear 3
Key consideration: The overall complication rate for suture-related issues in facial procedures ranges from 5-34%, with extrusion representing approximately 5-11% of complications 1, 2. Most cases resolve completely with conservative management and suture removal 1, 3.