During surgery, wounds are closed by sewing the skin together with dissolvable sutures or stitches under the skin for healing, and a top layer of stitches is used to close the incision. The deep sutures are primarily dissolving ones. Your surgeon may only use dissolvable sutures or combine them with permanent sutures, depending on the procedure. The dissolvable sutures tend to be clear or white in color.
Although they are placed with precision and care, the body may view the sutures as foreign substances and reject them. This means that the body has a mechanism that naturally works to break down or remove objects that it feels don’t belong. While the sutures are meant to break down and dissolve over time, the body may reject them by pushing them out of the body, which is referred to as “spitting a stitch.” When this happens, it may seem like a reason to panic, however, it is a common occurrence during healing and recovery.
A spitting suture can be removed at home. When you notice the suture is protruding from the skin, try gently removing it with a sterilized tweezer or small scissor. If the suture proves difficult to remove, please contact your surgeon and make an appointment to have it removed at their office. Once the suture is taken out of the skin, clean the area with alcohol and place a warm, damp compress on the area for a few minutes. This may cause other sutures to come to the surface. If this is the case, remove them, clean the area, and reapply the warm compress. Pat the area dry with a clean cloth and apply antibiotic ointment to the area. A spitting suture should not affect the wound’s healing, which will continue on its own. It is important to follow your surgeon’s post-operative care instructions for wound care to avoid other issues with the incision or infection.
What Is a Spitting Suture?
In some cases, an absorbable suture can be “spit out” if the body doesn’t break it down. This happens when the stitch is gradually pushed out of the skin because the body is rejecting the material. Spitting sutures can feel like a sharp spot on the incision, and a small white thread may start emerging. Other times, a spitting suture can simply look a pimple or red bump near the wound. While this can happen with some patients after Mohs surgery, there are ways to reduce the risk of a spitting suture.
Dr. Mamelak utilizes specific suture types that tend to cause fewer adverse reactions. He also checks the size and depth of the suture to make sure any non-absorbable sutures are taken out when appropriate. In addition, there are some cases that don’t require the use of a suture at all, which completely avoids the chance of the body spitting it out.
Spitting Sutures After Tummy Tuck
It is well established that surgical complications and a poor scar outcome can have a remarkable impact on patient satisfaction.1 A common complication following dermatologic surgery is suture spitting, in which a buried suture is extruded through the skin surface. When repairing a cutaneous defect following dermatologic surgery, absorbable or nonabsorbable sutures are placed under the skin surface to approximate wound edges, eliminate dead space, and reduce tension on the edges of the wound, improving the cosmetic outcomes.
Absorbable sutures constitute most buried sutures in cutaneous surgery and can be made of natural or synthetic fibers. Hydrolysis, in which water breaks down the polymer chains of the suture filament, is a process that degrades absorbable sutures made from synthetic fibers. Mammalian collagen makes up natural absorbable sutures, and the enzymatic process of proteolysis breaks them down.
Tensile strength is lost long before a suture is fully absorbed. Although synthetic fibers have, in general, higher tensile strength and generate less tissue inflammation, they take much longer to absorb.2 During absorption, in some cases, a buried suture is pushed to the surface and extrudes along the wound edge or scar, which is known as spitting (Figure 1).
Figure 1. Spitting sutures (black arrows) developed 3 months after closure of a Mohs micrographic surgery defect on the left cheek.
How to Treat Spitting Sutures
Suture spitting typically occurs in the 2-week to 3-month postoperative period. However, with the use of long-lasting absorbable or nonabsorbable sutures, spitting can occur several months or years postoperatively. Spitting sutures are often associated with surrounding erythema, edema, discharge, and a foreign-body sensation—symptoms that can be highly distressing to the patient and can lead to postoperative infection or stitch abscess.
Herein, we review techniques that can decrease the risk for suture spitting, and we present a stepwise approach to managing this common problem.
The Technique
Choice of suture material for buried sutures can influence the risk of spitting.
Factors Impacting Increased Spitting. Poliglecaprone 25, polyglactin 910, and polydioxanone are the most common absorbable sutures used in dermatologic surgery. Polyglactin 910 has been shown to spit out more often than poliglecaprone 25 and polydioxanone. But because polydioxanone can take up to 8 months to be fully absorbed, this suture might “spit” a lot later than polyglactin 910 or poliglecaprone 25, which usually break down completely after 3 or 4 months. Placing sutures superficially in the dermis has been found to increase the rate of spitting.5 Throwing more knots per closure also has been found to increase the rate of spitting.
How to Decrease Spitting: Careful choice of suture material and proper depth of suture placement might decrease the risk for spitting in dermatologic surgery. Furthermore, if polyglactin 910 or a long-lasting suture is to be used, sutures should be placed deeply.
What to Do If Sutures Spit: When a suture has begun to spit, the extruding foreign material needs to be removed and the surgical site assessed for infection or abscess. Exposed suture material typically can be removed with forceps without local anesthesia. In some cases, fine-tipped Bishop-Harmon tissue forceps or jewelers forceps might be required.
If the suture cannot be removed completely, it should be trimmed as short as possible. This can be accomplished by pulling on the exposed end of the suture, tenting the skin, and trimming it as close as possible to the surface. Once the foreign material is removed, assessment for signs of infection is paramount.
How to Manage Infection—Postoperative infection associated with a spitting suture can take the form of a periwound cellulitis or stitch abscess.3 A stitch abscess can reflect a sterile inflammatory response to the buried suture or a true infection; the former is more common.3 In the event of an infected stitch abscess, provide warm compresses, obtain specimens for culture, and prescribe antibiotics after the spitting suture has been removed. Incision and drainage might also be required if notable fluctuance is present.
It is crucial for dermatologic surgeons to identify and manage these complications. Figure 2 illustrates an algorithmic approach to managing spitting sutures.
Practical Implications
Spitting sutures are a common occurrence following dermatologic surgery that can lead to remarkable patient distress. Fortunately, in the absence of superimposed infection, spitting sutures have not been shown to worsen outcomes of healing and scarring.5 Nevertheless, it is important to identify and appropriately treat this common complication. The simple algorithm we provide (Figure 2) aids in cutaneous surgery by providing a straightforward approach to managing spitting sutures and their complications.
how to treat spitting stitches
Spitting sutures are a common complication of dermatologic surgery following closure of a cutaneous defect using buried sutures. This development can be distressing and uncomfortable for patients and may lead to further complications, such as surgical-site infection and abscess. Presented here is a straightforward and reliable algorithm to guide management of spitting sutures and their complications.
Practice Gap
It is well established that surgical complications and a poor scar outcome can have a remarkable impact on patient satisfaction.1 A common complication following dermatologic surgery is suture spitting, in which a buried suture is extruded through the skin surface. When repairing a cutaneous defect following dermatologic surgery, absorbable or nonabsorbable sutures are placed under the skin surface to approximate wound edges, eliminate dead space, and reduce tension on the edges of the wound, improving the cosmetic outcomes.
Absorbable sutures constitute most buried sutures in cutaneous surgery and can be made of natural or synthetic fibers. Hydrolysis, in which water breaks down the polymer chains of the suture filament, is a process that degrades absorbable sutures made from synthetic fibers. Mammalian collagen makes up natural absorbable sutures, and the enzymatic process of proteolysis breaks them down.
Tensile strength is lost long before a suture is fully absorbed. Although synthetic fibers have, in general, higher tensile strength and generate less tissue inflammation, they take much longer to absorb.2 During absorption, in some cases, a buried suture is pushed to the surface and extrudes along the wound edge or scar, which is known as spitting (Figure 1).
Figure 1. Spitting sutures (black arrows) developed 3 months after closure of a Mohs micrographic surgery defect on the left cheek.
Suture spitting typically occurs in the 2-week to 3-month postoperative period. However, with the use of long-lasting absorbable or nonabsorbable sutures, spitting can occur several months or years postoperatively. Spitting sutures are often associated with surrounding erythema, edema, discharge, and a foreign-body sensation—symptoms that can be highly distressing to the patient and can lead to postoperative infection or stitch abscess.
spitting stitches years after surgery
When we repair a wound, we sew your skin together like layers on a cake, aligning each layer. A deep layer of sutures, also known as stitches, is used under the skin to guide the healing process, and a top layer of sutures is used to close the skin. The deep sutures are primarily dissolving ones. Dissolvable sutures are usually clear in color, and permanent sutures are dark blue or black in color.
Since all sutures are technically “foreign substances,” the human body has a tendency to reject them. Ideally, this means the body breaks them down and dissolves them. Sometimes, instead of dissolving the sutures, your body will push the suture out of your body. When it does this, we call it “spitting” a stitch. This happens quite commonly, and when a stitch does come out, it can come to the surface with an inflamed red spot. Usually, you can feel something like a fishing line around this area.
If the suture does “spit,” it is not something to worry about. If you are able to grab it with a tweezer, give it a gentle pull. Applying a warm, moist compress to the area may help bring more of the suture to the surface. At that point, the surface material may be cut or trimmed away. After removal or trimming, clean the area with a little rubbing alcohol and then apply Vaseline. If the area is persistently irritated or is getting increasingly painful, then you may require an office visit.
Brandon Kirsch, MD FAAD is a board-certified dermatologist, as well as the founder of Kirsch Dermatology in Naples, Florida and the Chief of Dermatology at the Naples Community Hospital.
should i pull out a spitting stitch
When Mohs surgery is performed to remove skin cancer, the last step of the procedure is typically closing the wound with a suture. This can be accomplished using different techniques, such as a side-to-side linear closure or a skin flap, but regardless of the reconstructive approach, the surgical site is usually closed in two layers of stitches. “A deep layer of stitches is used under the skin to guide the healing process, and a top layer of sutures is used to close the skin,” says fellowship-trained Mohs micrographic surgeon Dr. Adam Mamelak.
As surgical materials have continued to advance, a variety of sutures are available based on the details of the case. Non-absorbable sutures may be used, which will need to be removed later. Others are absorbable, which means the body will naturally break them down over the course of about 3 to 4 months. These absorbable stitches are ideal for closing the deeper layer of tissue after Mohs surgery. However, keep in mind that although they dissolve, absorbable sutures are still a foreign object that the body may reject.