"Allergy" to sutures or stitch "reaction"--is this a real phenomenon?

Richard H. Tholen, MD, FACS
Article by
Minneapolis Plastic Surgeon

 

 

Lots of surgeons tell patients they are allergic to Vicryl (sutures). I believe they are wrong.

Vicryl sutures (made by Ethicon) are made of polyglactin 910, which is a copolymer of 90%glycolide (polyglycolic acid) and 10% L-lactide.These are braided, absorbable sutures that retain 75% of their original strength at 14 days, and 25% at 28 days. Vicryl Plus sutures have an added coating of triclosan, a broad-spectrum antimicrobial. Both absorb by hydrolysis, which causes minimal inflammation at the site of use. (Catgut, by contrast, absorbs by proteolysis, a somewhat more inflammatory response.)

These sutures are commonly used for skin closure, and are often used just below the skin surface as subcuticular or buried interrupted closures. They have been around for several decades; I used them in my plastic surgery fellowship at the Mayo Clinic 27 years ago. Many surgeons still use them; some patients have what most doctors have termed "Vicryl reactions" for the tiny, inflammatory pus pockets that develop around some of these sutures. Wait, if you are having an "allergic reaction" to these sutures, shouldn't the "allergic reaction" and red spots occur at EVERY place these sutures were used, not just some? Hold that thought for now.

When patients who have these sutures develop tiny red pus pockets just below the surface of the skin during the healing process, suture removal (where possible), warm packs, topical antibiotic ointment, and rarely oral antibiotics are used. Wait a minute, if this is an allergic reaction, why isn't the doctor using an antihistamine? Antibiotics don't work for true allergic reactions; in fact, they are worthless for this!

Ethicon does not even list "allergic reaction" in their list of contraindications (it does list a potential sensitivity to triclosan, a broad-spectrum antimicrobial present in Vicryl-Plus sutures, NOT in regular Vicryl). In fact, if you think about it, the fact that the company has a variety of their braided absorbable suture that includes an antimicrobial is a hint to what is really going on--and it's not allergic reaction to polyglycolic acid or lactic acid!

So-called "Vicryl reaction" is simply bacterial contamination of the braided suture material, likely from "normal" skin bacteria present in the sweat glands and hair follicles the suture goes directly through during your surgeon's closure. These skin bacteria are actually protected from your body's defenses--your tissues' antibodies (and antibiotic, if given)--by the tiny interstices within the braided suture. These tiny microscopic hiding places are warm, wet, and a place that bacteria can multiply, causing the tiny red pus pockets in some locations. That's also why removing the stitch, opening the pus pocket, and topical antibiotics (or just time as the suture dissolves and your body can "get to" the bacteria and eliminate them) solve this problem. That's also why Ethicon has added an antimicrobial coating to their Vicryl Plus brand of suture. That's also why many surgeons, myself included, soaked our Vicryl sutures in antibiotic irrigation fluid before use; this reduced the "Vicryl reactions" in my practice for years. And now, many surgeons. myself included, have switched to a non-braided monofilament suture like monocryl, which has no interstices for bacteria to "hide" in, and rarely see any kind of stitch abscess, for that is what is REALLY happening. I truly understand my colleagues' reluctance to tell their patients that they have a stitch abscess; too many patients "freak out" at any mention of the word "Infection." It's often easier to avoid this topic altogether and call it a "reaction" or "allergy." It's NOT, but it's not an infection that amounts to a problem in the vast majority of those who have it.

BTW, suture is a foreign body, but this is also NOT "rejection", since the components of Vicryl are substances that are simple biochemical compounds, not complex immunoreactive proteins like a kidney transplant, or even a blood transfusion. You don't reject sutures any more than you "reject" artificial hips or pacemakers. You can get an infection around them, but this is definitely NOT rejection.

Patients who have chronic problems with suture abscesses may harbor more or worse bacteria in their pores, sweat glands, and hair follicles. Showering the night before and the morning of surgery with Hibiclens (chlorhexidine) may help to reduce suture problems. I'd also avoid braided sutures, but you DON'T have to list "allergic reaction to Vicryl" in your patient intake information. It's incorrect and inapplicable.