Surgical Sutures & Bandages

8/12/2019 Surgical Sutures & Bandages

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Table of Contents

Design......................................................................................................................................4

Background ....................................................................................................................... ...... 6

The Manufacturing Process...................................................................................................... 6

Quality Control.........................................................................................................................7

Polyglactin 91 !utures...................................................................................................... 1"

#au$e %andage...................................................................................................................... "&

W. O. W. Bandages................................................................................................................35

Co'(ression %andage..........................................................................................................."6

Tu%e %andage................................................................................................................ ........ "7

The )ole of MMPs in *ound Chronicity.............................................................................4"

Collagen+%ased *ound Dressings......................................................................................4"

Collagen, -ati e ersus Denatured....................................................................................44

Conclusion..........................................................................................................................4&

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SURGICAL SUTURES

Definition

Surgical suture is a medical device used to hold body tissues together after an injury or surgery. They generally consist of a needle with an attached length of thread .

INTRODUCTION

The medical textile industry has diversified with new materials andinnovative designs. Evolving polymer technology has yielded a widerange of applications of implantable medical textile devices or

biotextiles. King has defined biotextiles as: structures composed oftextile fibers designed for use in specific biological environments (e.g.surgical implants, biomass reactors , where their performance dependson their interactions with cells and biological fluids as measured in termsof their biocompatibility and biostability! ". #pplications of implantable

biotextiles range from polymeric valves through woven or $nittedartificial ligaments to polymeric wound closure devices. Examples ofimplantable biotextiles include cardiac support devices

%utures are the most common biotextile implantable devices due to their diverse usage insurgical procedures. They are used to achieve wound closure whenever tissue separation hasoccurred due to an incision, puncture, abrasion, or other in&ury.

Design

%utures are designed to meet many different needs. %utures for abdominal surgery, for example,

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are different from sutures used in cataract surgery. %ince no one type of suture is ideal for everyoperation, surgeons and medical designers have come up with sutures with varying 'ualities.

ne may be more absorbable but less flexible, while another is exceedingly strong but perhapssomewhat difficult to $not. This gives surgeons many options. )esigners of a new suture have tota$e into account many factors. The rate the suture degrades is important, not only along the

length of the suture but at the $not. %ome sutures need to be elastic, so that they will stretch andnot brea$. thers need to hold tight. %uture manufacturers use specially designed machines totest and study sutures. *ew suture designs are also tested by sub&ecting them to chemical tests,such as soa$ing them in various solutions, and testing on animals.

ISTOR! O" SUTURES

The history of wound closure dates bac$ to + - /.0., the origins of surgery". Earlywound closure devices were made of natural materials such as flax, sil$, linen strips, andcotton1. These natural materials were lubricated in oil and wine prior to application so as toreduce tissue drag and create a cleaner wound closure procedure1.

#nother early form of a wound closure techni'ue involved the use of the mandibles of soldierants . 2ith the development of synthetic polymers and fibers,synthetic sutures were introducedinto the mar$et. These sutures allow for designers to engineer the polymer configuration, thefiber type and si3e, and the surface lubricant and4or coating for specific applications. Today,surgical sutures come in many forms: natural, synthetic, nonabsorbable, and absorbable. Theapplication depends on the surgeon5s preference as well as the specific site and clinical techni'ue

being performed.

Through many millennia, various suture materials were used, debated, and remained largelyunchanged. *eedles were made of bone or metals such as silver, copper, and aluminum bron3ewire. %utures were made of plant materials (flax, hemp and cotton or animal material (hair,tendons, arteries, muscle strips and nerves, sil$, catgut . #frican cultures used thorns, and othersused ant sutures by coaxing insects to bite wound edges with their &aws and subse'uentlytwisting off the insects6 heads.

The earliest reports of surgical suture date bac$ to /0 in ancient Egypt, and the oldest$nown suture is in a mummy from "" /0. The first detailed description of a wound suture andthe suture materials used in it is by the 7ndian sage and physician %ushruta, written in + /0E.The 8ree$ 9father of medicine9 ippocrates described rudimentary suture techni'ues, as did thelater ;oman #ulus 0ornelius 0elsus . The 1nd-century ;oman physician 8alen has been creditedas the first to describe gut sutures or alternatively the " th-century #ndalusian surgeon al-


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The next great leap came in the twentieth century. The chemical industry drove production of thefirst synthetic thread in the early "A s, which exploded into production of numerous absorbableand non-absorbable synthetics. The first synthetic absorbable was based on polyvinyl alcohol in"A ". Bolyesters were developed in the "A+ s, and later the process of radiation sterili3ation wasestablished for catgut and polyester. Bolyglycolic acid was discovered in the "A@ s and

implemented in the "AC s. Today, most sutures are made of synthetic polymer fibers. %il$ andgut sutures are the only materials still - though rarely - in use from ancient times. 8ut sutures are banned in =apan and Europe

Ba#$g%o&nd

# surgical suture is used to close the edges of a wound or incision and to repair damaged tissue.There are many $inds of sutures, with different properties suitable for various uses. %utures can

be divided into two main groups: absorbable and non-absorbable. #n absorbable suturedecomposes in the body. 7t degrades as a wound or incision heals. # non-absorbable sutureresists the body6s attempt to dissolve it. *on-absorbable sutures may be removed by a surgeon

after a surface incision has healed.

T'e (an&fa#t&%ing )%o#ess

The manufacturing of sutures for surgical use is not very different from the production of othersynthetic textiles. The raw material is polymeri3ed, and the polymer extruded into fiber. Thefiber is stretched and braided on machines similar to ones that might be found in a factory

producing polyester thread for the garment industry. The manufacturing process typically occursat three sites: one plant produces the suture textile, another produces the needles, and a third

plant called the finishing plant attaches needles to the sutures, pac$ages, and sterili3es.

*. The first step in suture manufacturing is to produce the raw polymer. 2or$ers measurethe chemicals ma$ing up the polymer into a chemical reactor. 7n the reactor, thechemicals are combined (polymeri3ed , forced through a die, and discharged as tiny

pellets.+. *ext wor$ers empty the pellets into an extrusion machine. The extruder has a no33le,

loo$ing something li$e a shower head, pierced with many tiny holes. The machine meltsthe polymer, and the li'uid flows through the tiny holes, forming many individualfilaments.

3. #fter extrusion, the filaments are stretched between two rollers. The filaments stretch toas much as five times their original length.

,. %ome sutures are produced as monofilaments. thers are braided or twisted. To braid thesuture, the extruded monofilament is wound onto bobbins, and the bobbins are loadedonto an automatic braiding machine. %uch a machine is typically of an old design thatmight also be used in the manufacture of textiles for fabric. The number of filaments

braided together depends on the width of the suture made for the particular batch. # veryfine suture might braid 1 filaments, a medium width hundreds, and a very thic$ suturemight braid thousands of filaments. The braiding machine produces one continuous

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strand of braided material. 7t wor$s very slowly, and typically the machine is set to runfor as long as four wee$s at a time. The process is almost entirely automatic. 2or$ers inthe plant inspect the e'uipment for brea$-downs and reload empty bobbins, but generallythe process re'uires little man-power.

5. #fter braiding, the suture undergoes several stages of secondary processing. *on-braidedsutures will also go through these steps after extrusion and initial stretching. 2or$ersload the material onto another machine that performs another stretching and pressingoperation. Dnli$e the first stretching, this step might ta$e only a few minutes, and adds tothe length of the material by only about 1 . The suture passes over a hot plate, and anylumps, snags, or imperfections are ironed out.

-. *ext, wor$ers pass the suture through an annealing oven. The annealing oven sub&ectsthe suture to high heat and tension, which actually orders the crystalline structure of the

polymer fiber into a long chain. This step may ta$e several minutes or several hours,depending on the type of suture being made.

. #fter annealing, the suture may be coated. The coating material varies depending on whatthe suture is made of. The suture passes through a bath of coating material, which may bein solution or may be in a thic$, paste-li$e state called a sl&%%/.

0. #ll the ma&or manufacturing steps at the processing plant are complete at this point. *owthe 'uality assurance wor$ers test the batch of suture for various 'ualities. These wor$ersma$e sure the suture conforms to the proper diameter, length, and strength, loo$ for

physical defects, and chec$ the dissolvability of an absorbable suture in animal and test-tube tests. 7f the batch passes all the tests, it is shipped to a finishing plant.

1. The surgical needles are made at another plant, and also shipped to the finishing plant.The needles are made of fine steel wire, and drilled lengthwise. 2or$ers at the finishing

plant cut the suture into standard lengths. The length of suture is mechanically insertedinto the hollow in the needle, and the needle is crimped onto the fiber. This process iscalled s2aging .

* . *ext, the suture and attached needle are inserted into a foil pac$et and sterili3ed.%terili3ation differs according to the suture material. %ome sutures are sterili3ed withgamma radiation. 7n this case, the sutures are pac$aged completely. The whole pac$age,typically a sealed foil pac$ inside a cardboard box, is set on a conveyor belt. The sealed

pac$age passes under pencil-shaped lenses emitting gamma radiation. This $ills allmicrobes. The suture is now ready for shipment. %ome suture material cannot withstandgamma radiation, and it is sterili3ed in a different process. The suture and needles are

pac$aged in a foil pac$, but the pac$ is left open. The pac$ages move into a gas chamber,which is then filled with ethylene oxide gas. Then the foil pac$s are sealed, inserted into boxes or other pac$aging, and readied for shipment.

4&alit/ Cont%ol

%utures, as medical devices, are sub&ect to strict 'uality control. #ll the raw materials that arriveat the manufacturing plant are tested to ma$e sure they are what they are supposed to be. Each

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batch of sutures is tested after the main manufacturing steps for a variety of physicalcharacteristics such as diameter and strength. The suture industry has developed an array ofsophisticated instruments for testing special suture characteristics such as $not security and tissuedrag. Tests for diameter, length, and strength of the suture are also performed at the finishing

plant. The finishing plant must also test how well the needle is attached to the suture. 8uidelines

for suture 'uality control are laid down by the independent organi3ation Dnited %tatesBharmacopeia.

(AR ET SI6E

%urgical sutures serve as a means of wound closure and tissue approximation. %utures bringtogether and maintain the tissue on each side of a wound until the natural healing process has

provided a sufficient level of wound strengthF. 2hile other techni'ues for wound closure using,for example, clips, staples, or tissue adhesives have been developed in recent years, the suturecontinues to be the wound closure device of choice for most procedures. This is due to theextensive research and data that has been collected over time describing the exact behavior ofsuture materials and their tissue reactions invivo. 7n "AAA, there were F". million inpatient and

".+ outpatient surgeries performed in the Dnited %tates. )uring these surgical procedures,sutures were the most common form of wound closure device. This number of interventions

produced a mar$et si3e of G1" million worth of surgical sutures.

SUTURE (ATERIAL

%utures are made from both man-made and natural materials. *atural suture materials includesil$, linen, and catgut, which is actually the dried and treated intestine of a cow or sheep.%ynthetic sutures are made from a variety of textiles such as nylon or polyester, formulatedspecifically for surgical use. #bsorbable synthetic sutures are made from polyglycolic acid orother glycolide polymers. Host of the synthetic suture materials have proprietary names, such as)exon and Iicryl. The water-resistant material 8oretex has been used for surgical sutures, andother sutures are made from thin metal wire.

Dsually, the suture material comprises

Bolyester

%il$

*ylon

%tainless steel wire

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CLASSI"ICATION

%utures are also classified according to their form. %ome are monofilaments, that is, consisting of

only one thread-li$e structure. thers consist of several filaments braided or twisted together.%urgeons choose which type of suture to use depending on the operation. # monofilament haswhat is called low tissue drag, meaning it passes smoothly through tissue. /raided or twistedsutures may have higher tissue drag, but are easier to $not and have greater $not strength./raided sutures are usually coated to improve tissue drag. ther sutures may have a braided ortwisted core within a smooth sleeve of extruded material. These are $nown as pseudo-monofilaments. # suture can also be classified according to its diameter. 7n the Dnited %tates,suture diameter is represented on a scale descending from " to ", and then descending againfrom "- to "1- .

T!)ES O" SUTURES

These sutures can further be classified as: #bsorbable suture: The absorbable ones get dissolved in the body on their own and do not

re'uire removal.

*on absorbable suture: The non absorbable ones have to be removed after specified time.The type of suture is decided again by the location of the wound.

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The internal layers are stitched by absorbable sutures and the upper or the s$in may be stitched by the non absorbable sutures. >ocal or general anesthesia has to be given to the patient as perthe re'uirement before suturing.

"EATURES O" SUTURES

The body of suture is smooth.

The body of the suture does not cause any capillary and repelling reaction.

)ue to the softness of the suture, it will not tear at tissue.

7t is easy to $not and the $not tied is firm.

The brea$ing strength of suture and $not are strong.

The sewing is made firm, which is best for the healing of the patient without ductility.

)epending on the different human organs and operating location, different $inds and si3es ofsuture needles are chosen. The common features are that the body is smooth, the point type issharp, and is painless to the human.

Abso%bable S&%gi#al S&t&%es

%utures can be divided into two types J those which are absorbable and will brea$ downharmlessly in the body over time without intervention, and those which are non-absorbable andmust be manually removed if they are not left indefinitely. The type of suture used varies on theoperation, with the ma&or criteria being the demands of the location and environment anddepends on the discretion and professional experience of the %urgeons.

"eat&%es The body of suture is smooth.

The body of the suture does not cause any capillary and repelling reaction.

)ue to the softness of the suture, it will not tear at tissue.

7t is easy to $not and the $not tied is firm.

The brea$ing strength of suture and $not are strong.

The sewing is made firm, which is best for the healing of the patient without ductility.

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Host popular surgical sutures:

B8# %utures Bolyglactin A" %utures

0atgut %utures

Boliglecaprone %utures

Bolydioxanone %utures

)GA S&t&%es

B8# is an ideal and time tested synthetic absorbable suture, widely used by surgeons all over theworld. B8#6s superior features over catgut are predictable absorption, outstanding tensilestrength, in-vivo inertness and excellent handling properties.

Bolyglycolic #cid %uture is a synthetic, absorbable, sterile, surgical suture composed of "glycolide, coated with polycaprolactone and calcium stearate. B8# sutures retain approximatelyC+ of B8# initial strength after two wee$s. #pproximately F+ of the B8# suture5s originaltensile strength remains. Bolyglycolic #cid %uture has been found to be non-antigenic, non-

pyrogenic and elicit only mild tissue reactivity during the absorption process. The absorptiontime for Bolyglycolic #cid (B8# is @ to A days. #bsorption of bio-absorbable sutures occurs

by hydrolysis beginning with loss of tensile strength followed by loss of mass. B8# sutures areavailable in dyed (violet colour suture and also un-dyed versions from D%B si3es @- to D%Bsi3e 1. B8# sutures are indicated for use in general soft tissue approximation includingophthalmic surgery. Bolyglycolic #cid %uture is not indicated for cardiovascular andneurological tissue approximation. B8# sutures have first launched in 7ndia by us under the

/rand name Betcryl which provided the first %ynthetic #bsorbable %uture to the 7ndian mar$etapart from Iicryl sutures by Ethicon. Iicryl, being a Bolyglactin material is made from madefrom copolymer of A 8lycolide and " >-lactide but Betcryl sutures are " glycolide.

C'a%a#te%isti#s of )et#%/l )GA S&t&%es

Bolyglycolic #cid, better $nown as B8#, is composed of polymers of glycolide acids B8# surgical suture is coated to allow for easier passage through tissues with only

minimal drag.

Betcryl B8# sutures meet all the re'uirements established by the Dnited %tates

Bharmacopoeia (D%B and the European Bharmacopoeia (EB for %ynthetic #bsorbable%urgical %utures.

%mooth tie down

# decreased tendency to irritate tissue

8reater tensile strength

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>onger absorption period

)ol/gla#tin 1* S&t&%es

Betcryl A" ( Bolyglactin A" or B8># suture is an absorbable, sterile, synthetic, braided suture.B8># sutures are indicated for soft tissue approximation and ligation. The suture5s tensilestrength remains for approximately three to four wee$s in tissue. )ol/gla#tin A" %utures arecomposed of copolymers made from A glycolide and " >-lactide. Bolyglactin A" suture isan absorbable braided synthetic fibre. 7t is available as a plain (uncoated and coated suture. Thecoating is e'ual parts of a copolymer of lactide and glactide with calcium stearate. 0alciumsterate is a salt of calcium and stearic acid. This mixture forms an absorbable, adherent, non-fla$ing lubricant ideal for suture. #ll of these components are water repelling which slows tissuefluid penetration and absorption into the suture. 0linical trials have shown that after two wee$s,approximately C of Bolyglactin A" suture5s initial strength remained. Bolyglactin sutures arefound to be non-antigenic and non-pyrogenic, eliciting only mild tissue reactivity during theabsorption process. Bolyglactin A" sutures are available violet and colourless.

C'a%a#te%isti#s )ol/gla#tin 1* S&t&%es7

Bolyglactin A" suture is coated in order to create a smoother synthetic absorbable suturethat will pass through tissue readily.

Easy tissue passage

Brecise $not placement as compared with B8# sutures

Bredictable absorption by simple hydrolytic mechanism

# decreased tendency to irritate tissue

8reater tensile strength

# longer absorption period

Catg&t S&t&%es

0atgut or gut suture is an absorbable suture usuallymanufactured from the intestine of sheep or goat.0atgut sutures are composed of highly purifiedconnective tissue derived from either beef or sheep

intestines. The membrane is chemically treated andslender strands are woven together to form a suture.The grinding process creates a strand of uniformdiameter. The suture strand is then further polished toachieve maximum smoothness, for reliability andstrength. 0atgut sutures are available in the form of

plain catgut or chromic catgut.

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Blain catgut is usually having shorter absorption periods and is absorbed more rapidly in infectedareas. . The percentage of collagen in the catgut suture often determines the 'uality of the suture.

igher percentages of collagen allow for: superior tensile strength, longer absorption times, andlower reactions in vivo. Blain catgut is available in ivory colour.

0hromic catgut is treated with chromium salt solution to resist body en3ymes and slower theabsorption process thus supporting the wound for longer periods. 0hromic gut is chromicised before it is spun into strands. This allows control over the amount of chromic content for an evenabsorption rate. The chromic content not only increases the tensile strength, but also reducestissue irritation.

C'a%a#te%isti#s of Catg&t C'%o8i# S&t&%es

#bsorption within @ -A days for chromic sutures and @ -C days for plain gut sutures. #llows for smooth passage through tissue.

Bac$ed in 7B# to retain memory L increase pliability.

Dniform chrome content provides re'uired wound support and absorption.

0atgut sutures are available from D.%.B %i3es +- to 1

8eneral closure, phthalmic, rthopaedics, bstetrics48ynaecology and 8astro-intestinal Tract %urgery.

)oligle#a9%one S&t&%es

Boliglecaprone suture is a fast absorbing suture made of a

synthetic absorbable monofilament composed of glycolide andepsilon-caprolactone copolymer (usually called B80>sutures . 7t comes both dyed (violet and un-dyed (clear , andis a monofilament suture. Ethicon are the original inventors ofB80> sutures which are available under the brand nameHonocryl sutures.

Boliglecaprone suture has a low tissue reactivity, maintains high tensile strength, but B80>suture loses about F of its Tensile %trength within C to "F days and loses about + to @tensile strength by to F wee$s, and the suture is completely hydroly3ed by to F months.Brogressive loss of tensile strength and eventual absorption of B80> sutures occurs by means of

hydrolysis. Boliglecaprone 1+ copolymer has been found to be non-antigenic, non-pyrogenic andelicits only a slight tissue reaction during absorption. Boliglecaprone sutures are contraindicatedfor use in cardiovascular and neurologic tissues, and for usage in ophthalmic and microsurgery.Boliglecaprone sutures are rarely used for percutaneous s$in closure, and are not used in areas ofhigh tension. . The use of Boliglecaprone suture may be inappropriate in elderly, malnourished,or debilitated patients, or in patients suffering from conditions that may delay wound healing.

C'a%a#te%isti#s of )oligle#a9%one +5 s&t&%es7

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Iery high tensile strength initially Dsed for soft-tissue approximation and ligation.

Excellent $not security and high pliability

Iery low incidence of infection and trauma

%mooth tissue passage as it is monofilament

;eliable absorption

igh in vivo strength retention

)ol/dio:anone S&t&%es

Bolydioxanone suture (B) or B)% sutures or poly-p-dioxanone is a colourless, crystalline, biodegradable polymer. Bolydioxanone suture is an absorbable, sterile, surgical suture composedof the polyester, poly (p-dioxanone . Bolydioxanone suture has been found to be non-antigenic,non-pyrogenic, and elicits only minimal tissue reactivity during the absorption process.Bolydioxanone is a poly (ether-ester characteri3ed by a glass transition temperature in the rangeof M" and N0 and a crystallinity of about ++ . /ecause of the presence of an ether oxygengroup into the bac$bone of the polymer chain, materials prepared with polydioxanone li$esutures are provided with a good flexibility. Oor the production of sutures, polydioxanone isgenerally extruded into fibres, however care should be ta$en to process the polymer to the lowest

possible temperature, in order to avoid its spontaneous de-polymeri3ation bac$ to the monomer.The sutures prepared with this material typically lose half of their mechanical strength in about

three wee$s and complete degradation ta$es place in a time frame of around six months.

C'a%a#te%isti#s of )ol/dio:anone S&t&%es7

/est suited for use in general orthopaedic surgery, paediatric cardiovascular surgery,general, sub cuticular and fascia closure.

Hinimal tissue reaction. )oes not support infection.

#bsorbed slowly over a period of @ to C months, thus it provides wound support forlonger periods.

Bolydioxanone sutures retain approximately ? of initial Tensile strength after "F daysof surgery.

%mooth, pliable and minimal memory. )yed )ar$ /lue coloured for easy identificationduring %urgery.

Non;abso%bable s&%gi#al s&t&%es

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*on absorbable sutures are made of materials which are not metaboli3ed by the body, and areused therefore either on s$in wound closure, where the sutures can be removed after a fewwee$s, or in some inner tissues in which absorbable sutures are not ade'uate. This is the case, forexample, in the heart and in blood vessels, whose rhythmic movement re'uires a suture whichstays longer than three wee$s, to give the wound enough time to close. ther organs, li$e the

bladder, contain fluids which ma$e absorbable sutures disappear in only a few days, too early forthe wound to heal. 7nflammation caused by the foreign protein in some absorbable sutures canamplify scarring, so if other types of suture are less antigenic (i.e., do not provo$e as much of animmune response it would represent a way to reduce scarring.

There are several materials used for non absorbable sutures. The most common is a natural fibre,sil$, which undergoes a special manufacturing process to ma$e it ade'uate for its use in surgery.

ther non-absorbable sutures are made of artificial fibres, li$e polypropylene, polyester or nylonthese may or may not have coatings to enhance their performance characteristics. Oinally,stainless steel wires are commonly used in orthopaedic surgery and for sternal closure in cardiacsurgery. #ll nonabsorbable sutures are manufactured $eeping in mind several fundamentalcharacteristics, such as follows:

Dniform diameter

Dniform si3e

%terility

Bliability for ease of handling

Knot security

Dniform tensile strength

Oreedom from irritants or impurities

Oollowing is the list of *on-#bsorbable %utures:

". %il$ %utures J /lac$ /raided suture1. Bolypropylene sutures- monofilament suture

. *ylon suture or Bolyamide sutures- monofilament suture

F. Bolyester sutures- coated and braided suture+. Boly vinylidene fluoride sutures- monofilament sutures

)ol/9%o9/lene S&t&%e

Bolypropylene suture is a non-absorbable, sterile surgical suture composed of an isotacticcrystalline stereoisomer of polypropylene or synthetic linear polyolefin. Bolypropylene suture is

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commonly used in both human and veterinary medicine for s$in closure, 0ardiovascular,phthalmic, 8eneral 0losure, rthopedics, Blastic and Hicrosurgeries, soft tissue approximation

and, or ligation. #s it is a monofilament suture, it does not support bacterial growth. 7t is notaffected by blood, or wea$ened by tissue en3ymes. 7t offers prolonged tensile strength even ininfected areas as it is not degraded over time. This suture is $nown for low tissue drag, easy

handling and good strength. Bolypropylene sutures are normally available in blue colour,allowing for easy identification and better visibility against s$in when operating.

C'a%a#te%isti#s of )ol/9%o9/lene s&t&%e7

Bolypropylene suture is a non-absorbable

%mooth texture, resulting in minimal tissue trauma.

igh plasticity and difficulty of use compared to standard nylon sutures.

Dniform diameter with high tensile strength resists brea$age

ighly visible in the wound

Basses through tissue easily.

Coated < B%aided Sil$ S&t&%es

These braided sil$ sutures are specially treated with silicone or waxto give strength and smoothen the surface. #ll these sutures conformto the D%B standards and they are not used in biliary and urinary tractsurgery. 2idely used as ligature they have moderate tissue reactionand are also used for other applications li$e s$in, opthalmic, 87 tract,etc.

)OL!)RO)!LENE ERNIA (ES "OR ERNIA RE)AIR

2e are manufacturers of Bolypropylene Hesh for ernia repair under the brand name )olphinHesh. ur %urgical meshes are available in popular si3es of 1xF, x@, @x@ and "1x"1 inches. Tofacilitate the %urgeons convenience, )olphin mesh is made available in two types, namely BHand B% types. BH type mesh is thinner, smoother and more flexible. 2hereas B% mesh is %trong,thic$er and normal flexibility. )olphin ernia mesh is also $nown as surgical mesh or

".

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polypropylene mesh for hernia repair. ernia Heshes need to be strong and sturdy to withstandthe pressure, but they also need to be thin and flexible. ernia Hesh is used in both tension-freeand laparoscopic tension-free hernia repairs.

)ol/9%o9/lene (es' fo% e%nia Re9ai%

)olphin Heshes are ultrasonically cleaned and pac$ed in internationallyacceptable standard pouches, with E sterile proof. Ourther all edges ofmesh are sealed to avoid post surgical inconvenience. )olphin erniameshes are thermally annealed to prevent fabric curling and increasesoftness. )olphin ernia Heshes are provided with very igh /ursting%trength, Elasticity and tested for /io-compatibility after implantation.Ourther the )olphin ernia Heshes are made available to medicalfraternity at reasonable prices.

"eat&%es7

%urgical meshes are thermally annealed to prevent fabric curlingP Iariety of surgical meshes available to satisfy surgeons6 needsP ur surgical hernia meshes offer ideal flexibility and strength for hernia repairsP 7deal porosity for high visibility L coloni3ation.P igh strength L burst resistance for permanent support.P 2e offer our )olphin ernia Hesh under EH label at competitive prices

e%nia (es'

)RO)ERTIESDOL) IN (ES

)( T!)E )S T!)E

TE*%7>E %T;E*8T -0; %% 11 @

Qin *ewtonsR -> *8 11 F1

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/;E#K7*8 E> *8#T7 * - 0; %% "1 "1

- > *8 "+ "C

HD>>E* /D;%T Q*ewtonsR @ C

T 70K*E%% .+"mm .Cmm

Oabric weight Qgms4m1R @+ "1

Oabric count QdtexR "?@ "?@

Honofilament )iameter ."+mm ."+mm

Bore si3e .?+mm .?+mm

Needles fo% s&%gi#al s&t&%es7;

T%a&8ati# needles are needles with holes or eyes which aresupplied to the hospital separate from their suture thread. Thesuture must be threaded on site, as is done when sewing at home.

At%a&8ati# needles 2it' s&t&%es comprise an eyeless needleattached to a specific length of suture thread. The suturemanufacturer swages the suture thread to the eyeless atraumaticneedle at the factory. There are several advantages to having theneedle pre-mounted on the suture. The doctor or the nurse or odpdoes not have to spend time threading the suture on the needle. Hore importantly, the suture endof a swaged needle is smaller than the needle body. 7n traumatic needles with eyes, the threadcomes out of the needle6s hole on both sides. 2hen passing through the tissues, this type ofsuture rips the tissue to a certain extent, thus the name traumatic . *early all modern suturesfeature swaged atraumatic needles.

There are several shapes of surgical needles, including: straight half curved or s$i

"4F circle

4? circle

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"41 circle

+4? circle

compound curve

*eedles may also be classified by their point geometry examples include:

taper (needle body is round and tapers smoothly to a point cutting (needle body is triangular and has a sharpened cutting edge on the inside

reverse cutting (cutting edge on the outside

trocar point or tapercut (needle body is round and tapered, but ends in a small triangularcutting point

blunt points for sewing friable tissues

side cutting or spatula points (flat on top and bottom with a cutting edge along the frontto one side for eye surgery

Oinally, atraumatic needles may be permanently swaged to the suture or may be designed tocome off the suture with a sharp straight tug. These 9pop-offs9 are commonly used forinterrupted sutures, where each suture is only passed once and then tied.

S&t&%e 9la#e8ent # needle holder is used to grasp the needle at the distal portion of the body, one half to three'uarters of the distance from the tip of the needle, depending on the surgeon6s preference. The

needle holder is tightened by s'uee3ing it until the first ratchet catches. The needle holder shouldnot be tightened excessively because damage to both the needle and the needle holder may result.The needle is held vertically and longitudinally perpendicular to the needle holder.

The needle is placed vertically and longitudinally perpendicular to the needle holder.

7ncorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the s$in, and4or an undesirable angle of entry into the tissue. The needle holder isheld by placing the thumb and the fourth finger into the loops and by placing the index finger onthe fulcrum of the needle holder to provide stability. #lternatively, the needle holder may be heldin the palm to increase dexterity.

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The needle holder is held through the loops between the thumb and the fourth finger, and the index finger rests on the

fulcrum of the instrument.

The needle holder is held in the palm, allowing greater dexterity.

The tissue must be stabili3ed to allow suture placement. )epending on the surgeon6s preference,toothed or untoothed forceps or s$in hoo$s may be used to gently grasp the tissue. Excessivetrauma to the tissue being sutured should be avoided to reduce the possibility of tissuestrangulation and necrosis. Oorceps are necessary for grasping the needle as it exits the tissueafter a pass. Brior to removing the needle holder, grasping and stabili3ing the needle is important.This maneuver decreases the ris$ of losing the needle in the dermis or subcutaneous fat, and it is

especially important if small needles are used in areas such as the bac$, where large needle bitesare necessary for proper tissue approximation.The needle should always penetrate the s$in at a A N angle, which minimi3es the si3e of the entrywound and promotes eversion of the s$in edges. The needle should be inserted "- mm from thewound edge, depending on s$in thic$ness. The depth and angle of the suture depends on the

particular suturing techni'ue. 7n general, the 1 sides of the suture should become mirror images,and the needle should also exit the s$in perpendicular to the s$in surface.

not t/ing

nce the suture is satisfactorily placed, it must be secured with a $not. The instrument tie is used

most commonly in cutaneous surgery. The s'uare $not is traditionally used. Oirst, the tip of theneedle holder is rotated cloc$wise around the long end of the suture material for 1 completeturns. The tip of the needle holder is used to grasp the short end of the suture. The short end ofthe suture is pulled through the loops of the long end by crossing the hands, such that the 1 endsof the suture material are situated on opposite sides of the suture line. The needle holder isrotated countercloc$wise once around the long end of the suture. The short end is grasped withthe needle holder tip, and the short end is pulled through the loop again.

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The suture should be tightened sufficiently to approximate the wound edges without constrictingthe tissue. %ometimes, leaving a small loop of suture after the second throw is helpful. Thisreserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation oftissue because the tension exerted on the suture increases with increased wound edema.)epending on the surgeon6s preference, "-1 additional throws may be added.

Broperly s'uaring successive ties is important. That is, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny$not, which tends to slip and is inherently wea$er than a properly s'uared $not. 2hen thedesired number of throws is completed, the suture material may be cut (if interrupted stitches areused , or the next suture may be placed.

Knot tying.

Diffe%ent S&t&%e Te#'ni=&es

Si89le Inte%%&9ted S&t&%es

Te#'ni=&e

The most commonly used and versatile suture in cutaneous surgery is the simple interruptedsuture. F This suture is placed by inserting the needle perpendicular to the epidermis, traversingthe epidermis and the full thic$ness of the dermis, and exiting perpendicular to the epidermis onthe opposite side of the wound. The 1 sides of the stitch should be symmetrically placed in termsof depth and width. 7n general, the suture should have a flas$-shaped configuration, that is, thestitch should be wider at its base (dermal side than at its superficial portion (epidermal side . 7f

the stitch encompasses a greater volume of tissue at the base than at its apex, the resultingcompression at the base forces the tissue upward and promotes eversion of the wound edges.This maneuver decreases the li$elihood of creating a depressed scar as the wound retracts duringhealing.

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Simple interrupted suture placement. Bottom right image shows a flask shaped stitch, which maximi!es eversion.

7n general, tissue bites should be evenly placed so that the wound edges meet at the same level tominimi3e the possibility of mismatched wound-edge heights (ie, stepping . owever, the si3e ofthe bite ta$en from the 1 sides of the wound can be deliberately varied by modifying the distanceof the needle insertion site from the wound edge, the distance of the needle exit site from thewound edge, and the depth of the bite ta$en. The use of differently si3ed needle bites on each

side of the wound can correct preexisting asymmetry in edge thic$ness or height. %mall bites can be used to precisely coapt wound edges. >arge bites can beused to reduce wound tension. Broper tension is important toensure precise wound approximation while preventing tissuestrangulation.

"ine of interrupted sutures.

Uses

0ompared with running sutures, interrupted sutures are easy to place, have greater tensilestrength, and have less potential for causing wound edema and impaired cutaneous circulation.7nterrupted sutures also allow the surgeon to ma$e ad&ustments as needed to properly alignwound edges as the wound is sutured.

)isadvantages of interrupted sutures include the length of time re'uired for their placement andthe greater ris$ of crosshatched mar$s (i.e. train trac$s across the suture line. The ris$ ofcrosshatching can be minimi3ed by removing sutures early to prevent the development of suturetrac$s.

R&nning S&t&%es

Si89le %&nning s&t&%es

Te#'ni=&e

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The simple running suture is an uninterrupted series of simple interrupted sutures. The suture isstarted by placing a simple interrupted stitch, which is tied but not cut. # series of simple suturesare placed in succession without tying or cutting the suture material after each pass. %uturesshould be evenly spaced, and tension should be evenly distributed along the suture line. The lineof stitches is completed by tying a $not after the last pass at the end of the suture line. The $not is

tied between the tail end of the suture material where it exits thewound and the loop of the last suture placed.

#unning suture line.

Uses

;unning sutures are useful for long wounds in which wound tension has been minimi3ed with properly placed deep sutures and in which approximation of the wound edges is good. This typeof suture may also be used to secure a split- or full-thic$ness s$in graft. Theoretically, lessscarring occurs with running sutures compared with interrupted sutures because fewer $nots aremade with simple running sutures however, the number of needle insertions remains the same.

#dvantages of the simple running suture include 'uic$er placement and more rapidreapproximation of wound edges, compared with simple interrupted sutures. )isadvantages

include possible crosshatching, the ris$ of dehiscence if the suture material ruptures, difficulty inma$ing fine ad&ustments along the suture line, and puc$ering of the suture line when the stitchesare placed in thin s$in.

R&nning lo#$ed s&t&%es

Te#'ni=&e

The simple running suture may be loc$ed or left unloc$ed. The first $not of a running loc$edsuture is tied as in a traditional running suture and may be loc$ed by passing the needle throughthe loop preceding it as each stitch is placed. This suture is also $nown as the baseball stitch

because of the final appearance of the running loc$ed suture line.

#unning locked suture.

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Uses

>oc$ed sutures have increased tensile strength therefore, they are useful in wounds undermoderate tension or in those re'uiring additional hemostasis because of oo3ing from the s$inedges. ;unning loc$ed sutures have an increased ris$ of impairing the microcirculation

surrounding the wound, and they can cause tissue strangulation if placed too tightly. Therefore,this type of suture should be used only in areas with good vasculari3ation. 7n particular, therunning loc$ed suture may be useful on the scalp or in the postauricular sulcus, especially whenadditional hemostasis is needed.

(att%ess S&t&%es

>e%ti#al 8att%ess s&t&%es

Te#'ni=&e

The vertical mattress suture is a variation of the simple interrupted suture. 7t consists of a simpleinterrupted stitch placed wide and deep into the wound edge and a second more superficialinterrupted stitch placed closer to the wound edge and in the opposite direction. The width of thestitch should be increased in proportion to the amount of tension on the wound. That is, thehigher the tension, the wider the stitch.

$ertical mattress suture.

Uses

# vertical mattress suture is especially useful in maximi3ing wound eversion, reducing deadspace, and minimi3ing tension across the wound. ne of the disadvantages of this suture iscrosshatching. The ris$ of crosshatching is greater because of increased tension across the wound

and the F entry and exit points of the stitch in the s$in. The recommended time for removal ofthis suture is +-C days (before formation of epithelial suture trac$s is complete to reduce the ris$of scarring. 7f the suture must be left in place longer, bolsters may be placed between the sutureand the s$in to minimi3e contact. The use of bolsters minimi3es strangulation of the tissues whenthe wound swells in response to postoperative edema. Blacing each stitch precisely and ta$ingsymmetric bites is especially important with this suture.

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alf;b&%ied ?e%ti#al 8att%ess s&t&%es

Te#'ni=&e

The half-buried vertical mattress suture is a modification of the vertical mattress suture andeliminates 1 of the F entry points, thereby reducing scarring. The half-buried vertical mattresssuture is placed in the same manner as the vertical mattress suture, except that the needle

penetrates the s$in to the level of the deep part of the dermis on one side of the wound, ta$es a bite in the deep part of the dermis on the opposite side of the wound without exiting the s$in,crosses bac$ to the original side of the wound, and exits the s$in. Entry and exit points thereforeare $ept on one side of the wound.

Uses

The half-buried vertical mattress is used in cosmetically important areas such as the face.

)&lle/ s&t&%es

Te#'ni=&e

The pulley suture is a modification of the vertical mattress suture. 2hen pulley sutures are used,a vertical mattress suture is placed, the $not is left untied, and the suture is looped through theexternal loop on the other side of the incision and pulled across. #t this point, the $not is tied.This new loop functions as a pulley, directing tension away from the other strands.

%ulley stitch, type &.

Uses

The pulley suture facilitates greater stretching of the wound edges and is used when additionalwound closure strength is desired.

"a%;nea% nea%;fa% 8odified ?e%ti#al 8att%ess s&t&%esTe#'ni=&e

#nother stitch that serves the same function as the pulley suture is the far-near near-farmodification of the vertical mattress suture. The first loop is placed approximately F-@ mm fromthe wound edge on the far side and approximately 1 mm from the wound edge on the near side.The suture crosses the suture line and reenters the s$in on the original side at 1 mm from the

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wound edge on the near side. The loop is completed, and the suture exits the s$in on the oppositeside F-@ mm away from the wound edge on the far side. This placement creates a pulley effect.

'ar near near far pulley stitch.

Uses

The pulley suture is useful when tissue expansion is desired, and it may be used intraoperativelyfor this purpose. The suture is also useful when beginning the closure of a wound that is undersignificant tension. /y placing pulley stitches first, the wound edges can be approximated,thereby facilitating the placement of buried sutures. 2hen wound closure is complete, the pulleystitches may be either left in place or removed if wound tension has been ade'uately distributedafter placement of the buried and surface sutures.

o%i@ontal 8att%ess s&t&%e

Te#'ni=&e

The hori3ontal mattress suture is placed by entering the s$in + mm to " cm from the wound edge.The suture is passed deep in the dermis to the opposite side of the suture line and exits the s$ine'uidistant from the wound edge (in effect, a deep simple interrupted stitch . The needle reentersthe s$in on the same side of the suture line + mm to " cm lateral of the exit point. The stitch is

passed deep to the opposite side of the wound where it exits the s$in and the $not is tied.

(ori!ontal mattress suture.

Uses

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The hori3ontal mattress suture is useful for wounds under high tension because it providesstrength and wound eversion. This suture may also be used as a stay stitch to temporarilyapproximate wound edges, allowing placement of simple interrupted or subcuticular stitches.The temporary stitches are removed after the tension is evenly distributed across the wound.

ori3ontal mattress sutures may be left in place for a few days if wound tension persists after placement of the remaining stitches. 7n areas of extremely high tension at ris$ for dehiscence,hori3ontal mattress sutures may be left in place even after removal of the superficial s$in sutures.

owever, they have a high ris$ of producing suture mar$s if left in place for longer than C days.

ori3ontal mattress sutures may be placed prior to a proposed excision as a s$in expansiontechni'ue to reduce tension. 7mproved eversion may be achieved with this stitch in woundswithout significant tension by using small bites and a fine suture.

7n addition to the ris$ of suture mar$s, hori3ontal sutures have a high ris$ of tissue strangulationand wound edge necrosis if tied too tightly. Ta$ing generous bites, using bolsters, and cinchingthe suture only as tightly as necessary to approximate the wound edges may decrease the ris$, asdoes removing the sutures as early as possible. Blacing sutures at a greater distance from thewound edge facilitates their removal.

B&%ied S&t&%es

alf;b&%ied 'o%i@ontal s&t&%es o% ti9 stit#'es

Te#'ni=&e

The half-buried hori3ontal suture or tip stitch begins on the side of the wound on which the flapis to be attached. The suture is passed through the dermis of the wound edge to the dermis of the

flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip,and reenters the s$in to which the flap is to be attached. The needle is directed perpendicularlyand exits the s$in then, the $not is tied.

Tip stitch.

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Uses

The half-buried hori3ontal suture or tip stitch is used primarily to position the corners and tips offlaps and to perform H-plasties and I-S closures.

Abso%bable b&%ied s&t&%es#bsorbable buried sutures are used as part of a layered closure in wounds under moderate-to-high tension. /uried sutures provide support to the wound and reduce tension on the woundedges, allowing better epidermal approximation of the wound. They are also used to eliminatedead space, or they are used as anchor sutures to fix the overlying tissue to the underlyingstructures.

De%8al;s&bde%8al s&t&%es

Te#'ni=&e

The suture is placed by inserting the needle parallel to the epidermis at the &unction of the dermisand the subcutis. The needle curves upward and exits in the papillary dermis, again parallel to theepidermis. The needle is inserted parallel to the epidermis in the papillary dermis on theopposing edge of the wound, curves down through the reticular dermis, and exits at the base ofthe wound at the interface between the dermis and the subcutis and parallel to the epidermis. The$not is tied at the base of the wound to minimi3e the possibility of tissue reaction and extrusionof the $not. 7f the suture is placed more superficially in the dermis at 1-F mm from the woundedge, eversion is increased.

Uses

# buried dermal-subdermal suture maximi3es wound eversion. 7t is placed so that the suture ismore superficial away from the wound edge.

B&%ied 'o%i@ontal 8att%ess s&t&%e

Te#'ni=&e

The buried hori3ontal mattress suture is a purse-string suture. The suture must be placed in themid-to-deep part of the dermis to prevent the s$in from tearing. 7f tied too tightly, the suture maystrangulate the approximated tissue.

Uses

The buried hori3ontal mattress suture is used to eliminate dead space, reduce the si3e of a defect,or reduce tension across wounds.

>a%iations of R&nning S&t&%es

R&nning 'o%i@ontal 8att%ess s&t&%es

Te#'ni=&e

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# simple suture is placed, and the $not is tied but not cut. # continuous series of hori3ontalmattress sutures is placed, with the final loop tied to the free end of the suture material.

Uses

The running hori3ontal mattress suture is used for s$in eversion. 7t is useful in areas with a hightendency for inversion, such as the nec$. 7t can also be useful for reducing the spread of facialscars. 7f the sutures are tied too tightly, tissue strangulation is a ris$.

R&nning s&b#&ti#&la% s&t&%es

Te#'ni=&e

The running subcuticular suture is a buried form of the running hori3ontal mattress suture. 7t is placed by ta$ing hori3ontal bites through the papillary dermis on alternating sides of the wound. *o suture mar$s are visible, and the suture may be left in place for several wee$s.

Subcuticular stitch. The skin surface remains intact along the length of the suture line.

Uses

The running subcuticular suture is valuable in areas in which the tension is minimal, the deadspace has been eliminated, and the best possible cosmetic result is desired. /ecause theepidermis is penetrated only at the beginning and end of the suture line, the subcuticular sutureeffectively eliminates the ris$ of crosshatching. The suture does not provide significant woundstrength, although it does precisely approximate the wound edges. Therefore, the runningsubcuticular suture is best reserved for wounds in which the tension has been eliminated withdeep sutures, and the wound edges are of approximately e'ual thic$nesses.

R&nning s&b#&taneo&s s&t&%es

Te#'ni=&e

The running subcutaneous suture begins with a simple interrupted subcutaneous suture, which istied but not cut. The suture is looped through the subcutaneous tissue by successively passingthrough the opposite sides of the wound. The $not is tied at the opposite end of the wound by$notting the long end of the suture material to the loop of the last pass that was placed.

Uses

The running subcutaneous suture is used to close the deep portion of surgical defects undermoderate tension. 7t is used in place of buried dermal sutures in large wounds when a 'uic$

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closure is desired. )isadvantages of running subcutaneous sutures include the ris$ of suture brea$age and the formation of dead space beneath the s$in surface.

S&t&%e Re8o?al and Alte%nati?e (et'ods of Wo&nd Clos&%e

S&t&%e %e8o?al%utures should be removed within "-1 wee$s of their placement, depending on the anatomiclocation. Brompt removal reduces the ris$ of suture mar$s, infection, and tissue reaction. Theaverage wound usually achieves approximately ? of its expected tensile strength "-1 wee$safter surgery. To prevent dehiscence and spread of the scar, sutures should not be removed toosoon.

#s a general rule, the greater the tension across a wound, the longer the sutures should remain in place. #s a guide, on the face, sutures should be removed in +-C days on the nec$, C days on thescalp, " days on the trun$ and upper extremities, " -"F days and on the lower extremities, "F-1" days. %utures in wounds under greater tension may need to be left in place slightly longer./uried sutures, which are placed with absorbable suture material, are left in place because theydissolve.

Broper suture removal techni'ue is important to maintain good results after sutures are properlyselected and executed. %utures should be gently elevated with forceps, and one side of the sutureshould be cut. Then, the suture is gently grasped by the $not and gently pulled toward the woundor suture line until the suture material is completely removed. 7f the suture is pulled away fromthe suture line, the wound edges may separate. %teri-%trips may be applied with a tissue adhesiveto provide continued supplemental wound support after the sutures are removed.

Alte%nati?e 8et'ods of 2o&nd #los&%e

Ste%i;St%i9s

2ound closure tapes, or %teri-%trips, are reinforced microporous surgical adhesive tape. %teri-%trips are used to provide extra support to a suture line, either when running subcuticular suturesare used or after sutures are removed. 2ound closure tapes may reduce spreading of the scar ifthey are $ept in place for several wee$s after suture removal. ften, they are used with a tissueadhesive. These tapes are rarely used for primary wound closure.

Sta9les

%tainless steel staples are fre'uently used in wounds under high tension, including wounds on thescalp and trun$. #dvantages of staples include 'uic$ placement, minimal tissue reaction, low ris$of infection, and strong wound closure. )isadvantages include less precise wound edgealignment and cost.

Tiss&e ad'esi?e

%uperglues that contain acrylates may be applied to superficial wounds to bloc$ pinpoint s$inhemorrhages and to precisely coapt wound edges. The usefulness of rapidly polymeri3ing

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plastics is limited because of the difficulty in handling the adhesive and the potential for tissuetoxicity and inflammation. The use of tissue adhesives in dermatologic surgery is still evolving.#s new and improved products are developed, the use of adhesives for s$in closure mayincrease.

8reenhill and 6;egan reported on the use of *-butyl 1-cyanoacrylate (7ndermil for closure of parotid wounds and its relationship to $eloid and hypertrophic scar formation versus usingsutures. Their results indicated a simpler techni'ue and a comparable result. 7n a related area,Tsui and 8ogolews$i report on the use of microporous biodegradable polyurethane membranes,which may be useful for coverage of s$in wounds, among other things.

Ba%bed s&t&%es

# barbed suture has been developed and is being evaluated for its efficacy in cutaneous surgery.The proposed advantage of such a suture is the avoidance of suture $nots. %uture $notstheoretically may be a nidus for infection, are tedious to place, may place ischemic demands ontissue, and may extrude following surgery. # randomi3ed controlled trial comparing a barbedsuture with conventional closure using - polydioxanone suture suggests that a barbed suturehas a safety and cosmesis profile similar to the conventional suture when used to close cesareandelivery wounds. #dditional studies are li$ely needed before the barbed suture is accepted forwidespread use.

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BANDAGES

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Bandages# bandage is a piece of material used either to support a medical device such as a dressing orsplint, or on its own to provide support to the body. /andages are available in a wide range oftypes, from generic cloth strips, to specialised shaped bandages designed for a specific limb or

part of the body, although bandages can often be improvised as the situation demands, usingclothing, blan$ets or other material.

7n common speech, the word 9bandage9 is often used to mean a dressing, which is used directlyon a wound, whereas a bandage is technically only used to support a dressing, and not directly ona wound.

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T/9es of Bandages

" 8au3e bandages

1 0ompression bandages

Triangular bandages

F Tube bandages

+ 0ollegan bandages

@ #lginate /andages

)au!e bandage

The most common type of bandage is the gau3e bandage, a simple woven strip of material, or a wovenstrip of material with a Telfa absorbant barrier to

prevent adhering to wounds, which can come in any number of widths and lengths. # gau3e bandage can be used for almost any bandage application, including holding a dressing in place.

E:a89les

C&%it/ Ga&@e S9onges

%urgical mesh efficiently controls bleeding, fluid suppuration ighly absorbent mesh allows wounds to drain naturally

Edges are folded in no loose threads

*on-sterile

W. O. W. Bandages" cotton, /B %tandard2hite paper banded 4 roll and blue craft paper 4 do3en

Thread 0ount per s'. 7nch: 1F 1 , 1? "?, 1? 1F, 12idth: ", 1, , F L @ inch>ength: F, +, @, " yds

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Thread 0ount per s'. 7nch: 1 ?, F 1C (/. B. 2idth: +, C, " , "1, "+ L 1 cm>ength: F, +, @, " m

*ompression bandage

The term 6compression bandage6 describes a wide variety of bandages with many differentapplications.%hort stretch compression bandages are good for protecting wounds on one6s hands,especially on one6s fingers.

S'o%t st%et#' #o89%ession bandages are applied to a limb(usually for treatment of lymphedema or venous ulcers . Thistype of bandage that is capable of shortening around the limbafter application and is therefore not exerting ever-increasing

pressure during inactivity. This dynamic is called resting pressure and is considered safe and comfortable for long-termtreatment. 0onversely, the stability of the bandage creates a very high resistance to stretch when

pressure is applied through internal muscle contraction and &oint movement. This force is calledwor$ing pressure.

Long st%et#' #o89%ession bandages have long stretch properties, meaning their highcompressive power can be easily ad&usted. owever, they also have a very high resting pressureand must be removed at night or if the patient is in a resting position.

E:a89les

BSN; OBST Co?e%let Ad'esi?e D%essings

%pecial flexible fabric allows 0overletU to move and conform to bodycurves#dhesive mass provides firm and even adherence, yet is easy to remove, whichhelps limit s$in irritation and scab removal

%imple, peel open pac$age

#vailable in " shapes and si3es

(ed#o S'ee% S9ots

0ircular shape, perfect for the smallest scrapes and cuts %terile pad won6t stic$ to wound

%emi-transparent blends with s$in

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T%iang&la% bandage

#lso $nown as a cravat bandage, a triangular bandage is a piece of cloth cut into a right-angledtriangle. 7t can be used fully unrolled as a sling, folded as a normal bandage, or for speciali3edapplications, as on the head. ne advantage of this type of /andage is that it can be ma$eshift

and made from a fabric scrap or a piece of a t-shirt. The /oy %couts populari3ed use of this bandage in many of their first aid lessons. They carry a cravat bandage with their uniform in theform of a nec$erchief.

E:a89les

W%ist B%a#e CE A99%o?ed

%uitable for bone surgery operation, orthoraedic gypsum, healthy sports matreial for slim figureand so on.

Dnder the tenet of 9ta$e people and sincerity as bases, abide by professional ethics, always ta$e demotic health as its duty9, we aredetermined to ma$e our company become the high 'uality and efficientcompany.

Tube bandage

# tube bandage is applied using an applicator, and is woven in a continuous circle. 7t is used tohold dressings or splints on to limbs, or to provide support to sprains and strains, and it stops the

bleeding.

E:a89les

3( Ste%i;St%i9s S$in Clos&%es

Hicroporous, non-woven rayon-bac$ed material permits s$in ventilation, but isreinforced with filaments for strength to provide wound support and assist inincreasing tensile strength of wound, permitting early staple4suture removal

ypoallergenic adhesive

Dse results in greater resistance to infection than sutures or staples alone

#llows for finer wound edge approximation

%trips are pac$aged singly in boxes of "? or + to an envelope in 1+ -ct. boxes to an envelope in"+ -ct. boxes

Le&$ost%i9 Ad'esi?e S$in Clos&%es

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V %terile wound closure with programmed elasticity! maintains precise tissue approximationduring and following edemaV #ir and exudate permeable, speeding healingV ypoallergenic adhesive minimi3es ris$ of reaction

(an&fa#t&%ing )%o#ess

The manufacturing process has different stages, through which material passes and changed into bandages

Cotton Wool )%o#essing Lines

The processing of cotton wool starts from cotton wastes and low gradecottons, which are cleaned, bleached and dryed, after carded andtransformed in finished products.

# cotton wool processing line gives the possibility to obtain bleachedcotton in bales. This cotton can be sold to companies speciali3ed infinishing and pac$aging, or can be exported with an added value in respectto the raw cotton. 7n this way it is also possible to obtain a saving on transport costs, which arecalculated on a higher value product.Oinished products of a cotton wool processing line, destined to the sanitary and cosmetic use

Ga&@e Bandage (an&fa#t&%ing

(EDICAL is a special crochet machine for the production of cotton gau3es and elastic bandages in there'uested width, with already-made selvedges.

#s no longitudinal cutting is re'uested, there are nomore floating threads (very dangerous for health andcotton gau3es have a good strength in both directions.

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The total width of the machine is ? cm. 8au3es and bandages are produced in the re'uestedwidth from min. + cm up to cm. 7t is also possible to produce gau3es of ? cm, in certainconditions.

Hedical machines are fed from yarns on cones. The cone creel is included in the machine. #t

exit, gau3es and bandages are rolled on big bobbins (around cm of diameter , or can becollected into a container in loose form.

HE)70#> machines prouduce cotton gau3es starting from bleached cotton yarns. These yarns can be easily found onthe mar$et.

0ompanies which want to start this production are notobliged to afford big investments to install costly bleachingand drying e'uipment.

The big versatility of this machine allows to produce alarge variety of rigid and elastic bandages, by using yarnsof different nature: cotton, wool, polyester, nylon, lycra,rubber threads.

Ad'esi?e bandage 8an&fa#t&%ing

; T B>#%TE; #0 is used for the production and single-wrapping ofadhesive first aid bandages of various sizes and shapes with island or continuous pad, round orsquare edges and hot perforation

; T B>#%TE; #0 has a production capacity up to 1 pieces4min (based on si3e"AxC1 mm . The production speedcan vary according to the 'uality of raw materials.

Brecision, simplicity and versatility are thecharacteristics of ; T B>#%TE; #0 machines.

; T B>#%TE; #0 machines are completelycontrolled by electronics.#ll modules and raw material feeding groups are driveneach by a separate brushless motor. The completeoperating cycle is controlled and synchroni3ed by a B0,specially programmed for the production of adhesive

bandages.

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#ccording to the 'uality of raw materials, it is sufficient to select the proper programme to getthe correct and complete set up of the machine, including the tension of raw materials.

*o manual regulation is re'uested on this machine, which is self-regulating.

; T B>#%TE; #0 machines can produce with all $inds of adhesive substrates, such as: plastic, nonwoven, fabric, as well as all new materials re'uested by the medical mar$ets. #lso pre-printed substrates can be used, as this machine is able to center the print.

The modular construction of machines allows easy and 'uic$ change of si3e and setting, for a better efficiency.

Berforators, die-cutters, counter-rollers and all rotary parts of ; T B>#%TE; #0 machinesare made in our factory with absolute precision, using top 'uality materials.; T B>#%TE; machines are fed from raw materials in reels ext. diameter + mm foradhesive substrates and F mm for all other materials. ;eel width depends on bandage si3e to

be produced.

;aw materials are: adhesive substrates: BE, BI0, BD, nonwoven, non stretchable cloth, pre-print substrates absorbent pad: nonwoven

release papers: single-face silicone paper, embossed film

wrapping papers: cold sealable paper.

; T B>#%TE; #0 can produce all usual formats and si3es of adhesive first aid bandages

and many others on client re'uest.

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may aid in dissociating $eratinocytes from collagen-rich matrix and thereby promote efficientmigration over the dermal and provisional matrices. 0ellular functions are regulated by theE0H. The information provided by E0H macromolecules is processed and transduced into thecells by speciali3ed cell surface receptors. + Evidence demonstrates that the receptors play ama&or function in contraction of wounds, @,C migration of epithelial cells, ? collagen deposition, A

and induction of matrix-degrading collagenase. #lthough $eratinocytes will adhere to denaturedcollagen (gelatin , collagenase production is not turned on in response to this substrate. "

Keratinocytes have been $nown to recogni3e and migrate on Type 7 collagen substratum,resulting in enhanced collagenase production. "" 0ollagen plays a $ey role in each phase ofwound healing.

emostasis (duration X minutes . Blatelets aggregate around exposed collagen. Blatelets thensecrete factors, which interact with and stimulate the intrinsic clotting cascade, which strengthensthe platelet aggregate into a stable hemostatic plug.! /lood platelets also release Ya-granules,which release a variety of growth factors (8Os and cyto$ines, such as platelet derived 8O(B)8O , insulin-li$e 8O (78O-" , epidermal 8O (E8O , and transforming 8O-beta (T8O-b , "1

which call! a variety of inflammatory cells (neutrophils, eosinophils, and monocytes to thewound site and initiate the inflammatory phase.

7nflammation (duration X days . Broteolytic en3ymes are secreted by inflammatory cells thatmigrate to wound sites, notably neutrophils, eosinophils, and macrophages. The action of

proteolytic en3ymes on the macromolecular constituents of the E0H (such as collagen givesrise to many peptides (protein fragments during wound healing. These degradation productshave a chemotactic effect in the recruitment of other cells, such as mononuclear cells, additionalneutrophils, and macrophages. #ctivated macrophages secrete T*O-a, which among other things,induces macrophages to produce 7>-"b. 7>-"bZ is mitogenic for fibroblast and up-regulatesmatrix metalloproteinase (HHB expression. T*O-Y and 7>-"bZ are $ey pro-inflammatory

cyto$ines, which directly influence deposition of collagen in the wound by inducing synthesis ofcollagen via fibroblasts and down regulation of tissue inhibitors of matrix metalloproteinases(T7HBs . "1 7nflammatory cells also secrete growth factors including T8O-b, T8O-b, b /-E8O,and bO8O. "1 These 8Os continue to stimulate migration of fibroblasts, epithelial cells andvascular endothelial cells into the wound. #s a result, the cellularity of the wound increases. This

begins the proliferative phase.

Broliferation (duration X wee$s . 0leavage products resulting from collagen degradationstimulate fibroblast proliferation. Oibroblasts secrete a variety of 8Os (78O-", bO8O, T8O-b,B)8O, and K8O , "1 which guide the formation of the E0H. The collagen cleavage products alsostimulate vascular endothelial cell proliferation. These cells secrete a variety of 8Os (IE8O,ZO8O, B)8O , "1 which promote angiogenesis. 2ith a vasculari3ed E0H, granulation isachieved. 0ollagen cleavage products also stimulate $eratinocyte migration and proliferation.Keratinocytes secrete a variety of 8Os and cyto$ines, such as T8O-b, T8O-b, and 7>-". "1 #s$eratinocytes migrate from the edge of the wound across the newly formed granulation tissue, re-epitheli3ation is achieved.

;emodeling (duration X " year [ . # balance is reached between the synthesis of newcomponents of the scar matrix and their degradation by HHBs, such as collagenase, gelatinase,

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and stromelysin. Oibroblasts are the ma&or cell type that synthesi3es collagen, elastin, and proteoglycans. They are also the ma&or source of HHBs and T7HBs. 7n addition, they secretelysyl oxidase, which cross-lin$s components of the E0H. #ngiogenesis ceases and the density ofcapillaries in the wound site decreases as the scar matures. The result is the creation of a strongerscar, though the s$in only regains almost C+ of its original tensile strength.

T'e Role of (()s in Wo&nd C'%oni#it/

2ound bed preparation (2/B can be described as the management of the wound to accelerateendogenous healing or to facilitate the effectiveness of other therapeutic measures. " ,"F The F

basic aspects of 2/B can be represented by the acronym: T7HE. T X tissue (nonviable ordeficient 7 X infection or inflammation H X moisture control E X epidermal margin. "+

Oocusing on the E! in T7HE, collagen dressings possess properties, which lend themselves tocreating a wound environment favorable to the migration of cells from the epidermal marginacross granulation tissue, encouraging wound closure. )ue to a number of potential stimuli (localtissue ischemia, bioburden, necrotic tissue, repeated trauma, etc. , the wound has stalled in the

inflammatory phase contributing to the chronicity of the wound. #s a result of theaforementioned pro-inflammatory stimuli, the wound is overstimulated and inflammatory cells,such as macrophages, are present in higher numbers and are more active than they typicallywould be in an acute wound. 7n addition, the cells, such as fibroblasts and endothelial cells, aresenescent and unable to function properly as they would in an acute wound. 2ith theoverabundance of macrophages, there is an overabundance of $ey pro-inflammatory cyto$ines,such as T*O-b and 7>-"b, secreted by the macrophages. These pro-inflammatory cyto$inessignal the fibroblasts to secrete HHBs, but due to the overabundance of pro-inflammatorycyto$ines the fibroblasts secrete elevated levels of HHBs. #t this level, HHBs not only degradenonviable collagen, but also viable collagen laid down by the fibroblasts themselves.#dditionally, the fibroblasts are unable to secrete tissue inhibitors of HHBs (T7HBs at an

ade'uate level to control the activity of the HHBs. These events prevent the formation of thescaffold needed for cell migration and ultimately prevent the formation of the E0H. 7n addition,cells in a chronic wound tend to be senescent, thus unable to communicate with other cells andunable to function properly. ne result of this is a lac$ of endothelial cell activity slowing theformation of blood vessels. 2ithout an ade'uate blood supply, tissue can die and as a result,there is an increase in wound si3e. #ll of the aforementioned phenomena impede the formationof viable granulation tissue and thus inhibit re-epitheliali3ation (ie, wound closure . "1 ne of the$ey contributors to wound chronicity is an overabundance (and4or activity of HHBs in thewound the ability to inhibit or deactivate a number of excess HHBs may help create anenvironment more conducive to the formation of granulation tissue, and eventual wound closure.

Collagen;based Wo&nd D%essings

There are a number of different collagen dressings available, which employ a variety ofcarriers4combining agents such as gels, pastes, polymers, oxidi3ed regenerated cellulose ( ;0 ,and ethylene diamine tetraacetic acid (E)T# . The collagen within these products tends to bederived from bovine, porcine, e'uine, or avian sources, which is purified in order to render itnonantigenic. The collagen in a given collagen dressing can vary in concentration and type.0ertain collagen dressings are comprised of Type 7 (native collagen whereas, other collagen

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dressings contain denatured collagen as well. # given collagen dressing may contain ingredients,such as alginates and cellulose derivatives that can enhance absorbency, flexibility, and comfort,and help maintain a moist wound environment. 0ollagen dressings have a variety of pore si3esand surface areas, as well. #ll of these attributes are meant to enhance the wound managementaspects of the dressings. Hany collagen dressings contain an antimicrobial agent to control

pathogens within the wound. 0ollagen dressings typically re'uire a secondary dressing (see#ppendix 7 for a summary of currently available collagen-based wound dressings .

Hode of action (Ho# . ;esearch has shown that some collagen-based dressings produce asignificant increase in the fibroblast production have a hydrophilic property that may beimportant in encouraging fibroblast permeation enhance the deposition of oriented, organi3edcollagen fibers by attracting fibroblasts and causing a directed migration of cells aid in theupta$e and bioavailability of fibronectin help preserve leu$ocytes, macrophages, fibroblasts, andepithelial cells and assist in the maintenance of the chemical and thermostatic microenvironmentof the wound. "@J1 The Ho# of several collagen dressings includes the inhibition or deactivationexcess HHBs. #s mentioned, excess HHBs are a $ey contributor to wound chronicity.

Collagen7 Nati?e ?e%s&s Denat&%ed

7n addition to the various sources of collagen (bovine, porcine, etc. , collagen dressings can alsocontain different types of collagen. These types of collagens may result in uni'ue activity in thewound bed as they have different substrate specificity. Oor example, Type 7 (native collagenattracts HHB-". "

)enatured collagen (gelatin attracts HHB-1 and HHB-A. ",1" 8elatin also attracts stromelysinand matrilysin.1" These HHBs (among others are found in excess in chronic wounds andcontribute to a wound5s chronicity (see #ppendix 77 for a brea$down of collagen source4type per

collagen dressing .

/iochemistry of collagen types. 2hen a migrating cell (such as a $eratinocyte encounters Type7 collagen, the cell secretes HHBs in order to denature the Type 7 collagen to gelatin. # criticalreason for this is that once Type 7 collagen is converted into gelatin, many active sites (;8)se'uences are made accessible to the cells. ;8) (#rg-8ly-#sp se'uences are attachment sitesand are chemotactic for a variety of cells responsible for creating granulation tissue. Thus, acollagen dressing containing gelatin could provide enhanced signaling to the cells responsible forcreating granulation tissue. # collagen-dressing containing only Type 7 collagen re'uires HHB-"to initially convert collagen to gelatin, so cells in the wound must first release HHB-" to changethe Type 7 collagen into gelatin to get this benefit.

Bore si3e and surface area. Bore si3e of collagen dressings is important to allow cells to enter thedressing and concentrate therein. 7n addition, surface area plays a role in managing exudate.Typically the larger the surface area, the more exudate is absorbed.

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Con#l&sion

Breviously, collagens were thought to function only as structural support however, collagen andcollagen-derived fragments control many cellular functions, including cell shape anddifferentiation, migration, and synthesis of a number of proteins. 0ollagen also plays a critical

role in all phases of wound healing (hemostasis, inflammation, proliferation, and remodelling . 7tis also clear that while much of the Ho# of the various collagen dressings is similar, there are$ey differences as well.

Refe%en#es

". =effrey =. Hetalloproteinases and tissue turnover. 2 D*)%. "AA+ C(%uppl # :" #J11#.1. Hontesano ;, rci >, Iasselli B. 7n vitro rapid organi3ation of endothelial cells into capillary-li$e networ$s is promoted by collagen matrices. = 0ell /iol. "A? AC(+ Bt " :"@F?J"@+1.

. Hadri =#, Harx H. Hatrix composition, organi3ation, and soluble factors: modulators ofmicrovascular cell differentiation in vitro. Kidney 7nt. "AA1 F"( :+@ J+@+.F. #lbini #, #delmann-8rill /0. 0ollagenolytic cleavage products of collagen Type 7 aschemoattractants for human dermal fibroblasts. Eur. = 0ell /iol. "A?+ @(" :" FJ" C.+. ynes ; . 7ntegrins: versatility, modulation, and signaling in cell adhesion. 0ell."AA1 @A(" :""J1+.@. Klein 0E, )ressel ), %teinmayer T, et al. 7ntegrin alpha 1 beta " is upregulated in fibroblastsand highly aggressive melanoma cells in three-dimensional collagen lattices and mediates thereorgani3ation of collage 7 fibrils. = 0ells /iol. "AA" ""+(+ :"F1CJ"F @.C. %chiro =#, 0han /H, ;oswit 2T, et al. 7ntegrin alpha 1 beta " (I>#-1 mediatesreorgani3ation and contraction of collagen matrices by human cells. 0ell. "AA" @C(1 :F JF" .?. %charffetter-Kochane$ K, Klein 0E, einen 8, et al. Higration of human $eratinocyte cellline ( a0aT to interstitial collagen Type 7 is mediated by the alpha 1 beta "-integrin receptor. =7nvest )ermatol. "AA1 A?(" : J"".A. Krieg T. 0ollagen in the ealing 2ound. 2 D*)%. "AA+ C(%uppl # :+#J"1#." . %ubdec$ /), Bar$s 20, 2elgus 8, Bentland #B. 0ollagen-stimulated induction of$eratinocyte collagenase is mediated via tyrosine $inase and protein $inase 0 activities. = /iol0hem. "AAF 1@A(FC : 11J 1A."". Betersen H=, 2oodley )T, %tric$lin 8B, 5Keefe E=. Enhanced synthesis of collagenase byhuman $eratinocytes cultured on Type 7 or Type 7I collagen. = 7nvest )ermatol."AA AF( : F"J F@."1. %chult3 8, Hast /. Holecular analysis of the environment of healing and chronic wounds:cyto$ines, proteases and growth factors. 2 D*)%. "AA? " (@ suppl :"OJAO." . %ibbald ;8, 2illiamson ), rsted >, et al. Breparing the wound bed\debridement,

bacterial balance, and moisture balance. stomy 2ound Hanage. 1 F@("" "FJ +."F. Oalanga I. 0lassifications for wound bed preparation and stimulation of chronic wounds.2ound ;epair ;egen. 1 ?(+ : FCJ +1."+. %chult3 8%, %ibbald ;8, Oalanga I, et al. 2ound bed preparation: a systematic approach towound management. 2ound ;epair ;egen. 1 ""(%uppl " :"J1?."@. )oillon 0=, %ilver O . 0ollagen-based wound dressing: effects of hyaluronic acid andfibronectin on wound healing. /iomaterials. "A?@ C(" : J?."C. )oillon 0=, %ilver O , lson ;H, Kamath 0S, /erg ;#. Oibroblast and epidermal cell-Type

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7 collagen interactions: cell culture and human studies. %canning Hicrosc. "A?? 1(1 :A?+JAA1."?. /urton =>, Etherington )=, Beachey ;). 0ollagen sponge for leg ulcers. /r = )ermatol."AC? AA(@ :@?"J@?+."A. )oillon 0=, 2hyne 0O, /erg ;#, lson ;H, %ilver O . Oibroblast-collagen spongeinteractions and spatial deposition of newly synthesi3ed collagen fibers in vitro and in vivo. %can

Electron Hicrosc. "A?F (Bt :" " J" 1 .1 . Balmieri /. eterologous collagen in wound healing: a clinical study. 7nt = Tissue ;eact."AA1 "F(%uppl :1"J1+.1". Bar$s 20. The production, role, and regulation of matrix metalloproteinases in the healingepidermis. 2 D*)%. "AA+ C(%uppl # :1 J C.11. Hignatti B, ;if$in )/, 2elgus 8, Bar$s 20. Broteinases and tissue remodeling. 7n: 0lar$;#O, ed. The Holecular and 0ellular /iology of 2ound ;epair. 1nd ed. *ew Sor$, *S:Blenum Bress "AA@:F1CJFCF.

Alginate D%essing

Des#%i9tion

#lgisite H sheets may be applied to exuding lesions including leg ulcers, pressure areas, donorsites, and most other granulating wounds but for deeper cavity wounds and sinuses, the rope

pac$ing form is generally preferred. The dressing also appears to be of value as an ad&unct to thesystemic treatment of infected or malodorous wounds and for the management of p

Surgical Sutures & Bandages

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Transcript of Surgical Sutures & Bandages