November 16, 2009 A-B Tech Kurt Prewitt This promotional educational activity is brought to you by Ethicon, Inc. and is not certified for continuing medical education.

SUTURES SUTURE OVERVIEW ABSORBABLE SUTURES NON-ABSORBABLE SUTURES SUTURE SELECTION BY TISSUE

SUTURES OVERVIEW 3

Aspects of wound healing Differentiate among the types of sutures OBJECTIVES Trace the evolution of sutures as a method of ligating and approximating tissue Aspects of wound healing Differentiate among the types of sutures SUTURES OVERVIEW 4

WHAT IS SUTURE? Suture Definition The word “suture” describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues

HISTORY OF SUTURES A Timeline 50,000 BC Eyed needles are invented. 20,000 BC Bone needles are standard. 1600 BC One of the earliest known references to suture material. Sutures are made from flax, hemp, bark fiber, hair, etc. 900 AD Used strings from a kit, a guitar-like musical instrument 1867-9 Joseph Lister proves that the body absorbs catgut sutures. However he is most famous for demonstrating the need for antiseptic techniques for sterilization of implanted sutures. 1918 George Merson begins the sale of eyeless needled sutures where one strand of suture material is attached to the butt of the needle. This type of swaged needle is still in use and is the standard today. 1947 Introduction of Nylon. 1972 First synthetic absorbable suture introduced. 2000 Distribution of gut material ends in many parts of Europe and Japan due to Bovine Spongiform Encephalopathy (“Mad Cow Disease”) SUTURES OVERVIEW 6

Minimal tissue reaction/trauma High tensile strength retention IDEAL SUTURE Sterile Easy to handle Minimal tissue reaction/trauma High tensile strength retention Knot security Absorbable Useful in all tissues SUTURES OVERVIEW 7

CRITICAL WOUND HEALING PERIOD Skin Mucosa Subcutaneous Peritoneum Fascia 0 5 7 14 21 28 Days 5-7 Days 7-14 Days 14-28 Days Tissue Healing Times SUTURES OVERVIEW 8

Size 7-0 approximately corresponds to the thickness of human hair SUTURE SIZING Ethicon Suture Sizing Ranging from 7 to 11-0 Size 7 is largest Size 11-0 is smallest Size 7-0 approximately corresponds to the thickness of human hair SUTURES OVERVIEW

HISTORY OF INNOVATION SUTURES OVERVIEW 1887 2007 1947 1958 1969 1974 1976 1979 1989 1992 1993 1995 1996 1998 2002 2003 2006 ETHIBOND EXCEL* Polyester Suture Silk and Cat Gut Nylon MERSILENE* Polyester Fiber Suture PROLENE* Polypropylene Suture VICRYL* (polyglactin 910) Suture Coated VICRYL* (polyglactin 910) Suture PDS* II (polydioxanone) Suture ETHIGUARD* Blunt Point Needle MONOCRYL* (poliglecaprone 25) Suture VICRYL RAPIDE* (polyglactin 910) Suture Dyed MONOCRYL* (poliglecaprone 25) Suture DERMABOND® Topical Skin Adhesive DERMABOND® Topical Skin Adhesive High Viscosity Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture PDS* Plus Antibacterial (polydioxanone) Suture (May 2007 Launch) MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture * Trademark SUTURES OVERVIEW

SUTURE CLASSIFICATIONS Absorbable / Non-Absorbable Natural / Synthetic Braided / Monofilament Antibacterial Sutures SUTURES OVERVIEW 11

ABSORBABLE / NON-ABSORBABLE SUTURES Sutures that undergo degradation in tissues, losing their tensile strength within 60 days Absorption Rate: Time required for a suture to be fully absorbed into the tissue Tensile Strength In Vivo: Tension which a suture will withstand before it breaks down inside the tissue Non-Absorbable Sutures Sutures which are not digested by body enzymes or hydrolyzed in body tissue SUTURES OVERVIEW 12

NATURAL / SYNTHETIC SUTURES Natural Sutures Sutures made of material that can be found in nature Absorption method (if absorbable): Enzymatic Synthetic Sutures Sutures made of materials created by man Absorption Method (if absorbable): Hydrolysis – breakdown in the presence of water or moisture SUTURES OVERVIEW 13

MONOFILAMENT / BRAIDED SUTURES A single strand of material Less resistance as it passes through tissue Resists bacterial harboring compared to braided Braided Multifilament sutures that consist of several filaments or strands, twisted or braided together Greater tensile strength Pliability and flexibility SUTURES OVERVIEW 14

ANTIBACTERIAL SUTURES Properties of Antibacterial Sutures Biocompatibility Effectiveness against S.Aureus and S.Epidermidis (most common for device infections) among other bacteria1-3 Ability to withstand manufacturing process Heat, humidity, solvent, sterilization, etc Mass production Will not negatively alter suture properties Ability to maintain antibacterial activity on the suture for a clinically relevant duration 1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. 3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. SUTURES OVERVIEW 15

CDC SURGICAL WOUND CATEGORIES1 Class I Clean Uninfected wound in which no inflammation is encountered and respiratory, alimentary, genital, or uninfected urinary tract is not entered. Class II Clean-contaminated Operative wound in which respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Class III Contaminated Open, fresh, accidental wounds. Class IV Dirty-infected Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. Note: The Centers for Disease Control and Prevention, or CDC, classifies surgical wounds into 4 categories: Class I/Clean Class II/Clean-contaminated Class III/Contaminated Class IV/Dirty-infected 1. CDC=Centers for Disease Control and Prevention. Mangram AJ et al. Am J Infect Control. 1999;27:97-134. SUTURES OVERVIEW

COMPLICATIONS IN WOUND HEALING Infection (including SSIs) Wound Disruption Deshiscence – Splitting open of the wound due to Too much tension placed on the wound Improper suturing technique Inappropriate suture materials Weakened tissue Evisceration – Protrusion of the bowel through the separated edges of the abdominal wound closure SUTURES OVERVIEW 17

PLUS ANTIBATERIAL SUTURES Coated polyglactin 910 sutures with triclosan exhibit antibacterial activity on the suture in vitro against methicillin- sensitive and -resistant S aureus and S epidermidis compared with untreated controls1 Antibacterial activity endures on the suture despite extended exposure to aqueous environment1 Suture diameter, knotting, or passage through tissues does not diminish antibacterial activity of triclosan-coated sutures1 Note: This study supports the conclusion that Coated VICRYL Plus Suture provides an antibacterial effect sufficient to prevent in vitro colonization by S aureus and S epidermidis 1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3(suppl):S79-S87. SUTURES OVERVIEW 18

IRGACARE® MP IRGACARE® MP, the antibacterial component of Ethicon Plus Sutures, is effective on the suture against the pathogens most commonly associated with SSIs1 Staphylococcus aureus Staphylococcus epidermidis Methicillin-resistant Staphylococcus aureus (MRSA) Methicillin-resistant Stapylococcus aureus (MRSE) Escherichia coli † Klebsiella pneumoniae † 1. Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial adherence to surgical sutures J Am Coll Surg. 2006;203:481-489. † Only for MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture and PDS* Plus Antibacterial (polydioxanone) Suture * Trademark SUTURES OVERVIEW

ZONE OF INHIBITION PLUS Antibacterial Sutures kill bacteria on the suture and inhibit bacterial colonization of the suture1-3 MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture PDS* Plus Antibacterial (polydioxanone) Suture Zone of Inhibition – Areas of inhibited bacterial growth for Plus Antibaterial Sutures Note: This slide demonstrates the zone of inhibition of a triclosan-coated VICRYL Plus Suture The petri dish is colonized with bacteria. The clear area around the suture is the zone of inhibition This is a powerful image to share with customers because it clearly demonstrates the effectiveness of Plus SUTURES This image is included in the following pieces: Plus Slim Jim Zone of Inhibition Video PlusSUTURES.com Plus Public Relations Media Kit Demo Device This would be a good opportunity to hand out the above tactics 1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. 3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. * Trademark SUTURES OVERVIEW

PLUS ANTIBACTERIAL SUTURES In vitro testing (petri dish) has shown Plus Antibacterial Sutures create a zone of inhibition around the suture in which certain bacteria are unable to grow1-3 IRGACARE® MP in the Plus Sutures creates a zone of inhibition which lasts in vitro for: Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture Minimum of 7 days for S.Aureus MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture 31 days for S.Aureus 21 days for E.Coli PDS* Plus Antibacterial (polydioxanone) Suture 23 days for S.Aureus 17 days for E.Coli 1. Rothenburger S et al. Surg Infect (Larchmt). 2002;3:S79-S87. 2. Ming X et al. Surg Infect (Larchmt). 2007;8:201-207. 3. Ming X et al. Surg Infect (Larchmt). 2008;9:451-457. * Trademark SUTURES OVERVIEW

ABSORBABLE SUTURES 22

ABSORBABLE SUTURE TYPES Natural Short-Medium Short Fast Absorbing Gut Plain Gut Medium Chromic Gut Virtual Monofilament Natural Absorbable Synthetic Absorbable Synthetic Monofilament Braided Short / Medium Long Short Medium PDS* II (polydioxanone) Suture, PDS* Plus Antibacterial (polydioxanone) Suture VICRYL RAPIDE* (polyglactin 910) Suture MONOCRYL* (poliglecaprone 25) Suture, MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture Coated VICRYL* (polyglactin 910) Suture, Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture * Trademark ABSORBABLE SUTURES

NATURAL ABSORBABLE SUTURES Ethicon Gut Sutures1 Submucosal or serosal layer of animal intestine 97-98% pure collagen Clean and purified Strands twisted for controlled diameter Packaged wet to maintain pliability Spun and polished into virtual monofilament strands 1. Wound Closure Manual, page 13 ABSORBABLE SUTURES

NATURAL ABSORBABLE SUTURES Plain gut TRU-GAUGING process1 Eliminates high and low spots Greater surface smoothness No fraying of the suture Better knot security Uniform diameter across entire length Uniform high tensile strength Wound support for approximately 2 weeks 1. Wound Closure Manual, page 13,14 ABSORBABLE SUTURES 25

NATURAL ABSORBABLE SUTURES Chromic gut TRU-GAUGING process1 TRU-CHROMICIZING process1 Entire cross-section of strand is evenly chromicized Minimizes tissue irritation Less reaction Wound support for approximately 4 weeks2 Fast-absorbing gut Plain surgical gut is heat treated to accelerate tensile strength loss and absorption1 Wound support for approximately 1 week Chromic Gut Wound Closure Manual, page 13,14 Chromic Gut Product Insert ABSORBABLE SUTURES 26

SYNTHETIC ABSORBABLE SUTURES VICRYL RAPIDE* (polyglactin 910) Suture Short-term wound support1 7-10 days Rapid strength loss Absorption complete in just 42 days For mucosa and superficial closure of skin Convenient for the patients No return visit necessary for suture removal 1. Wound Closure Manual, page 14 * Trademark ABSORBABLE SUTURES 27

SYNTHETIC ABSORBABLE SUTURES VICRYL RAPIDE* (polyglactin 910) Suture Initial strength comparable to that of Nylon and Gut Fastest-absorbing synthetic suture Elicits lower tissue reaction than chromic gut suture 1. Wound Closure Manual, page 14; Product Inserts of VICRYL RAPIDE* (polyglactin 910) Suture, ETHILON* Nylon Suture and Chromic Gut * Trademark ABSORBABLE SUTURES 28

ANTIBACTERIAL SUTURES Wound support for approximately 14 days Consistent handling and performance Significantly less tissue drag than chromic gut sutures and braided synthetic absorbable sutures Excellent knot security 1. Wound Closure Manual, page 14; MONOCRYL Plus Suture Product Insert * Trademark ABSORBABLE SUTURES 29

ANTIBACTERIAL SUTURES Reliable Strength Consistent absorption rate with a predictable decrease in tensile strength over time Stronger than gut suture initially and through the critical wound-healing period Offers protection for subcuticular closure and soft tissue approximation 1. Wound Closure Manual, page 13,14; MONOCRYL Plus Suture Product Insert, Chromic Gut Product Insert * Trademark ABSORBABLE SUTURES 30

ANTIBACTERIAL SUTURES Excellent handling and performance Knot security and knot snug-down First-throw holding security Smooth passage with minimal tissue drag Virtually no package memory * Trademark ABSORBABLE SUTURES 31

ANTIBACTERIAL SUTURES Exceptional strength Wound support for approximately 4 weeks Offers protection and strength for general tissue approximation 1. Product Inserts for Coated VICRYL Plus Suture, MONOCRYL Plus Suture, Chromic Gut and Plain Gut * Trademark ABSORBABLE SUTURES 32

ANTIBACTERIAL SUTURES Extended monofilament wound support for approximately 42 days Offers protection and strength for slow-healing tissue Fascia closure, Orthopedic surgery Blood vessel anastomoses Diabetic, cancer and obese patients 1. Wound Closure Manual page 20,21; PDS Plus Suture Product Insert * Trademark ABSORBABLE SUTURES 33

ANTIBACTERIAL SUTURES PDS Plus Sutures offer surgeons: Low out-of-package memory Smooth passage through tissue Low bending stiffness for more pliability and easier handling PDS Plus Suture stays stronger, longer† † Compared to Maxon™ or Biosyn™: Data from Maxon™, Biosyn™ and PDS* Plus Suture product inserts * Trademark ABSORBABLE SUTURES 34

NON-ABSORBABLE SUTURES 35 35

NON-ABSORBABLE SUTURE TYPES Natural Braided Monofilament Surgical Stainless Steel PERMA-HAND* Silk Suture Synthetic ETHIBOND EXCEL* Polyester Suture MERSILENE* Polyester Fiber Suture NUROLON* Nylon Suture PRONOVA* Poly (Hexafluoropropylene - VDF) Suture PROLENE* Polypropylene Suture ETHILON* Nylon Suture * Trademark NON-ABSORBABLE SUTURES

PERMA-HAND* Wax proofed Braided SILK - BRAIDED PERMA-HAND* Silk Suture1 Wax proofed Improves surface quality Reduces bacterial harboring Reduces capillarity Braided Excellent handling and knotting characteristics Used in a wide variety of surgical procedures 1. Wound Closure Manual, page 16 * Trademark NON-ABSORBABLE SUTURES 37 37

Surgical Stainless Steel Suture1 STEEL - MONOFILAMENT Surgical Stainless Steel Suture1 High tensile strength Reliable and ductile alloy Made of 316L stainless steel Optimal compatibility with stainless steel implants Low tissue reactivity Multistrand packaging Eliminates kinking and bending of strands 2 or 4 strands per pack 1. Wound Closure Manual, page 16 NON-ABSORBABLE SUTURES 38

ETHILON* NYLON - MONOFILAMENT Nylon Suture1 Well suited for skin and retention closure Finer sizes used in ophthalmic and microsurgery procedures May be clear, or dyed green or black for better visibility Specific codes (sizes 3-0 to 6-0) are “pliabilized.” Pliabilization Includes pre-moistening the suture to make it more pliable Enhances handling and knot tying characteristics to approximate that of braided sutures 1. Wound Closure Manual, page 17 * Trademark NON-ABSORBABLE SUTURES 39 39

NUROLON* NYLON - BRAIDED NYLON SUTURE1 Handles like silk Stronger than silk Better knot tie-down than silk Lower tissue reactivity Less fragmentation Ideal silk replacement in neurosurgery 1. Wound Closure Manual, page 17 * Trademark NON-ABSORBABLE SUTURES 40 40

MERSILENE* POLYESTER - BRAIDED Polyester Fiber Suture1 Polyester Permanent wound support Braided Good handling characteristics Provide precise and consistent suture tension Synthetic Less tissue reaction 1. Wound Closure Manual, page 18 * Trademark NON-ABSORBABLE SUTURES 41 41

POLYESTER - BRAIDED Polyester: permanent wound support Minimal tissue reaction; suture material and coating are pharmacologically inactive1 A central core and 16 outer carriers Tighter, compact and stronger braid Excellent handling properties (suppleness and pliability) Polybutylate coating Smooth knot tie-down High knot and tensile strength 1. Wound Closure Manual page 18 * Trademark NON-ABSORBABLE SUTURES

Many options available1: POLYESTER - BRAIDED Many options available1: Specialized CV Needles Single or Multi-strand D-Specials Pledgets – Soft and hard, 2 sizes In green & white for ease of use Available in many suture sizes & lengths used in CV and Ortho procedures 1. ETHIBOND EXCEL Suture Product Insert * Trademark NON-ABSORBABLE SUTURES 43

Improvements in ETHIBOND EXCEL Suture POLYESTER - BRAIDED Improvements in ETHIBOND EXCEL Suture Tight, compact braid Results in stronger suture Avoids suture bunching Effective coating levels Less “slippery” suture Excellent knot security Packaging Fast, reliable suture delivery Clear package and box graphics 1. CPC-2007-0160 and AST-2008-0046 ETHIBOND EXCEL Suture reports * Trademark NON-ABSORBABLE SUTURES 44

POLYPROPYLENE - MONOFILAMENT Minimal tissue reaction Polypropylene: Inert, reliable, strong, smooth, secure Will not fatigue with normal flexing Exceptionally smooth surface avoids snagging vessel adventitia Plastic knot deformity - When knotted, deforms and flattens to provide excellent knot security2 Controlled linear elongation - Excellent pliability2 Wound Closure Manual page 18 CPC-2006-0445 and CPC-2008-0046 PROLENE Suture Reports * Trademark NON-ABSORBABLE SUTURES 45

POLYPROPYLENE - MONOFILAMENT Laser scanning process for sizes 5-0, 6-0 and 7-0 More consistent diameter and improved tensile strength Sizes 8/0 and smaller are hand inspected * Trademark NON-ABSORBABLE SUTURES 46

POLYPROPYLENE - MONOFILAMENT Packaging Unique RELAY* Suture Delivery System Straight pack delivers the suture virtually memory-free Many options available1 Available in a variety of sizes and lengths used in different specialties Specialized Cardiovascular needles Single or multi-strand E-Packs and D-Specials 1. Prolene Package Insert * Trademark NON-ABSORBABLE SUTURES 47

PRONOVA - MONOFILAMENT Poly (hexafluoropropylene-VDF) Suture1 Offers excellent strength Less memory than polypropylene Exceptional strength for delicate tissues Monofilament, more resistant to bacterial colonization Strong resistance to handling damage and fraying Excellent handling and tying characteristics Excellent resistance to repetitive stress fatigue such as to those imposed by heart and vessels 1. Wound Closure Manual page 18 * Trademark NON-ABSORBABLE SUTURES 48 48

SUTURE SELECTION BY TISSUE TYPE 49 49

Joint Capsule (knee, hip, shoulder) SUTURE SELECTION Joint Capsule (knee, hip, shoulder) Recommended Suture† Needle Options†† OS-4, OS-6, OS-8, CT-1, CTX, MO-4 Tissue Characteristics Ligamentous sac surrounding the articular cavity of the joint; consists of vascular, very dense, fibrous tissue. Heals in approximately 3 weeks. † Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 50 50

Epidermis, Oral (facial)/Vaginal Mucosa, Perineal Skin SUTURE SELECTION Epidermis, Oral (facial)/Vaginal Mucosa, Perineal Skin Recommended Suture VICRYL RAPIDE* (polyglactin 910) Suture Needle Options† PC-1, PC-3, P-1, P-3, PS-2 Tissue Characteristics Superficial layer of skin; dense and tough, but thin. It is usually supported by dermal closure. † Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 51 51

Peritoneum SUTURE SELECTION Recommended Suture† Needle Options†† SH, CT-1 Tissue Characteristics Thin, membranous lining of the abdominal cavity. Very little fibrosis. Heals quickly. Closure is optional, based on surgeon preference. . † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 52 52

Dermis / Subcuticular SUTURE SELECTION Recommended Suture† Needle Options†† PC-5, PS-2, PS-1, PS#, PSL, PSLX# Tissue Characteristics Deep, vascular, subcuticular layer; 3 times thicker than epidermis; consists of dense connective tissue. Regains tensile strength slowly. Most of the stress placed upon the healing wound is absorbed by fascia. Sutures need only be strong enough to withstand natural skin tension and hold wound edges in apposition. † Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture # Available on ETHILON* Nylon Suture which may also used for subcuticular closure * Trademark SUTURE SELECTION 53 53

Abdominal Fascia SUTURE SELECTION Recommended Suture† Needle Options†† CT-1, CT, CTX, TP-1, XLH Tissue Characteristics Fibrous, sheath-like, connective tissue covering muscle. Strongest tissue in abdominal wall; regains 25% - 40% of original strength in 1 month; 55% - 65% in 3 months; 70% -80% in 9 months. Never regains full original strength. † Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 54 54

Urinary Bladder SUTURE SELECTION Recommended Suture† Needle Options†† RB-1, SH-1, SH Tissue Characteristics Very vascular, dense, tough, muscular membranous sac. Composed of multiple layers. Heals quickly, achieving 75% to 90% of original strength in 2 weeks. † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 55 55

Colon SUTURE SELECTION Recommended Suture† Needle Options†† SH, SHB Tissue Characteristics Wall varies in consistency and density; relatively soft and rubbery, with little dense, fibrous support. Heals rapidly, achieving 50% to 60% of original strength in 1 month. † Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 56 56

Ureter SUTURE SELECTION Recommended Suture† Needle Options†† TF, RB-1, SH-1 Tissue Characteristics Narrow tube with vulnerable blood supply. Easy to manipulate and penetrate, unless fibrous or hardened. Achieves normal healing in 7 days. † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 57 57

Ligament SUTURE SELECTION Recommended Suture† Needle Options†† PS-4, PS-2, OS-4, MO-6, CT-2, CT-1 Tissue Characteristics Very dense, longitudinally arrayed, collagenous tissue. Achieves 50% to 70% of original strength in 12 months. † PDS II Suture may also be used in place of PDS Plus Suture †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 58 58

Subcutaneous (fat) / Superficial Fascia SUTURE SELECTION Subcutaneous (fat) / Superficial Fascia Recommended Suture† Needle Options†† SH, CT-1 Tissue Characteristics Soft, friable, poorly vascularized tissue; fat does not hold sutures well. The goal of “suturing the fat” is to approximate the superficial fascia (Scarpa’s fascia) which is located in the upper 1/3 of the fatty layer. † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 59 59

Small Intestine SUTURE SELECTION Recommended Suture† Needle Options†† RB-1, SH-1, SH Tissue Characteristics Wall varies in consistency and density; relatively soft and rubbery, with little dense, fibrous support. Heals very rapidly, reaching maximum strength in approximately 14 days. † Coated VICRYL Suture, MONOCRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 60 60

Uterus SUTURE SELECTION Recommended Suture† Needle Options†† MO-4, MO-2, CT-1, CT, CTX Tissue Characteristics Very vascular, tough and muscular. † Coated VICRYL Suture and PDS II Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 61 61

Vagina SUTURE SELECTION Recommended Suture† VICRYL RAPIDE* (polyglactin 910) Suture Needle Options†† V-34, CP-1, CT-1, SH Tissue Characteristics Extremely thick, tough and vascular. Heals completely in 10 days. † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 62 62

Tendon SUTURE SELECTION Recommended Suture† Needle Options†† OS-4, MO-6, CT-2, CT-1 Tissue Characteristics Very dense, longitudinally arrayed, collagenous tissue. † PRONOVA* Poly (hexafluoropropylene-VDF) Suture and NUROLON* Nylon Suture may also be used to suture tendon to bone. PDS II Suture may also be used in place of PDS Plus Suture †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 63 63

Stomach SUTURE SELECTION Recommended Suture† Needle Options†† SH, SHB Tissue Characteristics Relatively soft and rubbery, with little dense, fibrous support. Submucosa / mucosa is especially thick and vascular. Heals quickly, achieving maximum strength within 21 days. † Coated VICRYL Suture and MONOCRYL Suture may also be used in place of respective Plus Sutures †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 64 64

NUROLON* Nerves, Dura Mater SUTURE SELECTION Recommended Suture NYLON SUTURE Needle Options†† TF, RB-1 Tissue Characteristics Dura mater tears easily and cannot withstand excessive tension. In nerve repair, the strength of sutures is less of a consideration than the degree of inflammatory and fibroplastic tissue reaction. †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 65 65

Eye, Ocular Muscles SUTURE SELECTION Recommended Suture Coated VICRYL* (polyglactin 910) Suture Needle Options†† CS140-6, CS160-6, CS90-6, CSB-6, TG140-8 Tissue Characteristics Cornea is avascular, therefore heals slowly and requires sutures to remain in place for at least 21 days. Ocular muscles, conjunctiva and the sclera have good blood supply and require suture support only for about 7 days. † PDS II Suture may also be used in place of PDS Plus Suture †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 66 66

Vessels and Anastomosis SUTURE SELECTION Vessels and Anastomosis Recommended Suture† PRONOVA* Poly (hexafluoropropylene-VDF) Suture Needle Options†† BV-1, BV130-5, BV175-6, BV175-7, BV175-8, CC, CC-1 Tissue Characteristics The outermost tunica adventitia is fibrous connective tissue. The innermost tunica intima is the thinnest. Excessive tissue reaction may lead to decreased luminal diameter or thrombus formation. Hence inert synthetics are material of choice. † PDS Plus Suture and PERMA-HAND Silk Suture may be used to permit future growth in patients such as pediatric patients †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 67 67

Vascular Prostheses and Heart Valves SUTURE SELECTION Vascular Prostheses and Heart Valves Recommended Suture Needle Options†† V-5, V-7 Tissue Characteristics Strong, dense and fibrous. Adapted to be highly resistant to fatigue. Since there is constant movement of the suture line, the sutures must retain their original physical characteristics and strength throughout the life of patient †† Refer to http://ecatalog.ethicon.com for available needle and suture combinations. Not all needle options available with each recommended suture * Trademark SUTURE SELECTION 68 68

BEST PRACTICE IN WOUND CLOSURE Surface: DERMABOND® Topical Skin Adhesive Dermis: MONOCRYL* Plus Antibacterial (poliglecaprone 25) Suture SubQ-Fat: Coated VICRYL* Plus Antibacterial (polyglactin 910) Suture Fascia/Muscle: ETHIGUARD* Blunt Point Needle with Coated VICRYL Plus or PDS* Plus Antibacterial (polydioxanone) Suture ETHICON promotes best practice in wound closure with products for every layer, including ETHIGUARD, Plus Sutures and DERMABOND. * Trademark SUTURE SELECTION

Thank you EP-0063-09-10/11