New and Emerging Uses of Barbed Suture Technology in Plastic Surgery

Transcription

1 Supplemental Article Review Article New and Emerging Uses of Barbed Suture Technology in Plastic Surgery Allen D. Rosen, MD Periodically, a new technology is developed that evolves into a specialty-altering, market-disrupting force, requiring a paradigm shift for surgeons. Liposuction and the use of lasers are examples of plastic surgeons developing new surgical techniques in response to technological advancements. The advent of barbed sutures for tissue fixation will give today s generation of surgeons a new tool for soft tissue fixation. Adding barbs to the suture in a helical fashion circumferentially distributes the dynamic tension forces along the length of the suture lines, whereas in a traditional smooth suture, tension is more focally concentrated at each individual suture loop. 1-3 Fewer barbed sutures are needed for closure since no extra material is needed for knot tying, and a growing body of evidence suggests that wound closure times are reduced in comparison to traditional closure techniques for the same reason. 4-6 It is clear that this technology has begun to revolutionize the field of orthopedics, 7-9 gynecology, 4,5,10-19 urology, and other surgical specialties. Since plastic surgeon Gregory Ruff invented this device, 1,24 our specialty continues to develop new and innovative ways to utilize it. 6,25-34 In this article, new and emerging uses of barbed sutures for tissue fixation in plastic surgery today are reviewed. I readily acknowledge that the data to support these uses currently lag behind the fast pace of development. In fact, Aesthetic Surgery Journal 33(3S) 90S 95S 2013 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Barbed sutures first received US Food and Drug Administration approval for soft tissue approximation in 2005 and early adopters readily embraced this device to develop new techniques. It has become apparent that the advantages are more than just skin deep. Superficial and deep fascia, cartilage, tendon, joint capsule, and fibrous periprosthetic capsules can also be manipulated. Barbed sutures have revolutionized our approach to facial rejuvenation and body contouring by enhancing our ability to quilt and powerfully lift tissue. The elimination of surgical drains and shorter surgical times has made this a true boon for plastic surgeons as well as many other surgical specialists. This article summarizes some of the current and evolving applications of this exciting new tool. Keywords barbed suture, progressive tension suture, quilting suture, body contouring, abdominoplasty, tummy tuck, rectus fascia plication, brow lift, SMAS plication, spreader graft Accepted for publication December 12, the evidence base in this field of plastic surgery is particularly limited, and much of the preference for barbed sutures is based on individual surgeons experiences with these devices. Development History As with many new surgical devices, early failures with barbed suture technology have helped pave the way for Dr Rosen is an Assistant Clinical Professor in the Department of Plastic Surgery, University of Medicine and Dentistry of New Jersey, Montclair. Corresponding Author: Dr Allen Rosen, Founding Partner and Medical Director, The Plastic Surgery Group & North Fullerton Surgery Center, 37 North Fullerton Ave, Montclair, NJ 07042, USA. adrmd@aol.com Scan these codes with your smartphone to see the operative videos. Need help? Visit

2 Rosen 91S today s successes. One of the first applications of the barbed suture was a closed suspension technique utilizing permanent polypropylene sutures known as a thread lift Closed suture suspension techniques were plagued by lack of long-term aesthetic correction, high cost, and complications Powerful and dramatic tissue lifting was achieved with closed deployment in facial rejuvenation, but longterm results were not possible without component separation, mobilization and redistribution of tissue. In addition, a variety of complications including suture palpability, breakage, and exposure resulted when the large-diameter permanent sutures were placed in the thin, subcutaneous soft tissues of the face. 39,40 Some early adopters were stigmatized by wound edge necrosis and suture exposures. Since 2010, when Shermak et al 40 reported their disappointing series involving the use of barbed sutures, marked improvements in suture options have evolved to virtually eliminate these issues. Smaller gauge sutures with quicker absorption rates, as well as different barb arrays and sizes, have optimized their use. We have learned that these materials require different deployment into tissue than smooth sutures, and it is critical to set the suture with much less force. Valuable lessons learned from these experiences have now been incorporated into new applications for soft tissue fixation in open procedures involving tissue undermining and redistribution. Technical improvements in materials have allowed for more appropriate and safer suture placement into different tissue layers. Novel techniques are evolving, including the quilting and lifting of tissues and progressive tension closures. 6,28 Surgeons are continuing to investigate new uses for barbed sutures in all soft tissue layers, including the deep fascia, cartilage, tendon, joint capsule, and breast capsule. Skin Closure By far, the most popular early use of this material by plastic surgeons has been for closure of skin and subcutaneous tissue. In this application, short-acting polyglactin absorbable sutures are preferred. In general, the more superficial the closure, the smaller the suture gauge needed. I use 3-0 Monoderm Quill (90-day absorption; Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada) 41 for all deep dermal and subcuticular running closures. In fact, an entire perilobular short scar facelift closure can be performed with a single bidirectional 3-0 Monoderm Quill suture. Note that, because the production of tissue retainers decreases the internal core diameter, the Quill device was designed to be approximately equal in strength to conventional sutures that were 1 size smaller. 41 Thus, the 3-0 Monoderm Quill suture is comparable in strength to a 4-0 monocryl smooth suture. The closure starts with the transition zone at the ear lobule and continues superiorly, with 1 arm of the suture used for repair of the preauricular/anterior hairline area and the other arm running posteriorly in the postauricular sulcus (Figure 1). Multilayered closures can be performed Figure 1. Perilobular short scar facelift closure performed with a single 3-0 Monoderm Quill. Reprinted with permission of the manufacturer Angiotech Pharmaceuticals, Inc. using a single continuous running barbed suture by simply stepping up to the more superficial layer when indicated. Superficial Fascia My initial interest in barbed sutures was inspired by Malcolm Paul s work 31,32 involving superficial musculoaponeurotic system (SMAS) deployment in facial rejuvenation. Scarpa s fascia and the SMAS/platysma counterparts in the head and neck can be effectively approximated with longer-acting sutures (PDO Quill, 180-day absorption). 27,42 Daniel Man s work 27 on gathering and lifting the SMAS with a U-shaped periauricular suture added further support to the concept that this material can powerfully lift, redistribute, and maintain the position of superficial fascial tissues until full cicatricial healing occurs. Ted Lockwood stressed the importance of the superficial fascial system for control of tension in body contouring, and further studies will determine whether the use of barbed sutures in this plane may be a better alternative to interrupted smooth sutures. Sub-Scarpa s Fat (Quilting) One of the most exciting uses of bidirectional barbed sutures has been in the sub-scarpa s fatty layer. Many methods have been used to tack down this layer, including tissue adhesives, 47,48 interrupted sutures, 49,50 suction drains (negative pressure), 51 and compression garments (positive pressure), all with mixed results. While each of these techniques is

3 92S Aesthetic Surgery Journal 33(3S) Figure 2. Suture placement and deployment pattern. Five running parallel rows of barbed suture are placed in a sequential fashion. The midline row was added after the original publication of this technique 5 to help midline contouring and further obliterate supraumbilical dead space. Revised from original. Reprinted with permission from Rosen. 6 (A video of this technique is available at You may also scan the code on the first page of this article with any smartphone to be taken directly to the video on effective, there are associated drawbacks. For instance, tissue adhesives add significant expense, drains can be cumbersome and uncomfortable for many, and interrupted sutures are more time-consuming to place. Compression garments, unfortunately, do not reduce shear forces and do little, if anything, to stabilize deep tissues in any significant way. Most surgeons today utilize a combination of these modalities for full effectiveness. Running barbed sutures to quilt or pleat the deep tissue layer has effectively replaced these modalities and resulted in time and cost savings. 28 The work of Pollock and Pollock 49,50 and others paved the way for placement of interrupted quilting sutures to reduce shear forces and dead space in abdominoplasty patients, eliminating the need for drains. My independent report 6 and that of Warner and Gutowski 28 subsequently confirmed that barbed sutures placed with progressive tension (PTS) during abdominoplasty closure could be used effectively to reduce operative time and eliminate drains (Figures 2 and 3). (A video of this technique is available at journal.com. You may also scan the code on the first page of this article with any smartphone to be taken directly to the video on Others have also confirmed the effectiveness of a quilting suture technique in body contouring procedures. 52,53 I have used a similar running quilting suture to secure the sub- Scarpa s fatty layer in widely undermined flaps during gynecomastia excision, in body contouring after massive weight loss, and for transverse rectus abdominus myocutaneous (TRAM) flap donor site closure. Figure 3. The deployment requires an assistant as the operating surgeon holds and advances the flap with his or her nondominant hand and places the suture with the other hand. The assistant grasps the needle as it passes from the abdominal fascia into Scarpa s in 1 bite, so the surgeon can regrab the needle for the next throw. I added a midline PTS suture, supplementing the 2 lateral rows on each side, subsequent to our original reported series, to help compartmentalize the supraumbilical area and reveal early contour definition to this region. Revised from original. Reprinted with permission from Rosen. 6 (A video of this technique is available at You may also scan the code on the first page of this article with any smartphone to be taken directly to the video on Deep Fascia and Subperiosteal Layers I have found the use of barbed sutures for repair of deep fascia (particularly the rectus sheath) and fixation of subperiosteal flaps to be exceptionally useful. Longevity and tensile strength are critical in these applications; therefore, long-acting absorbable or permanent sutures are recommended. I published results from a series of 34 middle-aged, thin women (body mass index <30; mean age 43.6 years) who underwent repair of rectus diastasis during abdominoplasty; the data clearly demonstrated the safety of long-acting absorbable barbed sutures for this application. 54 In addition, I have found that long-acting absorbable barbed polydioxanone or Prolene (Ethicon, Inc, Somerville, New Jersey) is an effective alternative to bone tunnels, cortical screws, and endotine devices for fixation of mid-face and forehead soft tissues after undermining and repositioning. Other Soft Tissues: Cartilage, Tendon, Joint Capsule, and Breast Capsule No long-term studies using barbed sutures for cartilaginous structures have been reported, and this remains an area of

4 Rosen 93S Figure 4. (A) Securing septal cartilage spreader grafts for internal valve repair during rhinoplasty. The first 2 passes with the barbed suture secure and unitize the spreader grafts to the dorsal septum at the transition zone of the bidirectional barbed suture. (B) The spreader grafts are shown completely secured by multiple back-and-forth passes with the bidirectional barbed suture. Reprinted with permission of the manufacturer Angiotech Pharmaceuticals, Inc. (A video of this technique is available at You may also scan the code on the first page of this article with any smartphone to be taken directly to the video on great potential usefulness for this material. I am presently utilizing bidirectional barbed suture in otoplasty (Mustardetype 55 ) and for securing septal cartilage spreader grafts for internal valve repair during rhinoplasty (Figure 4). (A video of this technique is available at You may also scan the second code on the first page of this article with any smartphone to be taken directly to the video on Knot tying is eliminated when barbed sutures are utilized, simplifying spreader graft fixation in open rhinoplasty. Barbed sutures may also revolutionize hand surgery. Knotless tendon repairs that are more secure, less devascularizing, and easier to deploy are being evaluated in human trials after being supported by encouraging data from animal and cadaveric studies I have successfully used barbed sutures in repairing capsules in interphalangeal joint injuries as well. In large capsule joint repair, orthopedic surgeons are leading the way. Knee arthrotomy closures performed with bidirectional barbed sutures have been shown to be more watertight than conventional closures, 7 with greater biomechanical integrity when intentionally cut and exposed to cyclic loading. 8 In the clinical setting, knee arthrotomy closures performed with barbed sutures were significantly faster than those performed with conventional sutures. 9 Barbed sutures are also advantageous for any application where it is technically more difficult to tie knots, such as in capsulorrhaphy for the treatment of breast implant displacement. Other reported uses of barbed devices in technically difficult areas include robotic sacrocolpopexy 5 and laparoscopic myomectomy. 4 For urologic surgeons, barbed sutures have become a time-saving device for performing the renorrhaphy technique during robot-assisted partial nephrectomy 20,59 and for closure of vesicourethral anastomosis during robot-assisted radical prostatectomy Conclusions Barbed suture applications are in their infancy. Technological advancement will help drive new techniques, and eventually, tissue-specific sutures with different barb arrays, barb sizes, barb spacing, and barb shapes will be developed. Barbed sutures for skin, fascia, joint capsule, cartilage, and viscera will all have their own unique configuration corresponding to individual tissue characteristics. Laser cut barbs on 10-0 nylon suture material will allow microsurgical procedures without knot-tying, and antibiotic-impregnated sutures will be available for relevant applications. The evidence base to

5 94S Aesthetic Surgery Journal 33(3S) support both current and new applications will need to catch up to the pace of development. It is in our best interest as plastic surgeons to adapt quickly and guide the evolution of this new technology for future surgeons. Acknowledgment I thank Dr Valerie J. Ablaza of The Plastic Surgery Group and Anneke Jonker and Hayato Tanaka of Angiotech Pharmaceuticals, Inc for their help in the preparation of this manuscript. Disclosures Dr Rosen was a paid member of the speakers bureau for Angiotech Pharmaceuticals, Inc (Vancouver, British Columbia, Canada). Funding Publication of the articles in this supplement was supported by a grant from Surgical Specialties Corporation, but the authors did not receive any direct compensation for writing the manuscripts. References 1. Murtha AP, Kaplan AL, Paglia MJ, Mills BB, Feldstein ML, Ruff GL. Evaluation of a novel technique for wound closure using a barbed suture. 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