Barbed Sutures in Progressive Tension Suture Technique ...
Transcript of Barbed Sutures in Progressive Tension Suture Technique ...
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Barbed Sutures in Progressive
Tension Suture Technique
Abdominoplasty
Karol A Gutowski, MD
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Disclosures
Speakers Bureau for AngioTech since April 2011
(Makers of Quill bi-directional barbed sutures)
Technique may be applicable to other brands of barbed sutures
NO financial interests in AngioTech
Will NOT discuss off-label use of products
Will NOT discuss non-FDA approved products
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Objectives
• Offer a modification of progressive tension suture
abdominoplasty using a continuous running
barbed suture (BS)
• Discuss pitfalls and key points of modified
technique
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Peer Reviewed Publications
ASJ 2009
PRS 2010
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Peer Reviewed Publications
ASJ 2009
PRS 2010
IN PRESS
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Public Reviewed Publications
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Public Reviewed Publications
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Public Reviewed Publications
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Update on Experience Since 2009
Abdominal contouring patients 145
Tumescent technique + liposuction
Firm abdominal binder for 1-2 weeks
Autologous breast reconstruction 7
Implantable “pain pumps”
No abdominal binder first week
All cases used standard technique with bi-directional
barbed sutures without drains
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Abdominal Contouring Procedures
Standard abdominoplasty 102
with inverted T incision 11
Circumferential abdominoplasty 26
with inverted T incision 6
TOTAL 145
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Abdominal Complications
Seroma 3
Drained by single needle aspiration 2
Drained by two needle aspirations 1
Wound dehiscence 5
Anterior & superficial (skin only) 2
Posterior & superficial (skin only) 2
Lateral & deep (Scarpa’s fascia) 1
Hematoma 0
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Breast Reconstruction Seroma
Bilateral DIEP breast reconstruction - Missing needle
Large right abdominal seroma 1 week post-op
Unresponsive to needle aspiration & drain placement
Required operative drainage and excision
Due to unintentional omission of PTS on right side
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Use size 2 or 1 PDO suture
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Place medial suture line to umbilical stalk
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Place lateral suture line to same level
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Advance needle 2 to 3 cm with each placement on
abdominal flap
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Secure to abdominal wall fascia while maintaining
progressive inferior tension on flap
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The PTS should include no more than half of the
abdominal flap thickness
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Use Non-Dominant Hand for
Traction Toward Incision
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Place contralateral medial and lateral sutures to
level of umbilical stalk
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Finish lower abdominal PTS
Address the umbilical transposition
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Finish lower abdominal PTS
Address the umbilical transposition
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Protect the Needles
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Practical Tips
• Instruct assistants on principals of this technology
– More familiarity = faster incorporation it into your practice
– Don’t cut off one of the two needles of the bidirectional sutures
• Suture is more firm
– Gentle stretching prevents loop and knot formation
• Avoid contact with gauze, lap sponges & similar materials
– Barbs may attract lint-like material onto the suture
• Two needles on operative field with each suture
– Protect the needle not in use with a needle holder
• If a barbed suture breaks
– Start a new suture with 3-4 cm of overlap with the old suture
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More Practical Tips
• Keep abdominal flap aligned
– Mark undersurface & avoid tendency to pull flap to one side
• Avoid excess tension as fat necrosis may result
• May apply techniques to circumferential abdominoplasty
– Use posterior “3-point” tissue fixation to close dead space
• Advise patients
– Small abdominal contour irregularities resolve in 1 to 2 weeks
– May feel “popping” sensation in 2 to 6 weeks
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Technique Advantages
• Fast closure
– 8 to 10 minutes additional time for PTS
• Can do without an assistant
• Maintains tissue approximation
– Less tissue pull-through
• Eliminate abdominal drains
• Need for abdominal binder?
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BS-PTS Abdominoplasty (1 year)
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BS-PTS Abdominoplasty (1 year)
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BS-PTS Abdominoplasty (5 months)
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BS-PTS Abdominoplasty (5 months)
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BS-PTS Abdominoplasty (5 months)
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BS-PTS Abdominoplasty (7 weeks)
Exposed #2 PDO Suture
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BS-PTS Abdominoplasty (7 weeks)
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MWL BS-PTS Abdominoplasty & liposuction (4 months)
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MWL BS-PTS Abdominoplasty & liposuction (4 months)
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MWL BS-PTS Abdominoplasty & liposuction (4 months)
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MWL BS-PTS Abdominoplasty & liposuction (4 months)
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BS-PTS “T-Incision” Abdominoplasty
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BS-PTS “T-Incision” Abdominoplasty
No undermining = no PTS
Undermining = BS-PTS
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BS-PTS “T-Incision” Abdominoplasty
After 2 weeks
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BS-PTS “T-Incision” Abdominoplasty
After 4 weeks
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BS-PTS “T-Incision” Abdominoplasty
After 3 months
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Lessons Learned
• Progressive tension sutures work
• Favorable learning curve
• Try it on a TRAM
• Resist temptation to advance PTS too far
• Teach your OR team
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Video Presentation
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More Information & Discussion
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Contact Information
773-870-0732
Everything presented will be in a special topic
issue of the Aesthetic Surgery Journal
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Barbed Sutures in Progressive
Tension Suture Technique
Abdominoplasty
Karol A Gutowski, MD