Introduction to the Barbed Sutures Supplement: The Expanding Applications of Barbed Sutures (original) (raw)

Abstract

In 1881, Alexander Graham Bell invented what arguably could be called the first metal detector. President James Garfield had been shot. His doctors needed to locate the bullet that was lodged in his chest, but the president already had lost a significant amount of blood. Doctors therefore were reluctant to perform manual exploration. Bell's invention seemed the best hope. What no one realized at the time was that the metal springs in the mattress upon which the president lay would render Bell's metal detector ineffective. Garfield ultimately died from his wounds. The metal detector endured. Through the work of later inventors, it evolved into a device serving a variety of important functions, most notably helping to ensure our safety in public places. 1 Many useful inventions originally intended for one purpose end up better serving another. In plastic surgery, such has been the evolution of barbed sutures. In the 1990s, lifting of the brows, midface, and neck using barbed sutures, usually applied subcutaneously with a threading technique, was widely promoted as a safer, quicker, and less invasive alternative to traditional surgical procedures. However, for many surgeons and their patients, both the short-and longer-term results were disappointing. Complications and other adverse events were common. Some problems were undoubtedly technique related, as practitioners with various backgrounds and little hands-on training with barbed sutures aggressively promoted themselves as experts and performed procedures without the requisite experience. Nevertheless, interest in these threading techniques for suspension of facial tissues waned considerably in the plastic surgery community. Subsequently, however, expanded applications for barbed suture technology have evolved. Sutures are essential in almost every procedure that we perform. The choice of suture depends on several variables, including the anatomic site, desired suture characteristics, and surgeon preference. In my practice, barbed sutures have come to play an important role in a growing number of procedures performed on a routine basis. Currently, I use them in conjunction with lateral browlifts, short-scar facelifts, breast lifts, breast reductions, and abdominoplasties. The following few paragraphs offer a brief summary of my current utilization of barbed sutures.

Figures (3)

Figure 1. (A) A 63-year-old woman concerned with periocular aging, shown following skin defect excision, prior to flap undermining. She had a positive elevation test (persistent upper eyelid skin excess after the brow is manually adjusted superiorly to its ideal position). Consequently, she will benefit from an upper lid blepharoplasty and lateral temporal lift. (B) Flap elevated above the frontalis muscle, demonstrating the widely dissected subcutaneous plane. The dissection is wider thar the 4- to 5-cm length incision and progresses to just below the eyebrow hairs. (C) Bidirectional, double-arm Quill (Angiotech, Inc, Vancouver, British Columbia, Canada) barbed suture used for single-layer wound closure. Three minutes of pressure is applied following tissue sealant. (D) The lateral temporal lift wound is closed with a 3-0 Monoderm bidirectional Quill suture, with a diamond point needle, 14 < 14 cm in length. (E) Wound closure and purse-string tightening of the Quill suture. Interrupted prolene sutures also can be used as indicated. (F) Appearance of the closed lateral temporal lift.

Figure 2. A 55-year-old woman, 3 weeks after a lateral temporal lift. The incision can be placed in the hair, at the hairline, or within the fine temporal hairs according to the patient’s anatomy and goals.

Figure 3. (A) Quill suture (Angiotech, Inc, Vancouver, British Columbia, Canada) for superficial musculoaponeurotic system (SMAS)-platysma imbrication. The laxity in the SMAS is first assessed with tissue forceps. Surgery begins by grasping the redundant SMAS at the apex of a triangle formed by the lateral border of the platysma and the zygoma, the base of which is parallel to the nasolabial fold. Final closure results in an inverted “L” in front of the ear. (B) The second suture continues down the front of the ear, toward the lateral border of the platysma, in continuity with the earlier SMAS closure (first suture). (C) The lateral border of the platysma is secured to the mastoid fascia. Prior to completing the imbrication of the platysma, the suture is J-locked in multiple spots along the sternocleidomastoid muscle fascia to avoid any suture slippage.

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