Background: Seroma and skin necrosis are potential complications following abdominoplasty. Many methods have been employed to prevent these complications, including the progressive tension suture technique.
Objective: The authors evaluate a progressive tension suture technique modification using the Quill barbed suture (Angiotech Pharmaceuticals, Inc., Vancouver, British Columbia, Canada) to determine whether the original benefits of this classic technique can be obtained in a shorter operative period.
Methods: The modified progressive tension closure technique with Quill sutures uses barbed sutures to plicate the abdominoplasty flap to the underlying abdominal wall. The placement of the suture is performed with a running suture technique and provides progressive tension, resulting in minimal tension along the incision line. Data from 58 patients undergoing abdominoplasty using this technique are examined, including time to insert the sutures and complications such as seroma, hematoma, and skin necrosis.
Results: There was a marked reduction in the time necessary to perform the modified progressive tension suture technique using barbed sutures compared to previously published data. The authors' average time was nine minutes to complete plication of the entire abdominal flap. One seroma is reported, which was resolved with one aspiration. No hematomas or skin necrosis complications are reported.
Conclusions: Using barbed sutures to perform progressive tension suture closure in abdominoplasty is a safe and effective way to considerably reduce operative time and retain all of the benefits of the original progressive tension suture technique.
The perfect candidate for abdominoplasty body contouring is someone who is young, healthy, a nonsmoker, close to their ideal body weight, psychologically stable, has good skin elasticity, understands what is involved with surgery, has realistic expectations, and has a minimal amount of excess skin, fat, and fascial laxity. Under these conditions, one may anticipate the fewest complications possible. However, abdominoplasty patients (along with other operative candidates) rarely fall into the “perfect” candidate category. Along with this variability of patients comes a variety of complications. The risk of complications rises when patients are in suboptimal health or show other less-than-ideal parameters.
There are many well-known complications associated with abdominoplasty, including systemic complications and those local to the operative field. The focus of this article includes skin necrosis and seroma under the abdominoplasty flap. Seromas can generally be aspirated in the office once detected. Hopefully one aspiration is enough to solve the problem and get the patient back onto a less intrusive follow-up schedule, but these seromas can often persist, requiring frequent and time-consuming follow-up. This may ultimately lead to subsequent anxiety for both patients and surgeons. Many surgeons use drains to combat seroma formation, but it has been our experience that drains lead to heightened patient anxiety, even when the experience of drain removal is minimized with the use of round drains and patient-comforting techniques. The use of progressive tension sutures has been evaluated and has been found to be as effective as drains, making that technique an attractive option. However, the original procedure as described has a significant limitation: additional operative time.
The use of progressive tension sutures in abdominoplasty has been well-described.1 In their article, Pollock and Pollock point out the advantages of this technique, including a very low local complication rate when compared with historical controls. In their series of 65 abdominoplasties, there were no reports of seromas, hematomas, or skin necrosis. This is further evidenced by Baroudi and Ferreira's earlier report2 of the “quilting” technique, it did not involve the progressive tension that would have led to less stress on the incision site and lower end of the flap, but did reduce dead space by approximating the deep layer of the abdominoplasty flap to the deep fascia of the abdomen. One of the primary drawbacks to this technique is the additional time necessary to place the multiple interrupted sutures. To address this drawback, we have evolved the progressive tension suture abdominoplasty technique further by using the Quill barbed suture (Angiotech Pharmaceuticals, Inc., Vancouver, British Columbia, Canada) to perform the progressive tension closure. The aim of the current study is to show that the operative time necessary to complete the progressive tension suture technique can be significantly minimized by using barbed sutures.
All procedures were performed on an outpatient basis at an accredited outpatient cosmetic surgery center. A total of 58 patients underwent an abdominoplasty procedure. All of the patients were females between 31 and 57 years of age (mean 42 years). Of these, 23 patients had flank liposuction at the time of the abdominoplasty and nine had circumferential abdominoplasties. Eleven cases were for massive weight loss patients. There were no exclusion criteria. All patients were marked preoperatively in the standing position and the procedures were performed under deep sedation or general anesthesia. In all cases, 1 to 2 L of tumescent fluid (500 mg of lidocaine and 1 mL of 1:1000 mg in 1000 mL normal saline) was infiltrated into the operative field for analgesia and hemostatsis. All of the procedures were performed as full abdominoplasties.
Flap elevation was performed with a combination of knife dissection and electrocautery. We plicated the midline rectus fascia in each case using interrupted 0 Vicryl sutures with a 0 polydioxanone running suture over the buried Vicryl sutures. The Quill suture is a bidirectionally-barbed suture with a needle on each end. It is currently available as a polydioxanone absorbable monofilament suture (the same material used in polydioxanone suture). To perform the progressive tension suture technique using these barbed sutures, one bidirectional size 1 suture was used on each side of the umbilicus, starting at the most superior aspect of the exposed abdominal wall. One half of the suture was run vertically on the medial half and the other half was run on the lateral half of the hemiabdominal wall (Figure 1). The abdominal flap was sutured to the abdominal fascia approximately seven times on the medial half of the suture and approximately seven times on the lateral half of the suture (Figure 2). This was then repeated on the opposite hemiabdominal wall (Figure 3). In many patients, especially those with longer flaps, it may be easier to perform simultaneous closure, switching from side to side as the flap is progressively tacked down to the abdominal wall. This may avoid difficult suturing on the opposite side once the first side is completed. Dimpling has not been a problem in our practice. One obviously wants to avoid deep dimples, but as outlined in previous articles, small dimples will disappear over time (Figure 4). The Scarpa layer, dermis, and skin were also closed using running Quill size 0 sutures. No drains were used. All patients were discharged home on the same day. Abdominal binders were not mandatory, but were offered for patient comfort. Patients were instructed to ambulate on the night of surgery.
In all cases, the typical time to complete progressive tension closure was 4.5 minutes per side (range 4–5 minutes), for a total of nine minutes to complete the entire abdominal flap plication. In 58 patients, there was one 10-mL seroma present in the epigastric region (1.7%), which resolved after a single needle aspiration. There were no hematomas, skin necrosis complications, infections, or revision procedures (0%).
Abdominoplasty has undergone a multitude of evolutionary changes since its first reported case in the late 19th century. Surgeons are no longer content with applying a single surgical technique to the variety of body morphology seen in the clinic. We now have at our disposal a number of techniques that have allowed us to individualize and fine tune the outcomes for our patients. These include liposuction, staged liposuction, liposuction combined with abdominoplasty, mini abdominoplasty, abdominoplasty with or without umbilical translocation, truncal contouring after massive weight loss, and a myriad of excision designs.
Throughout the evolution of abdominoplasty, the procedure has continued to have (as all procedures do) a host of potential complications. With the evolution of the techniques—especially those of combined procedures—new concerns and complications have been debated in the literature.3–6 Several complications, however, have persisted throughout the evolutionary process. Two of these complications include seromas and skin necrosis. Postabdominoplasty seroma rates have varied widely in the literature. Part of the problem with studies looking at seromas after abdominoplasty is determining what constitutes a seroma. It may be argued that all abdominoplasties have some degree of seroma, but radiographically detectable seromas are not always clinically relevant. Different techniques and biased surgeon reporting make it difficult to determine the true incidence of seromas and other complications. Interestingly, several reports have shown a correlation between obesity and the number of complications reported by plastic surgeons. With a growing trend in obesity, the risk factors for complications, including seroma and skin necrosis, also rises.4,7–9
Many different techniques have been reported as attempts to decrease seroma formation. Some of these techniques include drain placement, external compression, tissue adhesives, progressive tension sutures, avoidance of electrocautery, leaving some fat down on the abdominal wall to preserve lymphatics, and restricting the amount of flap elevation. With respect to drain use, it has been observed that troublesome seromas appear to be unrelated to the length of time the drains are left in place.10 Pollock and Pollock's original article1 reported a decrease in the number of seroma complications when using progressive tension sutures to seal the abdominal flap down to the underlying abdominal wall. Subsequent studies looking at the need for drains in conjunction with progressive tension sutures have shown that, while using drains versus progressive tension sutures had an equal seroma rate, using neither technique had a higher incidence of seromas and using both together had no benefit.11 We feel that the idea of drain placement, regardless of which drains are used or how they are managed, produces anxiety for patients based on their presumptions. Whether psychological or real, there is no doubt that patients complain of discomfort related to drains. Elimination of possible discomfort to patients is well worth the effort to any surgeon. We therefore agree with previous reports that it is not necessary to use drains when the progressive tension suture technique is performed.
In our previous use of progressive tension sutures, we noted a very low incidence of seromas and skin necrosis, but there was still one major limitation: the time necessary to complete the technique. One of the reported drawbacks to the progressive tension suture technique is the added time that it takes to place 30 or 40 separate sutures to hold the abdominoplasty flap down to the abdominal wall. After timing their abdominoplasty operations, Andrades et al11 reported an average time of 50 minutes to place the 30 to 40 separate absorbable progressive tension sutures. An average time may be realistically estimated between 20 and 50 minutes to place these types of sutures. The authors' previous use of interrupted progressive tension sutures required about 15 to 20 minutes for the entire abdominal wall, but on average involved only 20 to 30 separate sutures. We sought a way to capture the benefit of the progressive suture technique without adding undue additional time to the procedure. The Quill suture simultaneously addresses both of these issues. Using the technique outlined in this article, the average time needed to complete the progressive tension closure in our abdominoplasties was a total of nine minutes. We find this to be a negligible amount of time considering the trade-off—happier patients who do not have to deal with drains, as well as a lower incidence of troublesome postoperative seroma and skin necrosis complications.
Progressive tension sutures do have notable benefits, especially increased patient satisfaction when drains are not required. We present an evolution of the abdominoplasty progressive tension suture technique that addresses its only major drawback: increased operative time. This is an easy technique to learn and is a quick modification that captures all of the benefits of Pollock and Pollock's1 original contributions.
The authors have no financial interest in and receive no compensation from manufacturers of products mentioned in this article.