The breadth of literature regarding barbed suture applications in plastic surgical procedures and of importance to this article, barbed suture applications in breast surgery, is growing dramatically as surgical practitioners are becoming more familiar with the advantages of this new suture technology. Barbed suture devices were first implemented by plastic surgeons for the use in various minimally invasive techniques for facial rejuvenation, but have now surpassed these applications and are now much more commonly used in Breast and Body closures.
Key points
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In primary and revisional breast surgery, incisions are limited, and it often feels like trying to operate through a “mail slot”!
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In these limited access applications barbed technology is extremely useful by facilitating suturing internally in limited spaces without the need for tying knots.
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This limited access application and increased speed and efficiency of incisional closures are the main applications and benefits of using these barbed devices.
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The future development of barbed sutures technology along with the number of applications continues to grow.
Background
The breadth of literature regarding barbed suture applications in plastic surgical procedures signifies the importance of this article Barbed suture applications in breast surgery is growing dramatically as surgical practitioners are becoming more familiar with the advantages of this new suture technology. Barbed suture devices were first implemented by plastic surgeons for the use in various minimally invasive techniques for facial rejuvenation. Although the initial devices had their share of pitfalls, the most noticeable advantage in their implementation was a reduction in procedural time. With the increase of bariatric procedures, there has been a similar increase in the number of body-contouring procedures in order to address the significant skin redundancies related to massive weight loss of the breast and body. In an effort to improve operative efficiency, the implementation of barbed suture technologies has increased to streamline the closure of large skin resection margins of the body and also the breast, particularly breast reductions and mastopexy procedures. A common theme to the advantages of this modality of tissue closure is the speed and ease of placement. Often either deep suture material is not required or fewer deep approximation points are necessary, which subsequently reduces the operative closure time. In addition, complications associated with more conventional suture material related to knot slippage or breakage, suture extrusion or spitting, and infection may be reduced. Furthermore, tension may also be more uniformly distributed along the wound, and the barbed nature of the suture prevents tissue sliding with more than 20 points of fixation per square inch. Some have even suggested that the final scar result is subjectively improved from a clinical perspective as a result of a reduction of tissue-related ischemia, less suture extrusion, and locking of the tissues more tightly through the barbing, although this is difficult to prove clinically when Monocryl-type sutures are used.
Three main barbed suture device companies are currently being used for soft tissue closure in breast, body contouring, and other soft tissue closure procedures in the United States. A bidirectional self-retaining suture (Quill SRS, now Surgical Specialties, Vancouver, British Columbia, Canada) uses a helically distributed back-cut spaced distance of 5.08 mm apart on a variety of monofilament sutures of both the absorbable (polyglycolic acid/polycaprolactone [Monoderm]) and polydioxanone (PDO) along with nonabsorbable (nylon and polypropylene) ( Figs. 1 and 2 ). The barb cut in the strand reduces the diameter of the suture such that a 3-0 suture has the corresponding strength of a 4-0 standard monofilament suture. Quill suture is available in both bidirectional and unidirectional formats.
Surgical Specialties licensed their Quill technology to Johnson & Johnson/Ethicon in 2012, who is also marketing and distributing their barbed suture under the trade name Stratafix (Somerville, NJ, USA). Quill and Stratifix 3-0 suture have a tensile strength of a 4-0 suture, while V-Loc keeps the 1:1 ratio of standard suture, so that a 3-0 Monocryl is the same diameter as a 3-0 V-Loc.
The third suture device is the Covidien V-Loc ( Fig. 3 ) wound closure system (Covidien, Mansfield, MA, USA), which consists of a dual-angled back-cut spaced helically with 20 barbs per centimeter in a unidirectional orientation. Similar to the Quill device, the back cut into the suture reduces the diameter such that a 3-0 V-Loc device has a corresponding strength profile of a 4-0 standard monofilament suture.
Background
The breadth of literature regarding barbed suture applications in plastic surgical procedures signifies the importance of this article Barbed suture applications in breast surgery is growing dramatically as surgical practitioners are becoming more familiar with the advantages of this new suture technology. Barbed suture devices were first implemented by plastic surgeons for the use in various minimally invasive techniques for facial rejuvenation. Although the initial devices had their share of pitfalls, the most noticeable advantage in their implementation was a reduction in procedural time. With the increase of bariatric procedures, there has been a similar increase in the number of body-contouring procedures in order to address the significant skin redundancies related to massive weight loss of the breast and body. In an effort to improve operative efficiency, the implementation of barbed suture technologies has increased to streamline the closure of large skin resection margins of the body and also the breast, particularly breast reductions and mastopexy procedures. A common theme to the advantages of this modality of tissue closure is the speed and ease of placement. Often either deep suture material is not required or fewer deep approximation points are necessary, which subsequently reduces the operative closure time. In addition, complications associated with more conventional suture material related to knot slippage or breakage, suture extrusion or spitting, and infection may be reduced. Furthermore, tension may also be more uniformly distributed along the wound, and the barbed nature of the suture prevents tissue sliding with more than 20 points of fixation per square inch. Some have even suggested that the final scar result is subjectively improved from a clinical perspective as a result of a reduction of tissue-related ischemia, less suture extrusion, and locking of the tissues more tightly through the barbing, although this is difficult to prove clinically when Monocryl-type sutures are used.
Three main barbed suture device companies are currently being used for soft tissue closure in breast, body contouring, and other soft tissue closure procedures in the United States. A bidirectional self-retaining suture (Quill SRS, now Surgical Specialties, Vancouver, British Columbia, Canada) uses a helically distributed back-cut spaced distance of 5.08 mm apart on a variety of monofilament sutures of both the absorbable (polyglycolic acid/polycaprolactone [Monoderm]) and polydioxanone (PDO) along with nonabsorbable (nylon and polypropylene) ( Figs. 1 and 2 ). The barb cut in the strand reduces the diameter of the suture such that a 3-0 suture has the corresponding strength of a 4-0 standard monofilament suture. Quill suture is available in both bidirectional and unidirectional formats.
Surgical Specialties licensed their Quill technology to Johnson & Johnson/Ethicon in 2012, who is also marketing and distributing their barbed suture under the trade name Stratafix (Somerville, NJ, USA). Quill and Stratifix 3-0 suture have a tensile strength of a 4-0 suture, while V-Loc keeps the 1:1 ratio of standard suture, so that a 3-0 Monocryl is the same diameter as a 3-0 V-Loc.
The third suture device is the Covidien V-Loc ( Fig. 3 ) wound closure system (Covidien, Mansfield, MA, USA), which consists of a dual-angled back-cut spaced helically with 20 barbs per centimeter in a unidirectional orientation. Similar to the Quill device, the back cut into the suture reduces the diameter such that a 3-0 V-Loc device has a corresponding strength profile of a 4-0 standard monofilament suture.
Clinical applications
Internal cost studies performed by the authors have shown that for most breast procedures the net cost of using barbed versus standard sutures is essentially equivalent. For instance, the cost of using one 2-0 Vicryl and two 3-0 Monoderm for a bilateral breast augmentation is cost equivalent to using two 3-0 and 4-0 Monocryl sutures. In addition, surgery time is expensive, approaching $100 per minute in large hospital settings; thus, any saving in Operating Room time may result in a significant overall cost savings. Additional advantages, such as time savings and closure techniques, have also been well outlined.
Two-layer breast augmentation closure
The authors’ longest and most used closure application with barbed suture is the 2-layer breast closure in primary augmentation and revisional breast surgery. The authors have used this specific closure method for the past 5 years in more than 1200 breast procedures. It is fast and efficient and works well with first assistants, residents, and fellows, or dual surgeons. The authors have not experienced any wound breakdown, skin dehiscence, or suture track infections since its implementation. Their average standard primary breast augmentation time is averages 35 minutes, skin to skin, with the incision closure time less than 5 minutes.
Following the breast augmentation and checking for pocket and implant symmetry, the deep closure is performed setting the inframammary fold, if the inframammary fold incision is being used, with either a 2-0 polydioxanone suture (PDS) or 2-0 Vicryl, placing the suture into the deep fascia directly in the fold and then through the breast fascia of the lower skin flap followed by the upper breast skin flap. Charles Randquist has termed this the “Baby-Sitter Stitch.” The authors place 1 or 2 of these sutures followed by running the deep fascia. A more superficial bite is taken directly over these 1 to 2 deep sutures to potentially avoid damaging the underlying device. The fascia is run under direct vision, allowing for a more uniform tightly approximated closure and avoiding the potential knuckling of the device that patients may palpate between interrupted sutures. Two to 3 sutures of this deep closure material (2-0 Vicryl) is then placed to approximate the incision edges just beneath the dermis. Following this, a 2-layer closure of 3-0 Monoderm or similar barbed suture completes the closure ( Fig. 4 and [CR] and [CR] ).
