Body Contouring
Commentary
Commentary on: Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?
Aesthetic Surgery Journal 2015, Vol 35(5) 581–582 © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv003 www.aestheticsurgeryjournal.com
Karol A. Gutowski, MD, FACS
Of the many methods described to reduce seroma formation after abdominoplasty, the use of internal suture techniques to secure the deep surface of the abdominoplasty flap to the superficial fascia of the abdominal wall seems to have the best track record. Although somewhat different in actual technique, both quilting sutures and progressive tension sutures appear to have the same result: no increase in seroma rates while allowing for shorter times to drain removal or even the elimination of drains altogether. This retrospective study by Sforza et al was able to show that among the three groups studied, quilting sutures dramatically reduced clinically detectable seroma formation.1 Unfortunately, the author’s hospital policy required placement of at least one drain in all abdominoplasties, so conclusions regarding the possibility of eliminating drains cannot be made based on this report. One barrier to the use of progressive tension sutures as first described was the additional 30 to 50 minutes required to place all the individual sutures.2 The introduction of barbed sutures allowed for a significant time reduction by using a running suture technique.3,4 After overcoming the learning curve, barbed suture placement can be done in 5 to 10 minutes. In this paper, the additional 9 to 15 quilting sutures added only 5 minutes to the procedure. Since barbed sutures are typically more expensive than the sutures used in this study, there may be an additional cost savings. In terms of drains, a recent meta-analysis was not able to find clinical support for the use of surgical subcutaneous drains in many common procedures.5 From personal experience, “letting go” of the drain in abdominoplasties may be a leap of faith which can be made easier by starting with selected patients. A thinner patient undergoing a simple abdominoplasty is a good way to start. Having an assistant help with suture placement is useful until the technique
becomes more familiar. There may be minor skin dimpling at the suture sites which resolves within a few days. Use of good quality compression garments, with Topifoam (Mentor, Santa Barbara, CA, USA) padding for the first 4 to 7 days helps close any remaining dead space. A brief check of the surgical site within the first 2 postoperative days will identify any early seromas. Patients are not confined to bed and advised to walk for a few minutes every hour while awake. The use of tumescent analgesia fluid, flap liposuction (lipoabdominoplasty), and lateral abdomen liposuction does not appear to increase seroma formation. One word of caution is that sutures placed on the lower abdominal wall may cause a sensory nerve entrapment,6 therefore sutures should not be placed in the “danger zones” around the inguinal ligament in order to protect the lateral femoral cutaneous nerve, genitofemoral nerve, and iliohypogastric nerve branches from injury.7 In conclusion, to answer Sforza et al’s question in the title of their paper, yes, quilting sutures are effective in preventing seromas in abdominoplasty (as are other suture techniques such as progressive tension sutures). This is supported by other large clinical studies3,8,9 which should offer surgeons enough encouragement to change their practice to a drain-free abdominoplasty.
Disclosures Dr Gutowski has a consulting relationship with Surgical Specialties Corporation (Vancouver, British Columbia, Canada), Dr Gutowski is an Adjunct Associate Professor in the Department of Surgery, Division of Plastic Surgery, University of Illinois – Chicago, Chicago, IL. Corresponding Author: Dr Karol Gutowski, Northwestern Specialists in Plastic Surgery, 676 N. Saint Clair Street, 15th Floor, Chicago, IL 60026, USA. E-mail: [email protected]
Aesthetic Surgery Journal 35(5)
582
manufacturer of Quill barbed sutures, a type of suture mentioned in this Commentary. Dr Gutowski has not received any payments or funding from Surgical Specialties Corporation in the past 12 months.
REFERENCES 1.
2.
3.
Sforza M, Husein R, Andjelkov K, Rozental-Fernandes PC, Zaccheddu R, Jovanovic M. Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective? Aesthet Surg J. 2015;35(5):574-580. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105(7):2583-2586. Rosen AD. Use of absorbable running barbed suture and progressive tension technique in abdominoplasty: a novel approach. Plast Reconstr Surg. 2010 Mar;125(3):1024-1027.
4. Warner JP, Gutowski KA. Abdominoplasty with progressive tension closure using a barbed suture technique. Aesthet Surg J. 2009;29(3):221-225. 5. Kosins AM, Scholz T, Cetinkaya M, Evans GR. Evidencebased value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis. Plast Reconstr Surg. 2013;132(2):443-450. 6. Matarasso A. Awareness and avoidance of abdominoplasty complications. Aesthet Surg J. 1997;17(4):256, 258-261. 7. Ducic I, Zakaria HM, Felder JM 3rd, Arnspiger S. Abdominoplasty-related nerve injuries: systematic review and treatment options. Aesthet Surg J. 2014;34(2):284-297. 8. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J. 2012;32(6):729-742. 9. Gutowski KA, Warner JP. Incorporating barbed sutures in abdominoplasty. Aesthet Surg J. 2013;33(3 Suppl): 76S-81S.
Commentary
Commentary on: Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective?
Aesthetic Surgery Journal 2015, Vol 35(5) 581–582 © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: [email protected] DOI: 10.1093/asj/sjv003 www.aestheticsurgeryjournal.com
Karol A. Gutowski, MD, FACS
Of the many methods described to reduce seroma formation after abdominoplasty, the use of internal suture techniques to secure the deep surface of the abdominoplasty flap to the superficial fascia of the abdominal wall seems to have the best track record. Although somewhat different in actual technique, both quilting sutures and progressive tension sutures appear to have the same result: no increase in seroma rates while allowing for shorter times to drain removal or even the elimination of drains altogether. This retrospective study by Sforza et al was able to show that among the three groups studied, quilting sutures dramatically reduced clinically detectable seroma formation.1 Unfortunately, the author’s hospital policy required placement of at least one drain in all abdominoplasties, so conclusions regarding the possibility of eliminating drains cannot be made based on this report. One barrier to the use of progressive tension sutures as first described was the additional 30 to 50 minutes required to place all the individual sutures.2 The introduction of barbed sutures allowed for a significant time reduction by using a running suture technique.3,4 After overcoming the learning curve, barbed suture placement can be done in 5 to 10 minutes. In this paper, the additional 9 to 15 quilting sutures added only 5 minutes to the procedure. Since barbed sutures are typically more expensive than the sutures used in this study, there may be an additional cost savings. In terms of drains, a recent meta-analysis was not able to find clinical support for the use of surgical subcutaneous drains in many common procedures.5 From personal experience, “letting go” of the drain in abdominoplasties may be a leap of faith which can be made easier by starting with selected patients. A thinner patient undergoing a simple abdominoplasty is a good way to start. Having an assistant help with suture placement is useful until the technique
becomes more familiar. There may be minor skin dimpling at the suture sites which resolves within a few days. Use of good quality compression garments, with Topifoam (Mentor, Santa Barbara, CA, USA) padding for the first 4 to 7 days helps close any remaining dead space. A brief check of the surgical site within the first 2 postoperative days will identify any early seromas. Patients are not confined to bed and advised to walk for a few minutes every hour while awake. The use of tumescent analgesia fluid, flap liposuction (lipoabdominoplasty), and lateral abdomen liposuction does not appear to increase seroma formation. One word of caution is that sutures placed on the lower abdominal wall may cause a sensory nerve entrapment,6 therefore sutures should not be placed in the “danger zones” around the inguinal ligament in order to protect the lateral femoral cutaneous nerve, genitofemoral nerve, and iliohypogastric nerve branches from injury.7 In conclusion, to answer Sforza et al’s question in the title of their paper, yes, quilting sutures are effective in preventing seromas in abdominoplasty (as are other suture techniques such as progressive tension sutures). This is supported by other large clinical studies3,8,9 which should offer surgeons enough encouragement to change their practice to a drain-free abdominoplasty.
Disclosures Dr Gutowski has a consulting relationship with Surgical Specialties Corporation (Vancouver, British Columbia, Canada), Dr Gutowski is an Adjunct Associate Professor in the Department of Surgery, Division of Plastic Surgery, University of Illinois – Chicago, Chicago, IL. Corresponding Author: Dr Karol Gutowski, Northwestern Specialists in Plastic Surgery, 676 N. Saint Clair Street, 15th Floor, Chicago, IL 60026, USA. E-mail: [email protected]
Aesthetic Surgery Journal 35(5)
582
manufacturer of Quill barbed sutures, a type of suture mentioned in this Commentary. Dr Gutowski has not received any payments or funding from Surgical Specialties Corporation in the past 12 months.
REFERENCES 1.
2.
3.
Sforza M, Husein R, Andjelkov K, Rozental-Fernandes PC, Zaccheddu R, Jovanovic M. Use of Quilting Sutures During Abdominoplasty to Prevent Seroma Formation: Are They Really Effective? Aesthet Surg J. 2015;35(5):574-580. Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105(7):2583-2586. Rosen AD. Use of absorbable running barbed suture and progressive tension technique in abdominoplasty: a novel approach. Plast Reconstr Surg. 2010 Mar;125(3):1024-1027.
4. Warner JP, Gutowski KA. Abdominoplasty with progressive tension closure using a barbed suture technique. Aesthet Surg J. 2009;29(3):221-225. 5. Kosins AM, Scholz T, Cetinkaya M, Evans GR. Evidencebased value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis. Plast Reconstr Surg. 2013;132(2):443-450. 6. Matarasso A. Awareness and avoidance of abdominoplasty complications. Aesthet Surg J. 1997;17(4):256, 258-261. 7. Ducic I, Zakaria HM, Felder JM 3rd, Arnspiger S. Abdominoplasty-related nerve injuries: systematic review and treatment options. Aesthet Surg J. 2014;34(2):284-297. 8. Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J. 2012;32(6):729-742. 9. Gutowski KA, Warner JP. Incorporating barbed sutures in abdominoplasty. Aesthet Surg J. 2013;33(3 Suppl): 76S-81S.
