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Researchers bring science to art of suturing

Article-Researchers bring science to art of suturing

Key iconKey Points

  • Biomechanics research findings may help suggest most appropriate suture techniques for particular procedures
  • Researchers study complications after series of 1,000 short-scar facelift procedures

While much of cosmetic surgery is an art, a science-based approach to designing the technical components of various procedures may help to improve outcomes.

Dr. White
Based on this premise, Jeremy B. White, M.D., and colleagues from both the division of otolaryngology-head and neck surgery and department of mechanical and aerospace engineering, George Washington University, Washington, undertook a laboratory study to compare the biomechanical properties of two suture techniques used in SMAS plication during short-scar rhytidectomy.

Speaking at the 26th annual scientific meeting of the American Academy of Cosmetic Surgery, Dr. White reported that the results suggested that using a double-layered running locking (DRL) stitch might offer an advantage over multiple horizontal mattress sutures to avoid early failure after short-scar rhytidectomy. Nevertheless, a retrospective study undertaken to see if the laboratory findings translated into clinical practice failed to confirm this hypothesis.

The latter study identified complications occurring after a minimum of six months in a series of 1,000 short-scar facelift procedures performed with a variety of different suture techniques, as well as in a second group of 2,300 cases performed using only the DRL stitch. While use of the DRL stitch was associated with significantly higher rates of skin and subcutaneous suture extrusion, there was no significant difference between the two surgical groups in the rate of plication suture extrusion, and rhytidectomy revision rates were similarly very low in both groups.

Cheek SMAS being plicated posterosuperiorly with a double-layered running locking stitch, resulting in a secure lift. (Photo credit: William H. Lindsey, M.D., F.A.C.S.)
ABDOMINOPLASTY Suggesting that the study may have been inadequately powered to detect a statistically significant difference in rare events, Dr. White has proposed that the biomechanics research findings may have greater relevance in other procedures, such as abdominoplasty, where the plicated tissues are under greater tension.

"Use of the DRL stitch may not have a major impact on reducing facelift revision rates, because these procedures are associated with a very low incidence of early suture breaks. However, our laboratory finding that the DRL stitch holds more tension over a larger applied stress may be more relevant to abdominoplasty, which has reported dehiscence rates as high as 8 percent," Dr. White tells Cosmetic Surgery Times.

Dr. White, chief resident, division of otolaryngology-head and neck surgery, George Washington University, notes that the DRL stitch has become the favored technique of his collaborator and senior author, William H. Lindsey, M.D., clinical associate professor of otolaryngology-head and neck surgery, because it theoretically combines the tension distribution benefit offered by mattress sutures with the speed and strength advantages of a running locking stitch.

The idea to formally test the biomechanical properties of the DRL stitch derived from anecdotal clinical observations suggesting that certain suture techniques may be superior to others in maintaining a strong SMAS plication.

"In cases requiring early suspension-related revisions, sutures were noted to be lying superficial to the SMAS, suggesting that there was plication suture failure due to suture breakage or eruption through the scar tissue. Avoiding early failure and achieving prolonged improvement after rhytidectomy requires that the plication sutures hold the SMAS in place long enough for the plication to be secured by scar formation," Dr. White says.

LABORATORY DETAILS The laboratory evaluation was conducted with porcine skin, and the results were published in 2008 (Laryngoscope. 2008;118:2107-2110). Plications were performed to a standardized width and sutured with either the horizontal mattress technique, which was previously favored by Dr. Lindsey, or with the DRL, his current technique. 3-0 Mersilene polyester fiber was used for all sutures, and care was taken to avoid clamping the suture loop segment with the needle driver, which can cause severe material distortion and ultimately reduce breaking strength.

The test specimens were placed into a tensometer and exposed to a displacement force increasing at a constant rate. Forces causing the first, second and third suture breaks were recorded.

The results showed that the DRL stitch was not more resistant to an initial suture loop break compared with the horizontal mattress technique. However, measurements of stress ratios, taking into account force needed to cause second and third suture breaks, showed that the DRL stitch held more tension over a larger amount of applied stress. Furthermore, it was observed that after the first suture break, specimens with the DRL stitch did not have significant distraction of the plication line, whereas there were gaps in the folded tissue in specimens plicated with the horizontal mattress sutures.

"These findings may be due to the locking mechanism of the DRL stitch and suggest a possible advantage of the DRL stitch. In theory, if there is a failure in the DRL SMAS plication suture, the SMAS may be more likely to stay in place until the position of the lift is secured by internal scar formation," Dr. White says.

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