28. Progressive Tension Sutures
Definition: Progressive Tension Sutures
Progressive tension sutures (PTSs) securely anchor flaps over multiple points of fixation in an advanced position.
Mechanism of Action
Reduces or eliminates dead space
Compartmentalize space to smaller-volume areas more easily absorbed
Eliminate the need for postoperative drains
Prevents repeated disruption of weak, early healing from body motion
Tissues covered by overlying flaps in a highly mobile part of the body (e.g., abdomen, latissimus donor site) may shift with repeated movement.
Repeated disruption of early healing leads to inflammation.
Andrades and Prado’s analysis of seroma fluid 2 showed inflammatory exudate consistent with this mechanism.
Minimizes tension on the flap closure
Splinting healing wounds improves scar quality.
Reduces scar migration from flap tension
Distributes tension over multiple points of fixation, improving circulation to the distal flap and preventing complications such as necrosis/dehiscence
Secures a skin element in a new position (e.g., secures the brow in a browlift)
Indications and Contraindications
Senior Author Tip:
PTSs are based on a simple surgical concept that can be applied to any procedure involving an advancement flap. Therefore they have no specific indications or contraindications.
Indications
Abdominoplasty: Large area of dead space and skin excised and advanced in a highly mobile region of the body. PTS advancement and fixation:
Eliminates disruptive shearing forces on the healing flap
Reduces dead space
Actively advances the flap
Internally splints the healing skin flap and distal incision
Allows in-continuity umbilical inset: Sutures placed from deep surface of flap, facilitating a natural, inverted umbilicus
Facelift 3
Reduces dead space
Allows a controlled redraping of the skin after subcutaneous dissection
Subcutaneous browlift 4
Provides an accurate and secure positioning and shaping of the brows
Advances the flap
Reduces dead space
Allows skin closure under minimal tension
Eliminates the need for drains or lifting devices
Reconstructive advancement flaps 5
Reduces dead space
Actively and securely advances the flap
Prevents shearing forces on the healing flap
Contraindications
Progressive tension suturing is an adjunctive technique that can be applied to most conventional skin flap procedures. No unique contraindications are related to the addition of fixation sutures.
Preoperative Evaluation
PTSs require no unique steps in preoperative evaluation or preparation.
Informed Consent
Tip:
The addition of PTSs has been shown to reduce complications without adding significant risk; informed consent discussions should include the relative safety, effectiveness, and ease of recovery, compared with those of standard procedures.
In addition to the overall risks of surgery, plastic surgeons should discuss:
Seroma: Use of PTSs significantly reduces the risk but does not eliminate it.
Skin dimpling
Although this is a frequent concern, dimpling is uncommon and almost always temporary.
Some applications are more predisposed to dimpling. In browlifts and facelifts, PTSs are applied directly to the skin, increasing the possibility of dimpling, although it is typically temporary. In abdominoplasty, proper PTS placement between superficial fascia and deep fascia makes permanent dimpling highly unlikely.
Revisions: No greater than with traditional techniques
Senior Author Tip:
If PTSs are properly placed, all tension is on the fascia—not on the skin—and permanent dimples are unlikely.
Tip:
The internal splinting effect of PTSs allows early ambulation in an upright posture without restrictions. The obvious benefit is patient comfort, but by eliminating a flexed posture, venous circulation is improved and VTE reduced. 7
Equipment
Absorbable suture
Interrupted: Polyglactin suture: #0 or #00 sutures for PTSs
Continuous: Barbed polydioxanone suture
Quill (Angiotech Pharmaceuticals) is a bidirectional barbed suture secured and started in the middle of the incision area.
V-Loc (Medtronic) is a unidirectional barbed suture.
Senior Author Tip:
Surgeons choose the type or size of suture material and the exact placement or number of sutures to obtain a secure fixation of the skin flap in an advanced position.
Technique
Technique for Progressive Tension Sutures
Interrupted sutures (Fig. 28-1)
Incision for an abdominoplasty depends on the surgeon’s preference. (See Chapter 57 for detailed variations.)
Undermining is performed at the level of the deep fascia, wide enough to allow adequate flap advancement.
The lower abdominal dissection is full width of the abdomen, whereas the epigastric dissection is more limited. The width of dissection should be wide enough to repair the diastasis rectus without causing fullness.
Midline rectus plication is performed with #0 suture in the standard fashion.
Patient is placed in moderate flexion.
The surgeon controls the flap with the nondominant hand while placing the PTS through the superficial fascia, maximally advances the flap to determine the location of the level of the fixation to the deep fascia, and places the suture (Fig. 28-2).
The surgeon ties the suture while an assistant flap holds the flap in the advanced position. Once the suture is tied, minimal dimpling will be noticeable on the skin surface because of the tension of the advancement in that location.
Excessive or obvious dimpling once the next suture is tied may result from:
Too superficial suture placement
Excessive advancement of the flap
Placement of the sutures in the wrong direction
Senior Author Tip:
Placement of the midline PTS results in a midline depression that mimics a natural aesthetic contour.
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