The advent of barbed sutures has been a novel and useful adjunct for the aesthetic plastic surgeon in properly selected patients. The deployment of a barbed suture minimizes the risks of cheese wiring and stress relaxation, facilitating the minimally invasive repositioning of soft tissue in the head and neck, as well as optimizing and enhancing traditionally long and potentially tedious procedures in body contouring. This article highlights the advances, advantages, and efficacy associated with the use of barbed sutures in lifting and wound closure.
The expansion of aesthetic plastic surgery in the last 2 decades has been a combination of invasive and noninvasive procedures. In the past 10 years, invasive procedures have grown approximately 100%, whereas noninvasive procedures have grown almost 1000%. Although consumers of cosmetic plastic surgery seek to look and feel their best, most potential patients also generally desire procedures that are affordable and have minimal pain, recovery, and downtime. The mobilization and repositioning of soft tissue, whether of the brow, midface, neck, breast, or body contouring, is often a significant and important goal in an aesthetic plastic surgery procedure. The use of sutures to suspend soft tissues is not new. Suture suspension techniques have been used in medicine to treat several functional and aesthetic problems including congenital ptosis, sleep apnea, and bladder suspension for urinary incontinence. In aesthetic plastic surgery, nonbarb suture suspension techniques have been used alone or in combination with other surgical maneuvers to elevate soft tissue of the midface, brow, and cervical mental angle. The reported problems with simple 2-point suture fixation techniques are principally the phenomenon of cheese wiring of either end of the suture fixation and/or stress relaxation of the skin under tension, both of which compromise the suture suspended elevation and repositioning. Cheese wiring occurs when suspended tissues are under tension and, with constant movement, the sutures migrate through the soft tissue fixation points, even if fascial tissue sutures are deployed, resulting in the loss of part, or all, of the elevation or repositioning. The stress relaxation occurs when soft tissue, particularly skin, is held under tension in 2 points, and the tensile relaxation properties of the dermis reorganize the collagen, elastin, and ground substances to lengthen the distance between the fixation points. Like tissue expansion, the body’s ability to recruit tissue to reduce tension loading compromises the elevation when the repositioning is supported in only 2 points. Multiple-point fixation techniques and technologies, like the Endotine device or barbed sutures, can minimize stress relaxation and cheese wiring (Coapt Systems, Inc., Palo Alto, CA, USA). Without multiple fixation points, there is often limited long-term efficacy of pure suture suspension techniques.
The advent of barbed sutures has been a novel and useful adjunct for the aesthetic plastic surgeon in properly selected patients. The deployment of a barbed suture minimizes the risks of cheese wiring and stress relaxation, facilitating the minimally invasive repositioning of soft tissue in the head and neck, as well as optimizing and enhancing traditionally long and potentially tedious procedures in body contouring. This article highlights the advances, advantages, and efficacy associated with the use of barbed sutures in lifting and wound closure.
Science of barbed sutures
The advent of the barbed suture for lifting began with the antiptosis procedure using APTOS sutures. The APTOS suture, called Feather Lift, deployed a 15-cm segment length of dyed polypropylene suture with barbs cut at an angle in the suture and organized facing toward the midline in a bidirectional fashion. Both halves of the sutures had barbs pointed toward the middle. The Feather Lift approximated tissue but was not fixed to any stable craniofacial structures. APTOS sutures and the Feather Lift procedure were introduced into the worldwide market in the late 1990s, for nonfixed soft tissue repositioning of lax, soft tissue elements. Because APTOS sutures were not fixed to the cranial fascial skeleton, they were prone to migration, relapse, and long-term lack of efficacy. Because the sutures were dyed, there was a significant risk that, in time, they would become visible and palpable. Short-term results in the midface in early reports were acceptable; however, because of the lack of fixation and lack of long-term efficacy, the APTOS suture did not achieve US Food and Drug Administration (FDA) approval and they did not experience widespread popularity in the United States.
Surgical Specialties (Reading, PA, USA) and Dr Gregory Ruff introduced a clear, barbed polypropylene suture called the Contour Threadlift, which was FDA-cleared for soft tissue elevation of the midface in 2005. The Contour Threadlift suture was used and promoted principally for the closed soft tissue elevation of facial tissues. The purely closed Threadlift technique was designed to be delivered percutaneously with minimal to no undermining. Although there were some reasonably good results with repositioned soft tissue of the brow, midface, and neck, the Threadlift procedures were prone to unpredictability in efficacy, palpability of sutures, tenderness, extrusion of knots, fracture of the suture, and migration.
Angiotech Pharmaceuticals, Inc. (Vancouver, Canada) acquired Surgical Specialties and launched the Quill SRS (Suture Retained Suspension). The Quill suture has been available since January, 2007, and represents the evolution of the original contour thread. The Quill SRS suture is the most widely used barbed suture in the United States and worldwide. Its use continues to evolve into many applications of plastic surgery (as well as in general surgery, vascular surgery, gynecologic laparoscopic surgery, robotic surgery, and orthopedic surgery), and most of this article focuses on the Quill suture and its growing array of peer-reviewed applications.
The Quill SRS suture is a bidirectional barbed suture. It incorporates small barbs (which are back cuts in the suture performed in an automated computer-generated fashion). Approximately 30% of the diameter of the suture makes up the barb. The barbs are spaced evenly in helical array, like a DNA helix, along its length. The barbs face in opposite directions from the midpoint, the midpoint segment being approximately 2 cm in length, in the double-armed suture and toward the fixation end (entry end) on the single-armed suture. On either end of the Quill SRS suture are fixation needles, and the Quill barb suture comes in different lengths, absorbable and nonabsorbable, different diameters, and with different attached needles. The Quill SRS suture is available in a blue polypropylene and a clear polypropylene as well as a violet polydioxone and an absorbable superficial skin closure called Monoderm.
The science of the Quill fixation technology is based on multiple barbs engaging in the soft tissue at multiple points along a tensile loaded tissue and dispersing this tensile load along the length of the suture, rather than placing a maximal amount of tension at the knot and fixation point. In addition to spreading a tensile load along the length of the barbed segment, the Quill allows the surgeon to suture without the use of knots. The advantages of multiple barbs along the length of a closure are greatly reduced stress relaxation and cheese wiring effects with potentially more efficacious long-term closure of wounds under tension, such as midline abdominoplasty plications, dermal lipectomies, brachioplasties, mastopexy, and breast reduction procedures, in which the biomechanically efficient distribution of tensile load and high pull-out forces and breaking strengths of the barbed Quill SRS suture may optimize the short-term and long-term behavior of these scars. The use of multiple ischemia-inducing, 2-point fixation sutures (traditional wound closures with interrupted sutures), as opposed to a barbed suture and a no-knot tension balanced closure, has been shown to increase the risk of tissue ischemia, compromised wound strength, increased incidence of suture abscesses, wound dehiscence, and decreased scar cosmesis. Wounds closed under tension with even tension loading and diminished stress relaxation may have fewer hypertrophic scars and spread scars from wound ischemia and stress relaxation. Thus, the science of barb sutures may improve high-tension wound closure, facilitate more rapid closure, and result in superior scar cosmesis. In nonplastic surgery arenas such as laparoscopic and endoscopic endocorporal surgery, the advent of the Quill barbed suture has allowed endoscopic surgeons to perform anastomosis of delicate structures with reduced tissue ischemia, stronger anastomoses, and improved operative efficiency without the need to tie endoscopic knots.
The biomechanical in vivo characteristics of a barbed 0, 2-0 and 3-0 Monoderm (a bidirectional barbed, absorbable polyglycolide-poly-e-caprolictone copolymer) was compared with the nonbarbed equivalent Monocryl (a poliglecaprone 25, a copolymer of glycolide and e-caprolictone 1 size smaller, because of the barbs) In vitro tensile strength and break strengths were studied. Comparative studies of barbed and nonbarbed were also performed with polydiaxone and polypropylene. In all of these in vitro studies, the bidirectional, barbed, nonknotted, self-retaining sutures were significantly stronger than the conventional sutures of the same polymer of 1 size smaller (because of the barbs compromising 30% of the suture diameter) at each of days 7, 14, and 21. In most cases, the break strength for tension was nearly double that seen for the nonbarbed suture. Between days 28 and 45, the strength remaining was zero or minimal for all suture types and sizes regardless of barbed or nonbarbed configuration. These studies confirm that barbed sutures exhibit superior breaking strengths, tensile strengths, and pull-out strengths compared with their nonbarbed suture equivalents and that the tension loading of the barbed closure of the entire wound minimizes stress relaxation and cheese wiring, which may greatly aid in the long-term results of soft tissue repositioning and high-tension wound closure.
Although the Quill suture is FDA approved and by far the most commonly used barbed suture in aesthetic plastic surgery, there is another modified suture, called the Silhouette Suture (Kolster Methods, Inc. [KMI], Corona, CA, USA), which is also used internationally. The Silhouette Suture, instead of containing barbs within the polypropylene suture, has intermittent knots organized along both halves of the suture and the knots house, in a bidirectional fashion from each midpoint, little caps or cones of polyglactic acid. These polyglactic acid caps provide the tension loading for elevated soft tissue and, similar to the barb-modified sutures, are placed intermittently in helical fashion along each half of the suture. The cones are a copolymer of glycolic acid and lactic acid. Between the cones are knots that control the position of the cone, and the cone anchors the suture and allows in-growth of soft tissue. Unlike a barb, the cone grasps tissue in 360 degrees, whereas the barb only grasps the soft tissue at 1 fixed point, thus enhancing the tensile loading capability of a cone, not just across the length of the suture but in 360 degrees around the cone and the cone length of the suture. The Silhouette Suture is used principally for lifting and repositioning soft tissue of the midface and not for wound closure. The Silhouette Suture received its US FDA approval for midface suspension in November, 2006. The initial reports for this suture have been favorable for midface repositioning.
Classification of barbed sutures
The Quill SRS barb-modified suture, the most prevalent barbed suture used in plastic surgery worldwide, may be classified according to the suture polymer incorporated, the diameter, or barb technique, and the procedure in which they are used.
Classification of barbed sutures
- 1.
Tissue behavior and polymer content
- a.
Absorbable
- i.
Monoderm
- ii.
Polydioxanone (PDO)
- i.
- b.
Nonabsorbable
- i.
Polypropylene
- i.
- a.
- 2.
United States Pharmacopeia (USP) diameter size
- a.
2,1,0, 2-0, 3-0
- a.
- 3.
Clinical procedure
- a.
Facial soft tissue repositioning
- i.
Closed soft tissue repositioning
- ii.
Semiclosed, composite lifting
- iii.
Open face suspension
- i.
- b.
Body high-tension closure
- i.
Abdominoplasty (plication and/or wound closure)
- ii.
Brachioplasty
- iii.
Mastopexy or breast reduction closure
- iv.
Body lift.
- i.
- a.
Classification of barbed sutures
The Quill SRS barb-modified suture, the most prevalent barbed suture used in plastic surgery worldwide, may be classified according to the suture polymer incorporated, the diameter, or barb technique, and the procedure in which they are used.
Classification of barbed sutures
- 1.
Tissue behavior and polymer content
- a.
Absorbable
- i.
Monoderm
- ii.
Polydioxanone (PDO)
- i.
- b.
Nonabsorbable
- i.
Polypropylene
- i.
- a.
- 2.
United States Pharmacopeia (USP) diameter size
- a.
2,1,0, 2-0, 3-0
- a.
- 3.
Clinical procedure
- a.
Facial soft tissue repositioning
- i.
Closed soft tissue repositioning
- ii.
Semiclosed, composite lifting
- iii.
Open face suspension
- i.
- b.
Body high-tension closure
- i.
Abdominoplasty (plication and/or wound closure)
- ii.
Brachioplasty
- iii.
Mastopexy or breast reduction closure
- iv.
Body lift.
- i.
- a.
Barbed sutures for lifting
Closed Barbed Suture Lift of the Brow, Midface, and Neck
A closed, percutaneous barbed suture lift of the midface, brow, or neck requires little or no undermining. The barbed suture is used both as the lifting vehicle and fixation support mechanism, taking advantage of the antistress relaxation and even tension loading provided by the Quill SRS and the former Contour Threadlift suture. Although, in selected patients, the initial results can be impressive, there is unpredictability as to which patients will do well, and a high relapse rate, especially in the brow and neck. Contraindications for a closed barbed suture lift are patients with high body mass index (BMI), round heavy faces, excessive age and laxity, or those who are not opposed to an excisional procedure and more significant results. In selected patients, with thinner soft tissue envelopes with moderate midface ptosis who are opposed to an open procedure, the closed barbed closed skin lift may be a viable opportunity for short-term tightening. This is especially true with the advent of an absorbable, Monoderm suture, in which knot or fixation palpability, migration, and sensitivity are no longer postoperative concerns. The author has previously reported his experiences with 25 closed, percutaneous, polypropylene barbed suture lifts of midface. The results of this procedure in properly selected patients can be good, with long-term maintenance of midface position in more than 50% of patients at 12 months. The closed, absorbable barbed suture skin lift of the midface may be combined with soft tissue fillers, fractional and nonfractional lasers, and neurotoxins. This combination therapy, performed under local anesthesia with a recovery period of 3 to 4 days, has a definite place in modest facial aesthetic plastic surgery options, especially for patients seeking nonexcisional options.
Closed, Percutaneous, Composite, Widely Undermined Barbed Lift to the Brow, Midface, and Neck
The composite nonexcisional, percutaneous lift technique incorporates the concept of a wide surgically undermined tissue flap and then deploying the barbed suture as a passive fixation system, with the stress relaxation and tension load sharing of the barbed configuration. Like the closed barbed skin lift, the closed composite barbed suture lift does not involve excision of tissue and can be performed through small percutaneous stab incisions that do not need to be closed. Indications for a closed, composite barbed suture lift of the brow and/or midface lift are a patient with low BMI with moderate to thin facial soft tissue, reasonable expectations of a facial rejuvenation that is less than 50% of an open, excisional facelift (discussed later) and a patient not amenable to an open, excisional procedure (however, it should be offered).
Composite percutaneous barbed suture–supported midface lift
Under local anesthesia and oral sedation, 2 entrance points are chosen in the temporal hair-bearing scalp approximately 2 cm behind the hairline ( Fig. 1 A). One is 2 to 3 cm superior to the zygomatic arch. A 3-mm dermatologic punch is used to remove a portion of the scalp and dissection with a Stephens tenotomy scissor is carried down to the superficial layer of the deep temporal fascia. Through this small incision a small periosteal dissector is used to elevate the temporal parietal fascia down to the superior aspect of the zygomatic arch. No dissection is performed over the zygomatic arch, to minimize inadvertent neuropraxia of the frontal branch of the facial nerve (see Fig. 1 B). An intraoral transbuccal sulcus stab incision with a small 11 blade is made and the scissors are used in a closed fashion to dissect the soft tissue down to the maxillary buttress. A small periosteal elevator is then used to blindly dissect the inferior 70% of the malar fat pad, subperiosteally, over the malar eminence and up to the zygomatic process of the zygomatic arch (see Fig. 1 C). Again, a small composite amount of tissue is left intact over the zygomatic arch to preserve the frontal temporal branch. With the division and release of the periosteum through the blind buccal sulcus incision and elevation of the subperiosteal tissues, the mobile malar fat pad and the overlying soft tissue including the suborbicularis oculi fat (SOOF) and subcutaneous malar fat should be well mobilized. With the malar soft tissue fat pad adequately mobilized, using a long Keith needle, a barbed Quill suture is passed through the temporal dermatologic punch port over the superficial layer of the deep temporal fascia, care being taken not to engage this tissue layer, passing the Keith needle through to the zygomatic arch, then extending subcutaneously over the zygomatic arch, pinching the malar fat pad, and passing the Quill suture through the entire soft tissue mobile fat pad of the malar eminence and exiting approximately 1 to 2 cm lateral and posterior to the nasolabial fold, just above the lateral commissure (see Fig. 1 D). The second arm is passed a little more superiorly through and across the same planes but exiting approximately 3 to 4 cm superior to the previous suture, just lateral to the nasal base, and lateral to and posterior to the nasolabial fold. By pulling on the barbed sutures, the composite malar fat pad and periosteal tissue can be mobilized. The mobile malar fat pad should move significantly superiorly and laterally, creating a revolumization of the midface. An adequately mobilized composite malar fat pad barbed suture lift should result in an immediate and obvious correction with an improvement of the lower lid–malar junction and some amelioration of the nasolabial fold. The 2 proximal limbs of the barbed suture are then passed through the temporal parietal fascia, cephalad and out through a second dermatologic punch incision proximally where a knot is tied over the temporal parietal fascia, minimizing the risks of cheese wiring.
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