Introduction

Progressive tension sutures (PTS) is a technique for advancing and securing a flap.^1,2 Since it is not an abdominoplasty procedure in itself, PTS can be adapted to the surgeon’s personal abdominoplasty operation. PTS is used to decrease complications in abdominoplasty, especially seroma, while eliminating the need for drains. The mechanism of these sutures is to close dead space (Fig. 33.1), as well as, and maybe more importantly, to secure the skin flap to the underlying fascia to prevent disruption of early healing by abdominal motion (Fig. 33.2). Additionally, these sutures transfer the tension of the advancement over a broad area to the superficial fascial system and away from the skin, improving blood flow in the subdermal plexus and taking tension off the skin closure, to improve scarring. The secure fixation of the flap permits early ambulation in an upright posture, which likely decreases pulmonary and venothromboembolic (VTE) complications. What follows are details of the authors’ abdominoplasty technique, which details the use of PTS.

FIG. 33.1 Compartmentalization.

Drawing shows how PTS divide the larger dead space into smaller compartments that limit fluid accumulation.

FIG. 33.2 Effects of motion.

Diagram on the left shows that without fixation, the two layers are free to move relative to each other with motion. Diagram on the right illustrates the addition of PTS that affix the two layers and secure them with motion, thus preventing disruption of healing.

Preoperative Preparation

Since progressive tension sutures are simply advancement/fixation sutures that can be incorporated into any abdominoplasty procedure, no specific preparation is required. Each surgeon may incorporate their own preoperative regimen. We mark the patient in recumbent and standing positions, noting the midline, planned incisions, and areas to be liposuctioned. All patients get sequential compression devices placed prior to induction and other VTE prevention modalities are individualized. If posterior liposuction is to be performed, it is done first with the patient in a prone position. For the abdominoplasty, the patient is placed supine with the arms secured out on arm-boards. A pillow is placed under the knees. A wide prep and draping is used to the mid-thighs.

Surgical Technique

The procedure can be done under general anesthesia or intravenous sedation. In either case, the procedure starts with infiltration of local anesthetic into the planned circumumbilical and low transverse incisions. The areas of planned elevation and liposuction are infiltrated with standard tumescent solution (1000 ml normal saline, 30 ml lidocaine, and 1 ml epinephrine (adrenaline) 1 : 1000). If the upper abdomen is particularly bulky, liposuction is carried out in the upper abdomen and flanks prior to flap elevation. Care should be taken to suction deep to Scarpa’s fascia to avoid flap devascularization as well as over-suctioning. Over-suctioning of the area just above the umbilicus can lead to a mismatch between the thinner upper abdominal skin and the thicker mons. Additional liposuction can be done after flap advancement.

The circumumbilical incision is made within the umbilicus and the stalk is dissected down to the deep fascia. Next, the low transverse suprapubic incision is made and carried down to the muscle fascia. No attempt is made to leave fat on the fascia except for a few centimeters in the central area where bulk may be needed later to help with the esthetic transition from the thinner upper abdominal flap to the thicker mons pubis. Dissection is carried out both sharply and with electrocautery. We have not seen any increase in seromas with extensive electrocautery use. The technique and extent of dissection is based on the surgeon’s judgment and the individual patient’s anatomical characteristics. We use a triangular dissection, which is wider inferiorly and narrowest at the level of the xiphoid, but is individualized based on the width of rectus diastasis and extent of soft tissue to be advanced (Fig. 33.3).

FIG. 33.3 Dissection.

Picture demonstrating typical extent of dissection. This is individualized based on the patient’s esthetic needs.

When dissection is complete, the rectus diastasis is repaired with a 0-0 braided Nylon suture as a figure-of-eight alternating with simple inverted sutures spaced about 1 cm apart and then a second layer of 0-0 PTS barbed suture in an over-and-over fashion.

The fascia is then generously infiltrated with a long-acting local anesthetic for early postoperative pain control. In patients with wide diastasis recti, we often will place a continuous double-catheter pain pump with an infusion rate of 2 ml/hr per catheter. We bring the catheters out at the level of the xiphoid and use the introducers in a retrograde fashion (from inside to out) so they can be re-used for a retrofascial placement. The functional portions of the catheters are placed under the rectus fascia on either side of the umbilicus (Fig. 33.4A–C).

FIG. 33.4 Retrograde placement of the pain pump.

(A) Introducer brought from inside to out. (B) Catheter is fed into the introducer. With this technique, introducer can be preserved for retro-facial placement of catheters. (C) The introducer is fed behind the muscle fascia on either side of the umbilicus.

When a ptotic mons pubis is present, correction is important for a good esthetic result. The mons is undermined as needed and a few 2-0 Vicryl sutures are placed from the underside of the mons to the desired position on the deep fascia. Typically only three sutures are needed – one midline and one on either side, with 3–4 cm spacing. Care is taken to leave the edge of Scarpa’s fascia free for later suturing to the upper flap. Advancement to an appropriate position with secure fixation with progressive tension sutures gives the mons an attractive appearance and prevents unintentional excessive elevation by flap retraction (Fig. 33.5).

FIG. 33.5 Mons elevation.

Mons elevation is important for a good esthetic result. Secure and precise fixation avoids under or over-elevation. The mons area is undermined for a few centimeters and then advanced with PTS. Typically, three sutures are used, one in the midline (seen here) and one on either side about 3–4 cm away.