Expanding the Progressive Tension Suture Concept: A Study of its Utility in Body Contouring Procedures” | Aesthetic Surgery Journal
In a study for the Aesthetic Surgery Journal (2021, 1-10), Dr. Patronella was invited to contribute his work using progressive tension suturing (PTS) techniques in body contouring flap procedures as a way to reduce and limit seromas.
The technique and utility of progressive tension sutures (PTSs) for dead-space management, minimizing tension at the suture line and decreasing seroma rate, was first described by Pollock and Pollock in 2000.1 They described the use of PTSs in abdominoplasty, and reported no seromas in 65 procedures. Since this original publication, many subsequent studies have advocated the utility and benefit of PTSs not only in abdominoplasty, but also in facelift, component separation, DIEP (deep inferior epigastric artery perforator) flap donor sites, and latissimus flap donor sites.2-16 These studies all demonstrate a reduction in seroma rate, edema, and tension with the use of PTSs.
Body contouring skin excision or flap surgery has emerged as a subspecialty of plastic surgery, likely due to increasing numbers of massive weight loss patients, the limitations of liposuction when skin laxity is present, and the wider acceptance of scars by patients when improved aesthetics can be accomplished. Body contouring procedures, including abdominoplasty and lower body lift, are commonly performed in this population to address redundant skin following weight loss, and after pregnancy to address skin laxity and excess that occurs over the abdominal wall and often in the hip/buttock aesthetic unit. Thigh lift, torsoplasty, and brachioplasty are additional body contouring procedures more specific to the weight-loss population.
These procedures seek to tighten, shape, and contour the loose skin over the thighs, bra-line, and arms, respectively. Seroma formation is a common problem following body contouring, often leading to prolonged use of drains or frequent aspirations, infection, pseudobursa formation, and patient discomfort.4 In the literature, the rate of seroma is fairly high in body contouring procedures, ranging from 4% to 20% in abdominoplasty, 0% to 3% in torsoplasty, 3% to 33% in lower body lift, 2% to 6% in brachioplasty, and 2% to 25% in medial thigh lift.17-27 To date, no studies have been performed looking at the effects of PTS techniques and their role on the seroma rate in body lift procedures including lower body lift, brachioplasty, medial thigh lift, and torsoplasty. In these procedures, drains are commonly and routinely used. These flap procedures require elevation of a soft tissue flap and advancement, potentially creating dead space and thus posing an increased risk of shear stress and subsequent seroma. Seroma formation may result in frequent aspirations, infection, wound separation, patient discomfort pseudobursa formation, and adverse aesthetic consequences.
The senior author has utilized PTSs in these flap procedures for over 10 years. The goal of this study is to demonstrate the utility and technique of PTS techniques without drains in all flap procedures (abdominoplasty, lower body lift, brachioplasty, medial thigh lift, and torsoplasty) as well as to evaluate our experience over 3 years with the use of PTSs in these procedures.
A retrospective chart review was performed for all patients who underwent a flap procedure by the senior author (C.P.) over 3 years (January 2016-December 2018) at a single institution (Aesthetic Center for Plastic Surgery, Houston, TX). These were consecutive patients, and flap procedures included abdominoplasty, torsoplasty, brachioplasty, lower body lift, and medial thigh lift. Written informed consent was acquired from all patients and this study was guided by principles according to the Declaration of Helsinki. Demographic data were collected on patients, including age, gender, BMI, smoking history, medical history, date of surgery, flap procedure(s) performed, and additional procedures performed where applicable. Complications were tracked and divided into major and minor complications.
A major complication was defined as any complication that required a return trip to the operating room and/or hospitalization. A minor complication was defined as complications that were managed in the office without a need for return to the operating room and/or hospitalization. Complications, including necrosis, seroma, wound dehiscence, hematoma, and embolic events, were tracked. Scar revisions were tracked but were not considered as complications.
For all flap procedures, PTSs were used. No drains were used. For PTSs in abdominoplasty (Figure 1; Video 1), a 2-0 polydioxanone suture (PDS) is used for a running PTS in the midline along the linea alba from the xiphoid to the point immediately above the umbilicus. Interrupted 2-0 PDS sutures are placed along the semilunar lines bilaterally, and in the space lateral and medial to this. The needle is placed in Scarpa’s fascia, and does not traverse the dermis. Each bite is about 2 to 5 mm thick, depending on the person and their flap thickness, because this varies by person. Approximately 15 to 20 interrupted sutures are used for adequate space closure, adding 15 to 20 minutes to surgical time. The assistant advances the flap forward as each PTS is placed, ensuring adequate flap advancement and preventing a tethering effect with the previous PTS placement. In this manner, dead space is eliminated, shear stress is reduced, and skin tension is lessened at the incision site.
For other flap procedures, namely lower body lift, medial thigh lift, torsoplasty (bra-line lift), and brachioplasty, rows of running 2-0 PDS suture are used to advance the flap and eliminate dead space. Videos 2 to 4 show a demonstration of the senior author performing PTSs during a lower body lift (Videos 2 and 3) and torsoplasty (Video 4). For each of these flap procedures, the 2-0 PDS is placed along the most distal aspect of the flap, from the undersurface of the flap at the level of Scarpa’s fascia down to the level of the deep or muscular fascia. The PTS is placed in a running fashion sequentially in parallel rows with the 2-0 PDS until the distal flap is approximated to the proximal flap. The maneuver is repeated with the proximal flap if it is also mobilized with continuous dissection.
The final row of PTSs approximates Scarpa’s fascia of the proximal flap to Scarpa’s fascia of the distal flap with 3-point fixation to the deep fascia to complete the closure of the deep space in a simple interrupted or running fashion along the full length of the incision. Figure 2 demonstrates a patient in the operating room immediately following lower body lift with liposuction and fat grafting, and torsoplasty.
A total of 441 flap procedures were performed in 351 patients (340 female, 11 male); 271 patients (77%) underwent 1 flap procedure, whereas 70 patients (19%) underwent 2 flap procedures, and 10 patients (3%) underwent 3 flap procedures. Follow-up ranged from 3 months to 3 years. The average follow-up was 1 year. The average patient age was 49 years (range, 25-72 years). The average patient BMI was 26.5 kg/m2 (range, 17.8-35.3 kg/m2). Ten procedures were performed on active smokers; 59 procedures were performed on patients who had a prior history of smoking.
Of the 441 procedures, 136 were on patients who had comorbidities (hypertension, diabetes, hyperlipidemia, heart disease, thyroid disorders) (Table 1). Of the 351 patients, 75 (21.3%) were massive weight loss patients. Liposuction was performed as an adjunct in 234 procedures (53%), and fat grafting was performed as an adjunct in 125 procedures (105 abdominoplasties, 20 lower body lifts) (28.3%). Complications occurred in 72 of 441 procedures (16.3%) (Table 2). There were 3 major complications (0.68%), and 69 minor complications (15.7%). The major complications included 2 cases of deep venous thrombosis, which required anticoagulation and hospitalization. One-third of hematomas following abdominoplasty required a return to the operating room, whereas the remainder were treated conservatively. Of the 69 minor complications, there were 4 cases of skin necrosis, 42 wound dehiscence complications, 20 infections, 2 cases of wound dehiscence and infection, and 3 hematomas.
All of the minor complications were managed in the office/clinic with no need for a return to the operating room or hospitalization. There were no seromas. There was 1 case of a dry aspiration for a suspected seroma following an abdominoplasty. This was suspected due to fullness and swelling of the lower abdomen, but upon attempted aspiration, 0 mL was extracted. Our criteria for seroma include anything >1 mL. Table 2 shows a breakdown of complications by procedure.
Pollock and Pollock, in their original article on PTS in abdominoplasty, discussed the technical use of PTSs and proposed the mechanism for seroma reduction as an effect of dead-space elimination and reduced shearing forces across tissue planes.1 Early tissue adherence of the abdominal flap and muscular fascia may be interrupted by shearing movement, allowing inflammatory fluid to collect in a free potential space. Once a collection of fluid is established, a pseudobursa forms with a greater risk of persistence despite percutaneous drainage or the prolonged use of a drain.
The use of PTSs allows stabilization at the tissue interface so that early tissue adherence is maintained. Abdominoplasty and other flap procedures described in our study require significant flap mobilization through undermining to recruit redundant skin, thus creating substantial dead space with potential for the accumulation of inflammatory fluid. To combat this, drains, compression garments, and body casts have been proposed. However, these measures are temporary and do not completely eliminate or obliterate dead space, or prevent inflammatory fluid accumulation, and seroma rates remain high for each of these flap procedures. In 2016, Macias et al reviewed 451 abdominoplasties in 2 groups: (1) PTS and no drain vs (2) no PTS and with drains.
A seroma rate of 2% was noted in the PTS and no-drain group, whereas a seroma rate of 9% was noted in the no-PTS and drain group.5 In individuals who have drains, removal of the drain is typically done after 5 to 7 days, depending on fluid output, although prolonged serous fluid production may require the use of drains for weeks or serial aspirations. This adds pain, discomfort, inconvenience, and potential infection in the postoperative period and will have an undesirable effect on the patient’s experience. The risk of seroma is not eliminated after drain removal because the dead space remains “unmanaged” and shear stress is still present. Many seromas occur after this time period, creating the potential for development of a pseudobursa and chronic swelling.
By eliminating dead space and the shearing forces that contribute to inflammatory fluid production, we have found that PTSs effectively eliminate the occurrence of seroma, even without the use of drains, for all flap procedures. There were no seromas in our retrospective review of 441 flap procedures, demonstrating the benefit and utility of PTSs in abdominoplasty, torsoplasty, medial thigh lift, lower body lift, and brachioplasty. In addition, all patients avoided the discomfort, annoyance, and inconvenience of drains, especially patients undergoing multiple procedures (eg, abdominoplasty with lower body lift and torsoplasty) who might otherwise have been required to have 1 to 2 drains for each area treated (4 to 8 in total). The nonclinical impact of drainless surgery on the patient experience is difficult to quantify but substantial in our experience.
Nearly all patients seeking consultation for these procedures in our practices ask about the need for drains and are very relieved to learn that none are required. Many initial consultations arrive as a direct consequence of drainless procedures through referrals from others. Other studies do demonstrate seroma occurrence even with PTSs, although the rate is much reduced.5,6 This study represents the specific experience of a single practitioner who has been utilizing PTSs in flap procedures for over 10 years, allowing for very little variability in suture placement technique, clinical evaluation, and complication assessment. An effective application of the PTS technique as described here requires comprehensive elimination of dead space with relatively narrow spacing between each suture. For example, for the abdomen 8 to 12 sutures are placed on each side, spaced at 3- to 4-cm increments between each, horizontally and vertically. For the lower body, lift rows of running sutures are advanced in 3- to 4-cm increments horizontally and then the next row is advanced approximately 3 to 4 cm vertically. Depending on the total vertical length of the flap, 2 to 4 rows may be required for flap advancement. Incisional closure for all procedures is done with 3-point fixation of subcutaneous fascia to muscular fascia to complete the dead-space elimination.
The PTS technique affords the additional advantage of reducing tension on the incisional closure and appears to improve vascular perfusion by distributing tension broadly across the flap. A relatively low incidence of significant ischemic necrosis (0.9%) in our study reinforces our hypothesis. As one progresses with the learning curve, PTSs can also be used to enhance aesthetic contours in abdominoplasty and lower body lift procedures.9 In abdominoplasty, following precise sub-Scarpa’s fat thinning, PTS advancement can be employed to define the linea alba and linea semilunaris, enhancing anatomic definition and improving aesthetics (Supplemental Figure 1).9 In lower body lift procedures, PTSs assist in deepening the flank concavity (avoiding the tenting effect with excessive skin tension on the superior flap) and adding to hip fullness by advancing the autologous fat-fascia flap under the inferior skin flap (Figure 3). Disadvantages of PTSs include prolonged operative time (15-20 minutes for each procedure) and the technical learning curve required for effective application.
Our study included 305 abdominoplasties (69%) and 136 other flap procedures (31%). Ongoing studies will analyze each procedure independently, with and without liposuction for comparison. One limitation of this study is that we did not separate liposuction from the flap procedures because we had a very low seroma rate overall. A recent study by Gould et al demonstrated that seroma rates did not increase when combining liposuction and PTSs in abdominoplasty.10 Similarly, in our study, liposuction did not create a greater likelihood of seroma. An additional limitation is the retrospective nature of this study, and the fact that it is a single surgeon’s experience and practice. A prospective study or randomized control study looking at multiple surgeons, including those who do not utilize PTSs, and those who utilize drains, would have given a broader perspective, as would a drain vs no-drain comparison group in terms of seroma, hematoma, and complication rates.
With our initial review, we demonstrate the utility of PTSs in decreasing the seroma complication rate in both abdominoplasty and other flap procedure types with a good outcome and complication rates similar to those reported in the literature (Figures 3-5; Supplemental Figures 1 and 2). Our study is limited by the lack of a non-PTS group for comparison. Our study did not compare complications, including seroma occurrence, with those in a group that did not have PTS placement.
Our definitive experience with PTSs precludes offering a non-PTS option for patients. A prospective randomized control trial with a PTS group without drains and a non-PTS group with drains by multiple surgeons utilizing the same technique could provide more validation of the PTS method in reducing seroma development in flap surgery. Several concerns that surgeons have towards utilizing PTS include dimpling, risk of injury to blood vessels and nerves, and the hematoma risk with ambulation and movement. In extremities, avoiding the saphenous vein and medial antebrachial cutaneous nerve is facilitated by tumescent vasoconstriction, allowing easier identification of neurovascular structures and then protecting them from progressive suture advancement. PTSs are placed by advancing the flap, reducing tension along the most distal part of the flap.
The inner thigh is only slightly abducted as the sutures are advanced, limiting forces that tend to pull the sutures out from the deep tissue. For the outer thigh lift, an abduction pillow is used between the thighs with the patient in a lateral decubitus position. Regarding dimpling, PTSs are placed in Scarpa’s fascia, rather than in the dermis, reducing any tendency toward dimpling. In addition, sutures are sequentially advanced with progressive tension, eliminating the dimpling from the previous horizontal row. Residual dimpling will generally resolve in 3 months, although occasionally longer. We have no experience with unresolved dimpling but might expect sutures placed in the dermis to cause this. Although we favor the longevity of PDS, a faster-dissolving suture such as monocryl is an alternative and may provide more reassurance that visible dimpling will resolve faster.
Positioning is very important to note. With an abdominoplasty flap, for example, the patient is placed with their head/trunk flexed, and legs flexed (“beach chair position”), prior to placement of PTSs. Thus, no position changes are generally done after the PTSs are placed. Occasionally the patient may be flexed slightly at the trunk, but this is not detrimental because it is in the same direction as the PTSs. Extension would be detrimental because it can cause the sutures to pull away. The idea is to have the patient in the ideal position needed prior to initiation of suturing. With regards to the postoperative hematoma risk with movement in high-tension cases, we tend, in the first instance, not to place too much tension in general—this is simply not our practice. Dislodging sutures may happen and cause a sharp pain in the area as the suture pulls through the fascia.
Although a secondary late hematoma seems possible, our experience has demonstrated no significant occurrences and a low hematoma rate that is consistent with that found in the literature for the same procedures.
We have demonstrated that PTSs are an effective technique for reducing seroma occurrence in flap procedures without the need for drains. We believe that PTSs eliminate potential space and stabilize tissue adherence for wound healing, preventing the inflammatory fluid accumulation that leads to seromas. This study also demonstrates the utility of PTSs beyond the scope of abdominoplasty, establishing seroma risk reduction for lower body lift, medial thigh lift, brachioplasty, and torsoplasty procedures as well.