A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques

A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques

+ MODEL Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e5 A novel barbed suture tie-over dressing for skin grafts: A comparison...

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e5

A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques C.W. Joyce a,*, K.M. Joyce a, N. Mahon a, J.C. Chan a, C.M. Sugrue a, P. Dockery b, S.M. Carroll c, J.L. Kelly a a

Department of Plastic and Reconstructive Surgery, Galway, Ireland Department of Anatomy, National University of Ireland, Galway, Ireland c Saint Vincent’s University Hospital, Dublin, Ireland b

Received 22 February 2014; accepted 4 May 2014

KEYWORDS Barbed suture; Skin graft; Bolster; Tie-over dressing

Summary Introduction: Barbed suture devices have a widespread application in plastic surgery. The unidirectional nature of the barbs facilitates a strong grip on tissues and reduces the need to constantly tension the suture manually. We hypothesized that a barbed suture tie-over suture to secure skin grafts would be quicker to perform than traditional tie-overs and would also exert a greater downward pressure on the skin graft. Methods: Thirty uniform areas of skin were excised from a cadaver. A pressure transducer was placed on the wound bed and covered with the excised skin along with a mineral oil-soaked wool dressing to act as a bolster. Three different sutures were used to secure the graft in place and the pressure was recorded. The tie-over techniques used were the classic silk tie-over, a running Vicryl Rapide tie-over and a running barbed tie-over. Results: The barbed tie-over exerted the most downward pressure (82.8  7.3 mmHg) compared to the silk (46  4.85 mmHg) and the Vicryl Rapide (18.6  2.4 mmHg). Furthermore, the barbed tie-over was the quickest to perform (1:45  22 s) when compared to the Vicryl Rapide (02:57  27 s) and the silk tie-overs (04:26  39 s). Conclusion: Barbed sutures are a viable option for securing skin grafts. They are quick to perform and provide significantly improved downward pressure on the skin graft. We feel that this technique would be especially suited to the sole operator as it can be carried out without the need of an assistant. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Dept. of Plastic Surgery, University Hospital Galway, Ireland. Tel./fax: þ353 091 544 000 E-mail address: [email protected] (C.W. Joyce). http://dx.doi.org/10.1016/j.bjps.2014.05.005 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Joyce CW, et al., A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.005

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Introduction It has been well documented that even pressure must be applied over a skin graft for successful graft take.1 This was first documented by Blair and Brown2 in 1929 and since then, a variety of methods have been used to secure skin grafts yet no consensus exists as to which is the optimum method. The tie-over dressing is a well renowned and commonly used technique yet its necessity is often open to debate and it has yielded a plethora of modifications throughout the years. In our experience, the classic tieover is both time-consuming and laborious and can also be difficult to perform if operating without an assistant. There has been a renewed interest in barbed suture devices in recent years and their versatility is reflected in their reported application in wound closure, body contouring, facial rejuvenation3 and flexor tendon repair.4 The most common barbed devices commercially available are Stratafix (Ethicon Inc., Somerville, New Jersey, USA), Quill (Angiotech, Vancouver, BC, Canada) and V-Loc (Covidien, Mansfield, Massachusetts, USA). Both the Stratafix and Quill devices are bidirectional sutures with a needle on either end. At the centre of the device is the transition point where the barbs change direction. The VLoc is a unidirection device with a welded loop at one end. Barbed sutures are rated as equal to one United States Pharmacopoeia (USP) suture size larger than their standard equivalent.5 This is because there is a loss of the effective diameter during the process of creating the barbs. They are engineered to evenly distribute tension along the length of the suture and they provide immediate tissue hold on placement, thereby eliminating the need for assisting “third hand”. One of the main reported advantages of barbed sutures is the reduced operating time on account of no knot requirement.6 The purpose of this study was to examine the use of a barbed suture device as part of a tie-over dressing for skin grafts. We hypothesized that the barbed tie-over dressing would be quicker to perform than the conventional tie-over and would also generate increased downward pressure on

Figure 1 A defect with a diameter of 4 cm was excised from the anterolateral aspect of a cadaveric lower limb. The excised skin was utilized as a full thickness graft.

C.W. Joyce et al. the graft as tension is maintained consistently due to the unidirectional nature of the barbs.

Materials and methods A circular area (diameter Z 4 cm) of skin was excised on the anterolateral aspect of a formalin-preserved cadaver (Figure 1). The skin excised was utilized as a full thickness graft in this study. A piece of mineral oil-soaked cotton wool wrapped in fine gauze was used as the bolster and the same bolster was used for each tie-over dressing in our study. An intra-compartmental monitor (Stryker, MI, USA) was used to measure the pressure under the skin grafts. The needle at the end of the monitor was removed and replaced by fine tubing attached to a small fluid filled finger from a surgical glove (Figure 2). This created a closed system that measured pressure at the graftewound interface. Three types of tie-over dressings were assessed in this study. The running tie-over7 using a Vicryl Rapide suture, the classic tie-over with a silk suture and a novel running barbed method. A 4-0 Vicryl Rapide and 4-0 Mersilk (Ethicon Inc., Somerville, New Jersey, USA) were used for the running tie-over and the classic tie-over respectively. Each technique was performed a total of 10 times. For the running barbed method, a 3-0 Stratafix PDO suture was utilized as this is equivalent to a 4-0 non-barbed suture. For all of the tie-overs, six strands of suture material were used to bolster the graft to ensure uniformity in each of the groups. The bites were placed equidistant from one another at the 12, 2, 4, 6, 8, and 10 o’ clock positions of the graft. For the silk tie-over, interrupted silk sutures were placed at six points around the circumference of the graft and one tail was left long in order to tie-over the dressing. The Vicryl Rapide tie-over was performed by firstly securing the suture by tying a knot at the 12 o’ clock position and then running the suture back and forth across the graft at each of the six points. The running barbed technique was

Figure 2 An intra-compartmental pressure monitor was modified to create a closed system which could measure pressure. The finger off a surgical glove was filled with saline and attached to tubing. This reservoir was placed under the graft.

Please cite this article in press as: Joyce CW, et al., A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.005

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Tie-over dressing for skin grafts

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carried out by initially taking a small bite at the 12 o’ clock position of the graft (Figures 3 and 4) and the suture was then pulled through until resistance was met as this signified the transition point where the barbs change direction. The remainder of this technique was the same as for the running Vicryl Rapide method. The pressure transducer was positioned on the wound bed and the skin graft was laid over it. The bolster was then placed on top and the transducer was zero balanced prior to any suturing. The tie-over suture was performed by one of the authors (CWJ) who was unaware of any pressure readings on the transducer throughout all the experiments. For the silk tie-over dressing, an assistant was used to secure the knot when tying as in our experience this would be the norm in clinical practice.

Statistical analysis The Kolmogorov and Smirnov method was used to confirm Gaussian distribution of data. Statistical comparison was carried out using one-way analysis of variance (ANOVA). Tukey’s test was used for post hoc evaluation of differences between groups. A p value of <0.05 was considered to be statistically significant. All data represented are expressed as mean  standard deviation (SD).

Results The difference between the groups were found to be extremely significant (p < 0.0001). The running barbed tieover was the quickest technique to perform (1:45  22 s) compared to the running Vicryl Rapide (2:57  27 s) and classic silk tie-overs (4:26  39 s) (Table 1). With regards to pressure, the barbed suture generated significantly higher

Figure 4

Photograph of the running barbed tie-over.

pressures (82.8  7.3 mmHg) than both the Vicryl Rapide (18.6  2.4 mmHg) and silk tie-overs (46  4.85 mmHg) (Table 1).

Discussion The tie-over dressing technique for skin grafts was originally designed to immobilize the graft, reduce seroma and haematoma formation as well as minimize the amount of dead space.8 The classic silk tie-over, as described by Wolf et al.10 has been shown to create an even distribution of pressure over the skin graft. However, the act of tying the knot typically requires an assistant and can take a disproportionate amount of time relative to the excision procedure.14 The technique has undergone significant modifications throughout the years and many different types of materials have been utilized including nylon tiestrips,9 staples and foam,10 aluminium collars,11 plastic discs,12 locking rings13 and plastic twist wire.14 The variety in materials used reflects the lack of consensus as to the ideal technique. The theoretical mechanism for preventing haematoma or seroma formation is pressure formation and it has been proposed that a minimum of 25 mmHg is required to achieve this aim.1 Some authors believe that tie-over dressings do not exert enough force to the base of the graft to exceed capillary pressure and would therefore not reduce haematoma or seroma formation.1,14 It has been claimed by some authors that if the pressure exerted is too high, necrosis can

Table 1 The mean (SD) pressures that each tie-over technique generated as well as the mean time taken (SD) to perform them.

Figure 3 Diagram representing an aerial view of the running barbed method. A bite in the skin was made at the 12 o’clock position and the suture was pulled through to the transition point. Each arm of the barbed device was passed over the bolster dressing in order to secure it.

Tie-over method

No. of each method

Pressure  SD (mmHg)

Time  SD (min: s)

Silk Running Vicryl Rapide Barbed

10 10

18.6  2.4 46  4.85

02:57  27 04:26  39

10

82.8  7.3

1:45  22

Please cite this article in press as: Joyce CW, et al., A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.005

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Figure 5 A melanoma was excised from the lower limb and the defect was reconstructed with a full thickness skin graft.

occur. However this has mainly been reported when using tie-over dressings over bony prominences.1 Furthermore, some authors have reported that not using a bolster dressing does not deleteriously effect the outcome of the skin graft. However, an external pressure dressing was still required for 48 h to prevent any shearing forces.15 The advent of the running tie-over7 suture for securing skin grafts was most likely born out of a need to expedite a frequently tedious procedure. This running tie-over is a technique we have frequently used in our institution and we were surprised that this method generated the least amount of pressure in our study. This is likely due to the fact that tension is gradually lost when passing the suture back and forth over the graft. Another negative aspect of this method is the increased scarring that has been reported.16,17 Overall, we found the barbed tie-over technique very easy to learn and perform. This method requires no assistant and this would be particularly useful for the sole operator. The barbs also act as a grip on the underlying

Figure 6 A non adherent dressing along with mineral oilsoaked wool was used as a bolster dressing over the graft in Figure 5. This was secured in place with a barbed tie-over.

C.W. Joyce et al.

Figure 7 The full thickness graft in Figure 5 two weeks post removal of the tie-over dressing.

bolster dressing thereby preventing it from slipping off. The barbs anchor firmly with each bite and due to the unidirectional nature of the barbs there is no slippage so the tension is never lost on the bolster dressing overlying the skin graft. The barb device is also very easily removed by simply cutting the strands at the centre of the graft and pulling them in the direction of the barbs. One of the major limitations of this study is that all the procedures were carried out by the same surgeon, thereby rendering the various techniques operator dependent. It would be ideal to recreate this study with several surgeons each performing the three techniques. Another issue is that the three suture materials were all different with varying degrees of stiffness and this may well have effected the results in terms of mean pressures. However, there tends to be less stiffness with braided sutures and these did not generate as much pressures compared to the barbed device. One of the main downsides to the barbed sutures is their cost compared to conventional sutures. However, considering that a classic silk tie-over typically requires several silk sutures the overall disparity in cost between both methods is minimal when it comes to tie-over sutures. It would also be worth repeating this study to measure the pressures over a longer timeframe by leaving the tieover on for a week and checking the pressures on a daily basis. Ideally, it would be recreated on animal models so as to assess the effects of localized swelling and oedema on the pressures. However, further cadaveric studies would benefit from being carried out on non formalin-embalmed cadavers as formalin tends to cause tissues to become very rigid. Cadavers emabalmed using the new Thiel method where the tissues remain soft and lifelike would be preferable. In our institution, we have now started to secure bolster dressings with a barbed tie-over (Figures 5e7). We have carried out 15 at the time of writing. The majority of barb tie-overs were for full thickness skin grafts (12) and the remaining (three) for split thickness grafts. We were initially concerned that the exerted pressure would have been too high for the graft leading to necrosis but we found

Please cite this article in press as: Joyce CW, et al., A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.005

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Tie-over dressing for skin grafts that all the grafts took completely. Furthermore, we find the technique very quick to perform and the barbed device very easy to handle. Patients did not complain of any issues and the tie-over dressing was removed easily after five days prior to graft inspection. The only initial concern was suture marks from the tie-over but these seem to resolve completely over time. We report on a novel application of a barbed device for securing a skin graft. We found that the pressures created by this method far exceeded conventional methods. Furthermore, this technique is very simple and quick to perform. Considering we now inhabit an era where theatre time is becoming ever more precious, any method that speeds up operating time safely and efficiently is surely welcome. This technique certainly shows significant promise especially for the sole operator and we feel it warrants further study.

Conflicts of interest none.

Funding none.

References 1. Seymour FK, Giele HP. Tie-overs under pressure. Br J Plast Surg 2003;56:494e7. 2. Blair VP, Brown JP. The use and uses of large split skin grafts of intermediate thickness. Surg Gynaecol Obstet 1929;49:82. 3. Rosen AD. New and emerging uses of barbed suture technology in plastic surgery. Aesthet Surg J 2013;33(3 Suppl):90Se5S.

5 4. Joyce CW, Whately KW, Chan JC, Murphy M, O’ Brien FJ, Carroll SM. Flexor tendon repair: a comparative study between a knotless barbed suture repair and a traditional four-strand monofilament suture repair. J Hand Surg Eur Vol 2013;44: 1636e9. 5. Greenberg JA, Clark RM. Advances in suture material for obstetric and gynecologic surgery. Rev Obstet Gynecol 2009;2: 146e58. 6. Grigoryants V, Baroni A. Effectiveness of wound closure with VLoc 90 sutures in lipoabdominoplasty patients. Aesthet Surg J 2013;33:97e101. 7. Pelissier P, Martin D, Baudet J. The running tie-over dressing. Plast Reconstr Surg 2000;106:1436e7. 8. Atherton D, Sreetharan V, Mosahebi A, et al. A randomised controlled trial of a double layer of Allevyn compared to Jellonet and proflavin as a tie-over dressing for small skin grafts. J Plast Reconstr Aesthet Surg 2008;61:535e9. 9. Praveen N, Bhandari PL, Sreekumar NC. Use of nylon tie-strips for tie over dressing. J Plast Reconstr Aesthet Surg 2014;67: 135e6. 10. Wolf Y, Kalish E, Badani E, et al. Rubber foam and staples: do they secure skin grafts? A model analysis and proposal of pressure enhancement techniques. Ann Plast Surg 1989;40: 149e55. 11. Niranjan NSA. modified tie-over dressing for skin grafts. Br J Plast Surg 1985;38:415. 12. Silfverskiold KL. A new pressure dressing for securing skin grafts. Br J Plast Surg 1986;39:567. 13. Burd DAR. The pressure button: a refinement of the traditional “tie-over” dressing. Br J Plast Surg 1984;37:127. 14. Pleat JM, O’Reilly DJ, Cogswell LK, Richards AM. The "twist over": tie die? Plast Reconstr Surg 2006;117:324e5. 15. Ranario JS, Shimizu IB. Full-thickness skin grafts secured using 2-octylcyanoacrylate and adhesive strips. Dermatol Surg 2014; 40:203e5. 16. Skouge JW. The running bolster suture for full-thickness skin grafts. Dermatol Surg 2004;30:1180e1. 17. Adams DC, Ramsey ML, Marks VJ. The running bolster suture for full-thickness skin grafts. Dermatol Surg 2004;30:92e4.

Please cite this article in press as: Joyce CW, et al., A novel barbed suture tie-over dressing for skin grafts: A comparison with traditional techniques, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.005