Progressive Tension Sutures advance Abdominoplasty

North Dallas Plastic Surgery | Dr. Todd Pollock

 

This video demonstrates a simple surgical maneuver that can be added to any abdominoplasty procedure which will eliminate the need for drains, allow upright ambulation earlier yet, reduce the risk of other complications of abdominoplasty.  We term this technique progressive tension sutures, which are used to actively advance the abdominoplasty flap.

The concept of progressive tension sutures is seen in this animation--- that shows the placement of sutures from the superficial fascia of the abdominal flap to deep fascia of the abdominal wall.  As this suture is tied the flap is secured to the deep fascia and  advanced inferiorly. Tension is transferred from one suture to the subsequent one – hence the a name progressive tension sutures!  

 

The proposed incisons are injected with long-acting local anesthetic with epinephrine. The areas of planned dissection and liposuction are infiltrated with standard tumescent solution.  If indicated, at this time liposuction can be carried out in any area of excessive subcutaneous or deep fat. If upper abdominal liposuction is required it is limited to the fat deep to the superficial fasca.

 

The umbilicus is incised circumferentially –and partially dissected free with scissors.

 

A low transverse supra pubic incision is made down to  the deep fascia.

 

Undermining of the abdominal flap is carried out at the level of the rectus (deep fascia—this can be done with blunt and sharp dissection or as shown here electrocautery.  Either way blood loss is negligible.  

 

The flap is split to the umbilicus to facilitate supraumbilical dissection.

 

As demonstrated the lower abdomen dissection is full width, while the epigastrium is dissected only widely enough to accommodate the diastasis rectus repair and abdominal advancement and shaping,

 

Deep fascia is infiltrated with local anesthesia if the procedure is being done under sedation, but also for postoperative pain control. If a diastasis rectus is present, it is then repaired with 0 Mersaline as an interrupted and then a continuous sutures.  We repair only the muscle separation that is visible.  No tightening the fascia in a transverse dimension or excess tightening at the waist is done.

 

We will often use a continuous local anesthetic infusion catheter.  The catheters are placed  in a retrograde fashion.  We typically will bring these out just at the level of the xiphoid to make it easier for binder placement and patient mobility.   A wheal of local anesthetic is raised and the introducer is placed from the inside-out.     

 

We have found improved efficacy of the pain pump when placed in a sub-fascial position.  This is done also in a retrograde fashion running the introducer just under the fascia.  Because the introducer is not destroyed with retrograde placement, it can be used multiple times during the procedure.

 

It is time to actively advance the flap with the progressive tension sutures.  The patient is brought to a flexed position, while the table is placed in Trendelenburg position in order to facilitate exposure and  placement of the sutures.  The timeclock at the bottom right of the screen is real-time. You may note skips digit editing, however, the time is continuous. This will allow the viewer to note how long this portion of the procedure actually takes.

 

Suture placement is technically easy but coordination between the surgeon and an assistant can greatly facilitate the suture placement.  The surgeon controls the flap with his non-dominant hand—while the assistant provides exposure.  Here exposure is excellent without a retractor, which if helpful one can be used..  We typically use a  2-0 vicryl on a CTX needle . .  The surgeons non-dominant hand is able to detect the depth of suture placement.  It is important to EMPHASIZE THAT THE SUTURE MUST include  the superficial fascia.  In the upper midline, the suture can be  placed more superficially in order to achieve a longitudinal mid line depression for a more defined appearance.  In the periphery, only the superficial fascia is included.  The suture is first placed in the flap which is then advanced to the desired position.  The suture is then secured to the deep fascia to maintain the flap in an advanced position.  Typically, 2-3 sutures are placed above the umbilicus.

 

When the umbilicus is reached, the flap is defatted in a circular fashion adjacent to wear the umbilical stalk lies.  Just above this, a vertically oriented oblong circle is designed in the midline and excised.  The umbilicus is then inset with 3-0 Vicryl sutures from the underside of the dermis on the skin flap to the underside of the umbilical stalk dermis and then to the abdominal fascia.  This has the effect of inverting the abdominal skin and giving a more natural umbilical appearance.  This is done at four points around the umbilicus.  Placement is facilitated by placing the two lateral sutures before tying them.  

 

As you can see at this point, when the distal flap is advanced the umbilicus has a natural appearance. 

 

Now, the rest of the flap is advanced with additional progressive tension sutures.  The sutures are placed approximately 2 cm apart in the midline and then symmetrically in the periphery.  Minimal advancement is needed in the periphery.  IT IS IMPORTANT TO UNDERSTAND THAT THE PURPOSE OF THE PTS IS SECURE THE FLAP TO THE UNDERLYING FASCIA IN AN ADVANCED POSITION--- THIS REDUCES OR COMPARTMENTALIZES THE DEADSPACE.  THEREFORE, THE NUMBER OF SUTURES CAN BE MINIMIZED. 

 

At this point, one can see clearly the portion of the flap that has been advanced as compared to a more distal part that has not been advanced.  There is no obvious dimpling from individual sutures.  However, if dimpling is noted, it is not considered significant if the dimpling is minimal or eliminated when tension is placed on the flap distally.  If dimpling is considered significant, that suture can be removed and replaced.

 

Final pts are placed.---note the time on the timeclock – showing less than 25 minutes to place the PTS and inset the umbilicus.

 

Skin excess is excised in the standard fashion.  You will note that the skin edge is secure in place by the progressive tension sutures.  However, we have found that some tension on the skin is desirable to avoid fullness just above the incision.  So the skin flap is cut a few centimeters above the distal skin edge. 

 

A few 2-0 Vicryl sutures are used to approximate the superficial fascia.  This is done as three-point sutures between superficial fascia and deep fascia.  A few 3-0 Vicryl sutures are placed in the deep dermis to aline the closure.  Here, an Insorb subcutaneous stapler is used to expedite closure.  

 

A 4-0 PDS subcuticular stitch is used to close the skin.  

 

The umbilicus is inset with 5-0 interrupted Prolene sutures.  A light sterile dressing is then applied.

  

Please note the final appearance of the abdomen.  Note that there are no appreciable dimples and no drains.

Todd Pollock, MD | http://www.drpollock.com | Dallas: 214.363.2575 Allen: 214.509.0270