A routine step in nearly every surgery, wound closure is a critical and delicate procedure. Perhaps no one is more aware of that fact than plastic and cosmetic surgeons, specialists whose ultimate goal is improving patients' lives through their appearances and who aim to reach that goal by making their closures as unobtrusive and unnoticed as possible. As you'll see, however, cosmetic closure is not without its challenges.

Building on basics
In aesthetic surgery, as in any other specialty, "there are tried and true rules about wound closure, about how you technically go about closing any wound," says Andrew Schneider, MD, FACS, a plastic and reconstructive surgeon at Forsyth Plastic Surgery in Winston-Salem, N.C.

First, surgical site infection must be avoided at all costs, as an infection will limit the amount of healing that will occur, if not delay it outright, possibly resulting in scarring. Standard infection prevention and control techniques, from clinical hand hygiene to proper post-op patient care, are an important effort on this front.

There must be blood supply to the closure site to promote healing and prevent tissue damage or death. John Rachel, MD, FACS, an ENT and facial plastic surgeon at MetropolitanMDs in Chicago and Glenview, Ill., says patients with poor vascularity or compromised blood supply due to vascular disease, smoking or diabetes are at particular risk for such complications. In these situations, he says, patient selection may play a role in achieving good closure.

Closure must seal the tissue together, allowing no "dead space" where cavities of air or fluid may form beneath the skin. Dr. Schneider recalls a body contouring procedure on a 6-foot, 8-inch patient who'd weighed 650 pounds before massive weight loss. "It involved a lot of surgery to taper that excess skin and make it look good," he says, plus, due to its abdominal location, "the tummy tuck is prone to infection." As a result, "we used every trick in the book: tissue glue, absorbable staples, IV antibiotics, multiple drains. ' The suture line was a mile long."

Aesthetic aspects
For the patient undergoing the surgery, wound closure presents other concerns. "A very common question we get from patients is, What are the scars going to look like?" says Dr. Rachel. "Will they be visible? Can they be hidden in the hairline? We're constantly fielding questions from patients on whether anyone else is going to know whether they've had surgery."

"People are expecting more overnight results, with no scars, bruising or swelling," says Dr. Schneider, "and that presents a challenge to anyone performing cosmetic surgery. You've got to be straightforward with the patient as to what they can expect. There's nothing worse you can do than give a mistaken impression" of a procedure's results, including the recovery process.

Depending on the type of procedure being performed, the size and placement of the incision can be the first step toward a less visible scar, since a shorter incision means less risk of tissue trauma and the folds and creases in a patient's skin can help to camouflage a scar.

The incision scars resulting from face- and forehead-lifts are commonly concealed behind patients' hairlines, but this method depends, of course, on how much of a lift a patient needs and the condition of his hairline.

Dr. Rachel describes the forehead rejuvenation of a bald patient who had low eyebrows "to the extent that they were almost a visual obstruction," he says. A direct brow lift procedure would involve removing an ellipse of skin to allow the closure to raise the rest. "But without a hairline, it would prove difficult to hide the scars of a forehead lift."

The upshot? One edge of the removed skin was directly above the eyebrows to make the incision scar as imperceptible as possible. To minimize the considerable tension the brow would place on the closure and to prevent a widening wound, he used a multiple-layer closure, with stitches securing the deep layer, mid-layer and top layer tissue.

Technique plus technology
In surgery, says Dr. Schneider, "anything we use could benefit from a little bit of technology." The combination of technique and technology, he says, gives today's surgeons a step up from the past, especially in the field of wound closure. "We're better at preventing infection, at decreasing scars, at keeping them as small as possible."

Synthetic absorbable staples, for instance, help to speed up suturing while closing deeper layers, while synthetic absorbable sutures have reduced the red in wound closures by decreasing tissue reactions.

Tissue adhesives, also known as surgical glues, are another innovation that has been transforming wound closure since the Food and Drug Administration began approving their use in American ORs in the late 1990s.

Cyanoacrylate, a synthetic solution chemically similar to household "super glues," was approved for external use in closing low-tension incisions and lacerations and is sometimes used in conjunction with deeper dermal sutures. Marketed by Ethicon as Dermabond and by U.S. Surgical as Indermil, it has been enthusiastically adopted by plastic surgeons as well as ophthalmic and pediatric practitioners.

On the other hand, fibrin sealants - biomatter-based adhesives created in part with the patient's own plasma that use blood proteins to cause clotting - have also found plastic applications. While the FDA approved Baxter Healthcare's Tisseel VH, Ethicon's Crosseal and Orthovita's Vitagel for hemostasis in cardiac, liver, spleen and colon surgeries, their technology is now also used in the reconstruction and even cosmetic enhancement of deep tissue.

"When we lift large flaps of skin, [fibrin sealant] helps to secure tissue in a faster way than just closing up and hoping the tissue heals," says Dr. Schneider. He reports using the treatment routinely in breast reconstruction procedures to prevent seromas and in facelifts to reduce bruising and swelling.

New products for closing
As any materials manager will attest, and as many healthcare facilities' supply rooms will confirm, there's a mind-boggling number of suture types available. This abundant market hasn't curbed product improvement, however. Here are some recent additions to the field.

Ethicon, Inc., which dominates the U.S. suture market, has introduced the Vicryl Plus Antibacterial (polyglactin 910) Suture, a synthetic, absorbable, copolymer surgical suture coated with the broad-spectrum antibacterial agent triclosan to increase infection prevention efforts in wound closure. Citing a study by the CDC that calculated that 60 percent of surgical site infections occur at the incision, the company says its suture kills and inhibits colonization by the most common SSI pathogens. The suture is available undyed or dyed violet, and the company also offers Monocryl Plus Antibacterial (poliglecaprone 25) Suture.

"I think that [antibacterial suture] might have some impact," says W. Thomas Lawrence, MD, MPH, professor and chief of the plastic surgery division at the University of Kansas Medical Center in Kansas City, Kan. "Wherever we have dermal suture, the bane of our work is an inflammatory reaction to the suture."

"Who doesn't want something that's going to be a natural infection fighter?" says Dr. Schneider, who sees it as a logical step up from sterile suture.

B. Braun has been manufacturing sutures in Europe for nearly a century - the company manufactured the first industrial version of sterile catgut - but its surgical sutures product line is new to the U.S. market. Monosyn, which the company bills as "the first true mid-term monofilament," can be used in place of chromic catgut, braided synthetic material or other monofilament synthetic material. The company promotes its high tensile strength, softness for ease of handling, elasticity for secure knotting and complete mass absorption in 60 to 90 days.

In recent years, Angiotech (formerly Surgical Specialties) has been manufacturing and marketing Contour Threads, a polypropylene barbed suture designed for minimally invasive cosmetic lifts, in conjunction with Quill Medical, Inc. Angiotech's new Quill Self-Retaining System applies the barbed design to wound closure. The self-anchoring, knotless sutures combine the strength and control of sutures with the speed and ease of stapling, says the company.

"This may be the wave of the future, but then again, it may not," says Dr. Schneider, explaining that, in spite of its convenient aspects, most surgeons are just getting experience with the device. He also confesses a small amount of skepticism with the use of a synthetic, non-absorbable material in closure. "Before I put a foreign object under a patient's skin, I want to see a lot of evidence that it works. ' With [fibrin] tissue adhesives, at their worst, they're just not helping to close the wound."

For 3M, the next step in suturing is sutureless. The Steri-Strip S Surgical Skin Closure is a non-invasive adhesive device constructed of polyurethane pads and interlaced polyester filaments for fast and precise closure of low-tension incisions, says the company. Designed to assist deep tissue sutures or staples, or to reinforce a wound after their removal, the needle-free device minimizes tissue trauma and scarring. It is available in 10 widths, from 10mm to 100mm.

Dr. Rachel says that the product is likely to save a great deal of time, hold cosmetic appeal over a row of sutures and provide benefits to pediatric and other needle-shy patients, but he has concerns over its possible limited use: It could come in handy in facial plastic surgery, but hair-bearing areas such as the eyelid, the eyebrow and the scalp might limit its use.

Cost and benefits
Any new wound closure technology "needs to be studied as compared to the gold standard of suture and taping" to assess how well it saves time and money in the OR, says Dr. Rachel.

Says Dr. Lawrence, "We're bombarded by a lot of new things all the time. There's no time to try out everything that's new." A product's perceived utility, however, can make surgeons seek it out, even when they tend to be conservative in weighing the risks and benefits of new options.

"One of the things that's important for surgeons is to stay on top of the literature," says Dr. Schneider. "There's a lot of anecdotal evidence out there. But you have to go with the real data, what really works."

Considering the essential role that wound closure plays, physicians' suture preferences can be difficult to argue against. But it's an expensive detail, says Dr. Rachel. "Every surgeon has their different techniques and different sutures they like to use to get a good result," he says. "Ten different surgeons want 10 different kinds of suture."

Aside from the issue of stocking the suture, surgical use itself can eat into a supply budget. A short incision that uses three or four types of suture (at $20 to $30 a piece) only needs two or three inches of each, and renders the rest unusable. "That's wasting a lot of suture," says Dr. Rachel.

He recommends facility managers sit down with their physicians and their supply purchasing numbers to discuss standardizing supplies, both in preference and technique, so the amount ordered, and wasted, is limited.

"To be honest, most surgeons just may not be familiar with other sutures that may work just as well in most cases," says Dr. Rachel. "Show me what alternatives there are and, in most cases, I'm OK with those."