|Figure 1. Dual layer closure using Quill SRS sutures, with barbs that penetrate into the surrounding tissue and lock the suture in place without a knot.
The Quill Self-Retaining System (SRS) suture is an innovative tool that allows for more rapid closures of commonly performed procedures. This has a direct effect on surgical cost and efficiency. In addition, cosmetic results appear to be equivalent and at times superior with this suture.
The Quill SRS (Angiotech Pharma-ceuticals, Vancouver, British Columbia, Canada) is a knotless surgical wound-closure system that has tiny barbs on its surface. These barbs are arrayed in opposing directions on either side of a transitional unbarbed segment. When the suture is advanced, the barbs penetrate into the surrounding tissue and lock the suture in place without a knot (Figures 1 through 3, page 30, 32).
This novel wound-closure system eliminates the tedious and time-consuming step of tying suture knots in order to secure soft-tissue approximation. The technology may substantially decrease the time required for surgical wound closures, and therefore reduce both the surgeon’s time and operating room costs for an individual procedure.
|Figure 2. An example of a multilayer closure using the Quill SRS sutures.
The goal of this article is to objectively compare the difference in time and cost between traditional and Quill SRS closure of a brachioplasty, mastopexy, and abdominoplasty incision. Clinical applications are also presented.
The closure processes for three basic aesthetic procedures using traditional and Quill SRS techniques were timed and compared. In addition, the potential difference in costs of the suture material, anesthesia, and operating room facilities were contrasted.
Three surgeons with varying levels of experience (a junior plastic surgery resident, a senior plastic surgery resident, and a senior plastic surgery professor) performed the closures. Each surgeon was his own control. For example, one incision was closed in our traditional manner, and the second incision was closed using the Quill SRS by the same surgeon.
|Figure 2. An example of a multilayer closure using the Quill SRS sutures.
The traditional procedure involved a three-layer closure of the superficial fascia/deep tissue, deep dermis, and a running superficial dermal suture. The Quill closure involved the same three layers, but the superficial and deep dermis were closed with the same suture. This was easily accomplished, as the barbed segments allow equal distribution of tension along the suture and can easily and securely close more than one layer in the closure.
We compared the time, quantity of suture required, material cost, and operating facility costs between the Quill SRS and our traditional suture (Monorcyl 2-0, 3-0, 4-0). All procedures were performed on a nonpreserved fresh cadaver.
The Quill SRS wound-closure system eliminates the tedious and time-consuming step of tying suture knots in order to secure soft-tissue approximation.
Our small study showed that, regardless of the surgeon’s experience level, the Quill SRS suture decreased operative time by slightly less or more than 50%, depending upon the procedure performed.
With each surgeon serving as his own control, the junior resident closed both brachioplasties, the chief resident closed both mastopexies, and the senior plastic surgery professor closed both sides of the abdominoplasty.
Therefore, in the times listed in the charts, the 50% reduction in operative time was obtained at all three levels of training and experience, which also resulted in a 50% decrease in the cost for anesthesia and operating room facilities during the closure.
|Figure 4. Mastopexy reduction mammoplasty using Quill SRS sutures. In this study, the use of these sutures resulted in an overall reduction in operative time.
As the Quill SRS allows approximation of several soft-tissue layers with a single suture, there is no need to close the deep and superficial dermis in separate layers.
Looking at the charts, this is evidence where the superficial dermis is closed separately with traditional closure techniques but is included in one layer with the Quill SRS. This reduction in surgical time may also enable the surgeon to perform more cases in a day, which could lead to an increase in revenue.
The senior surgeon’s practice has demonstrated equivalent healing and scar formation between traditional and Quill SRS suture techniques. However, at times the Quill suture allowed for superior scar formation, shape, and contour after mastopexy when compared to the standard techniques.
The Quill technology allows for an even distribution of tension along the entire length of the wound. In addition, as no knots are required, there is less suture material near the surface to cause a foreign-body reaction. This potentially reduces incision line inflammation, discomfort, suture spitting, and poor scar formation along the length of the wound.
Although there may be the occasional extrusion of a barbed segment, the experience of the senior plastic surgeon has been quite favorable in observing wound healing in a variety of aesthetic plastic surgical procedures with an observation period of 3 to 6 or more months.
Applications in soft-tissue approximation for aesthetic plastic surgical procedures of the breast and body contouring include breast pillar approximation and wound closure for mastopexy and breast reduction, abdominoplasty (diastasis rectus fascial approximation, high-lateral tension sutures, and horizontal wound closure), and soft-tissue approximation for postbariatric procedures (for example, brachioplasty, lower-body lift, and medial thigh lift).
|Figure 5. In the case of abdominoplasties, the placement of barbed sutures can be less traumatic on tissues.
When performing a periareolar mastopexy, a purse string-type closure is not performed as each limb of the bidirectional barbed suture travels either clockwise or counterclockwise from the 12 o’clock position at the top of the areola to the 6 o’clock position (Figure 4). If the incision includes a vertical and a horizontal component, a longer suture (each limb measuring 24 centimeters) may be used in such a way that the suturing continues from the 6 o’clock position to the end of the vertical and horizontal incisions.
Likewise, in performing an abdominoplasty, the placement of high-lateral-tension Quill SRS sutures will narrow the waistline while eliminating the “dead space” (achieving the benefit of quilting sutures), thereby potentially decreasing the incidence of seroma formation.
Quill SRS sutures are also used to repair the diastasis recti and to close the abdominal incision (Figure 5). The placement of barbed sutures is potentially less traumatic on tissues. In addition, the closure is faster, a third hand is not needed, and less suture material is required than is typically used in traditional methods of soft-tissue approximation.
In addition, a variety of suture sizes, needle sizes, and suture lengths are available, as well as the option to use non-absorbable (nylon and polypropylene) or absorbable sutures (polydioxanone).
Malcolm D. Paul, MD, FACS, is a clinical professor of surgery at the Aesthetic and Plastic Surgery Institute, University of California at Irvine. He can be reached at .
Michael Budd, MD, is a plastic surgeon based in Orange, Calif. He can be reached at (562) 222-0990.