PHOENIX — Time is money. And with operating room time running $30 per minute or more at many hospitals, some cosmetic surgeons are switching from the hallowed traditional stitching techniques to considerably faster knotless means of wound closure.
Two novel technologies that garnered favorable reviews in studies presented at the annual meeting of the American Academy of Cosmetic Surgery were the Quill bidirectional barbed suture and 3M's Steri Strip S device.
Dr. Michael S. Kluska presented a comparative study involving 40 patients undergoing abdominoplasty or bilateral breast reduction. He closed half of the patients' wounds using traditional techniques, mainly multilayered interrupted individual absorbable sutures with Vicryl 3–0 or Monocryl 3–0 or 4–0. He closed the other half with Angiotech Pharmaceutical Inc.'s Quill double-barbed monofilament absorbable sutures.
With 22–27 traditional sutures being placed per breast reduction procedure, the cost of material is $325–$375 per patient treated. In contrast, the cost of the eight Quill sutures Dr. Kluska typically uses in breast reduction cases is $240. Moreover, total operating room time averages 2 hours with traditional wound closure versus 1 hour 40 minutes with the barbed suture, a hefty 20-minute savings in OR time.
Similar cost and time savings accrued through the use of barbed sutures in the abdominoplasty patients, noted Dr. Kluska of a plastic and cosmetic surgery center in Greensburg, Pa. The Quill sutures provided other advantages, too. Tissue approximation was better because of the continuous controlled tension achieved along the length of the wound.
“You don't have the scalloping that you get with individual interrupted sutures,” he said. “Individual sutures placed in subcutaneous and subcuticular space create microischemic changes, with chronic edema at the wound site. It can be a challenge to tie each suture to create closure without tissue death.”
Anecdotally, Dr. Kluska has noted that surgical wounds closed with barbed sutures heal much faster.
The technique involves placing a Quill suture in the subcutaneous space, bringing both ends out and making sure they're equal in length, then running the suture in one direction while the surgeon or an assistant runs it in the opposite direction.
“You run it very similar to a subcuticular stitch, in a linear U or horizontal fashion. When you finish, you pull it snug, cut it, and you're done. When you pull this suture taut in a linear fashion, the barbs deploy in a helical pattern. It creates a drawstring effect in the tissues,” he explained.
Applications for the barbed suture are “pretty much anywhere you do multiple-layer closures in the subcutaneous and subcuticular space,” he said.
Separately at the meeting, Dr. Abhishek Chatterjee presented a cost-savings analysis comparing the 3M Steri Strip S (3S) device and conventional sutures for the final layer of skin closure in abdominoplasty or bilateral breast reduction. Unlike prior studies that compared novel methods of wound closure, this analysis incorporated the opportunity cost (the dollar value of an activity that is forgone in order to participate in some other activity—in this case, conventional suture closure). Folding in the opportunity cost provides the truest estimate of the cost savings provided by an innovative device, because it includes the profit a surgeon could earn by doing something else in the time saved by not suturing, explained Dr. Chatterjee of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
He presented a randomized trial involving 27 abdominoplasty and 23 bilateral breast reduction patients. Each patient had half of their incision closed in traditional fashion using 4–0 polydioxanone (PDS) suture and the other half closed with 3S, all by the same surgeon.
The 3S closure saved 20 minutes in the breast reduction cases and 12 minutes per abdominoplasty. The hospital OR cost was an estimated $30 per minute.
A 3S device cost $14.82, with an average of 16 sutures used for the final layer of skin closure per bilateral breast reduction and 14 per abdominal closure. At $3.75 per PDS suture, the material cost for 3S closure was greater, but this was outweighed by the reduced operating room time.
With incorporation of the opportunity cost into the cost analysis, the true cost savings obtained by using the 3S instead of 4–0 PDS suture was $2,298 per bilateral breast reduction and $1,277 per abdominoplasty, Dr. Chatterjee concluded.
Dr. Chatterjee disclosed receipt of a research grant from 3M to conduct his study. Dr. Kluska indicated he had no financial conflicts of interest regarding his study.