Hudson, Donald A. F.R.C.S.
Department of Plastic and Reconstructive Surgery; Groote Schuur Hospital and Renaissance Clinic; Cape Town, South Africa
Correspondence to Dr. Hudson, Department of Plastic and Reconstructive Surgery, and Renaissance Clinic, H53 Old Main Building, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa, email@example.com
A face lift creates two hemifacial flaps with a large “dead space” beneath. Dead space should be reduced or eliminated. One method is using quilting sutures: this idea1–4 is not new, particularly in abdominoplasty1,2 The technique, outcome, and complications are discussed in 12 patients.
A tumescent infiltration technique was used. The face-lift subcutaneous flaps are raised and the superficial musculoaponeurotic system (SMAS) is manipulated as desired (plication, imbrication, or SMASectomy). As the skin flap is advanced laterally, quilting sutures are inserted (Fig. 1). Traction should be applied to the skin flap when these sutures are inserted, to allow an even distribution of skin tension.
The first quilting sutures are inserted medially and subsequent sutures are inserted more laterally. Thereafter, the skin flap is redraped and inset.
An average of eight sutures (range, six to 12), using 4-0 Vicryl (Ethicon, Inc., Somerville, N.J.) or catgut, are inserted per side. The quilting sutures oppose the SMAS to the overlying skin flap. Occasionally, the suture passes close to the dermis, which may cause skin dimpling, but this resolves in 1 month after gentle massage.
Silastic pencil drains were removed after 24 hours. The dead space was measured at the tragus and superoinferior after SMAS manipulation (Fig. 2).
The average age of the 12 female patients (24 hemifacial flaps) was 55 years (range, 46 to 63 years). Two patients underwent a SMASectomy, and the others had SMAS plication or imbrication.
The average “size” of the dead space was 6.9 cm (from the tragus) and 7.5 cm (superoinferior). One patient had a small hematoma expressed through the suture line. There were no cases of skin necrosis. Mean follow-up was 8 months.
It is a surgical dictum that dead space should be minimized and preferably eliminated. Drains may be used: these do not eliminate the dead space but rather assist the efflux of fluid.5 Subsequently, adherence between the tissue planes occurs if there is no movement of one plane on another, and if no fluid accumulation occurs. Drains may still be used as a conduit for the efflux of fluid. Similarly, studies1 using quilting sutures in abdominoplasty have found the need for drains.
Quilting sutures in rhytidectomy reduce dead space, which is achieved at multiple anchor points. The sutures oppose one tissue plane (SMAS) to another (subcutaneous flap), probably promoting healing.2,4 In addition, these sutures prevent movement of one tissue plane on another, reducing seroma formation. Also, the reduced dead space limits any expansion of a hematoma.
Another advantage is the even distribution of skin flap tension: these sutures prevent tension from being applied at the rhytidectomy suture line, with less risk of skin necrosis and better scars.2,4 This benefit has been described in abdominoplasty.2
The sutures take 5 to 10 minutes per side to insert. In addition, temporary dimpling of the skin may occur if the suture is inserted too close to the skin.
This study suggests that quilting sutures in a subcutaneous face lift after SMAS manipulation reduces dead space, opposes tissue planes, and distributes skin tension across the flap. It is a procedure of minimal morbidity. Dimples may occur, but these respond to gentle skin massage.
The author has no financial interest to declare in relation to the content of this article.
Donald A. Hudson, F.R.C.S.
Department of Plastic and Reconstructive Surgery
Groote Schuur Hospital and Renaissance Clinic
Cape Town, South Africa
1. Andrades P, Prado A, Danilla S, et al. Progressive tension sutures in the prevention of postabdominoplasty seroma: A prospective, randomized, double-blind clinical trial. Plast Reconstr Surg. 2007;20:935–946.
2. Pollock T, Pollock H. Progressive tension sutures in abdominoplasty. Clin Plast Surg. 2004;31:583–589.
3. Titley OG, Spyrou GE, Fatah MF. Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg. 1997;50:106–108.
4. Pollock H, Pollock TA. Management of face lifts with progressive tension sutures. Aesthet Surg J. 2003;232:28–33.
5. Dougherty SH, Simmons RL. The biology and practice of surgical drains: Part 1. Curr Probl Surg. 1992;29:559–623.
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