My Closure Technique: Internal Suture Lift

The process of becoming a world expert on a procedure involves constantly thinking about ways to improve patients’  surgical outcomes.  I would like to share here my latest iteration that I  feel has had a positive impact on my results.

The gland has been removed, now what?

A lot of my focus in the beginning parts of surgery is on getting the gland out completely and smoothly (two often competing goals).  Once this has been achieved?   What are the next critical steps to ensure the best patient and cosmetic outcome?  Attention to closure is the next level of care that distinguishes a regular surgeon from an expert surgeon.   A common practice in surgery is to delegate the closure of the wound to their assistants.   This misses an important opportunity to further enhance the results that can be obtained.

The final closure: 3D closure vs Incision Site only?

I first learned about quilting sutures from lectures focused on tummy tuck surgery.  Basically, instead of the last step of closure being at the level of the incision itself, some surgeons began placing sutures between the muscle wall and the raised/elevated skin.  While this sounds simple in practice, it is moderately difficult to place those sutures, and it has a “learning curve” because of the awkward angle.  Once the skin flap is reattached to the muscle wall, there is no need to no need to a plastic suction drain and gave rise to the drainless tummy tuck technique which I then adapted to offer my Drainless Gynecomastia surgery. 

Barbed sutures: the next level of ease

Placing the suture accurately through the small areola incision takes time and practice as the space is narrow.  This is why many surgeons just close the skin and rely on the drain to keep the skin/muscle attached enough without fluid in between them.  However, I gradually found that I liked my results and control over where the skin was placed with the quilting sutures.  The development of barbed or knotless sutures has allowed the surgeon to place many more sutures accurately and quickly.  These sutures quickly allowed me to place double the amount of fixation points in half the time.  

Benefits of the 3D quilting technique: 

1.  Drainless Gynecomastia Surgery: the physical approximation of the skin /subcutaneous tissue flap to the muscle fascia prevents the formation of fluid collections and hematomas, and obviates the need for the uncomfortable drain and avoids an extra scar (drain site)

2. Lifting the skin flap:   the quilting suture allows me to lift and fixate the skin and nipple in a higher position on the chest wall.  This allows the use of the quilting sutures that I was already placing to create a skin lift.

3. Advancing fat tissue (fat flap) to allow more complete removal of the gland.  The quilting sutures are used to set the subcutaneous tissues in a desired position, and around the areola this is used to advance the fat flaps towards the center to replace the space created by the complete removal of the visible gland, helping prevent a crater deformity.

4. Decrease hematoma rate? I feel the approximation of the scarpas to the muscle significantly decreases the risk of a blood accumulation (hematoma) as there is simply less space for the hematoma to occur before the pressure build-up results in the clotting of the bleeding vessel.

5. Quicker recovery: the adherence using the sutures has allowed me to release patients to lower body exercise at 10 days and upper body exercise (full release) at three weeks post-surgery, making significant strides in shortening the recovery period.

Conclusion: 

The quilting sutures have become a hallmark of my gynecomastia technique, distinguishing what I offer from other plastic surgeons.    While they add about 45 minutes to the case as compared to straight closure, I felt the benefits have helped me achieve exceptional results.