By Denise Mann
Progressive tension sutures makes drainless abdominoplasty a reality.
Texas plastic surgeon Harlan Pollock, MD, developed the progressive tension suture (PTS) abdominoplasty technique more than 30 years ago to reduce seromas and other complications, and speed recovery by allowing patients to ambulate upright and eliminate drains. Slowly, but surely, others are adopting the PTS technique and seeing some amazing differences in their complication rates and patient recovery time. Plastic Surgery Practice sat down with the PTS pioneer to find out more about this technique, its evolution, and its future.
PSP: How would you describe the standard approach to abdominoplasty?
HP: The standard procedure involves mobilizing the abdominal skin, removing excess skin, and passively advancing and securing the flap with sutures at the level of the skin closure. I refer to this as a bed sheet approach. Drains are used because of the large area of dead space, and patients are required to stand and walk bending at the hips to
PSP: How does your PTS technique differ from the standard approach?
HP: While the incision and abdominal flap mobilization is similar, the major difference is the active advancement and anchoring of the flap with the progressive tension sutures. The advancement is aggressive, and the PTS secures the superficial fascia of the flap to the underlying deep fascia, which eliminates dead space, while preventing shearing forces with patient movement. Seroma formation is virtually eliminated, and patient recovery is short-ended and improved.
PSP: How long have you been using PTS?
HP: I have been using advancement sutures for more than 30 years. The name “progressive tension sutures” was introduced in 2000 in our first article describing this technique. The term suggests the mechanism of action of PTS in which there is tension on each suture, which is relieved by the subsequent suture—hence, progressive tension on the sutures, not on the flap. In fact, the tension is placed on the superficial fascia of the flap, protecting the vascularity of the skin and
|Figure 1 Illustrates the placement and securing of a progressive tension suture.|
|Figure 2 Illustrates multiple PTS in place in the upper abdomen.|
PSP: Where did the idea of PTS come from?
HP: PTS were adapted from basic surgical principles as a logical solution to control certain variables of the advancement flap, namely, tension on the closure, which can cause hypertrophic scarring or migration of the transverse scar superiorly; dead space, which permits fluid accumulation; shearing motion of the flap on the deep tissues, which causes disruption of early healing, inflammation, and fluid accumulation; and splinting the healing wound, by placing all of the advancement force on the superficial fascia.
PSP: Does PTS work?
HP: Both in theory and in practice, PTS eliminates seromas, improves scarring, and allows patients to ambulate in an upright posture, unencumbered by drains. In our recently reported series of 597 consecutive cases, we have seen only one small seroma, two hematomas, one patient with skin necrosis due to pre-existing scars, and overall excellent aesthetic results. These findings appeared in Aesthetic Surgery Journal.
PSP: Were there any surprises in your study?
HP: There were several statistics that were unexpected in our case review. These included the surprisingly high number of concurrent procedures the we had done with our abdominoplasties. We
found that we had done 67% other procedures, even though we did not count liposuction of the abdomen or flanks. Other surprises included the decrease in the number of modified (partial) abdominoplasties that we did as the 12 years of the study transpired. We attribute this to the increasingly aggressive advancement with experience.
The absence of thrombo-embolic complication in nearly 600 consecutive patients was also eye-opening.
Harlan Pollock, MD, and son Todd Pollock, MD
Statistically, we should have seen 20 to 30 deep venous thromboses (DVTs) in this unselected group of patients. We attribute this result to early, upright ambulation in this series. We were thrilled with the effectiveness of PTS preventing seromas! Only one small seroma occurred in 597 cases. This is unparalleled by any other technique.
PSP: How does PTS prevent seromas?
HP: We believe that the elimination of the shearing forces is the primary reason we don’t see seromas in our patients, even without drains. This conclusion is substantiated by a published study that shows that the fluid in a seroma is actually inflammatory fluid, not serum.
PSP: Are other surgeons taking to this technique?
HP: We have been surprised at the length of time it has taken for the acceptance of the addition of PTS to abdominoplasty, and the elimination of the traditional drains. In recent informal surveys of audiences of plastic surgeons, approximately 30% use PTS. Elimination of drains is a more difficult change of habit patterns, but that is the surgeon’s choice. It is gratifying to hear comments by colleagues how much the simple addition of a few sutures has changed their practice.
PSP: What is the biggest change in your technique in the past 30 years?
HP: Without question, the biggest change has been the addition of the “incontinuity umbilical inset,” which produces a relatively natural appearance of the umbilicus. Once the PTS have secured the epigastrium, the umbilicus is inset from the deeper aspect of the flap, after excising the major part of the skin of the umbilicus, leaving only a base, which is sutured in a manner that pulls the scar into the umbilicus. Our gynecology colleagues and our patients love the resultant umbilicus.
Denise Mann is the editor of Plastic Surgery Practice. She can be reached at [email protected]