Tag Archives: wound

Plastic Surgery Stitches (Suture) Information

Cosmetic plastic surgery sutures to hold you together

As a cosmetic plastic surgeon I spend a great deal of my life placing plastic surgery stitches / sutures in patients as part of their cosmetic surgery. Though some stitches stay deep in the skin and are never removed or simply dissolve away, most have to be removed by the plastic surgeon or their nurse at some point. But when?

 

Types of sutures/stitches

There are a number of different types of sutures, varying in:                                                                                                 plastic surgery suture

  • Materials
  • Size
  • Strength

 

Types of sutures

 

Sutures can be divided into absorbable and permanent sutures.

 

Absorbable sutures

These are sutures that are designed to be dissolved by the body. Different types of sutures have different  rates of  dissolution, and during this time will lose strength at a predictable rate.  These sutures  are typically made of organic materials that the body can destroy.  Often, these stitches are  placed under skin and will dissolve with time. They are placed in locations where long-term/permanent strength is not needed and where natural scar tissue that forms in wounds can take over the function of  sutures.  Our bodies actually have to mount an inflammatory reaction to dissolve these sutures. They do not self-destruct like in Mission Impossible. Some sutures I use in cosmetic plastic surgery include:

  1. Catgut – actually made from sheep intestine these days; absorb quickly and not very strong
  2. Chromic catgut – catgut sutures that are treated with Chromium to increase their durability
  3. Silk – a very long-lasting absorbable suture
  4. Vicryl – a polysaccharide suture lasting about three months
  5. PDS  or Monocryl – another cross linked polysaccharide that lasts a long time

Permanent sutures

These are stitches that will not be dissolved by the body. They either stay in place forever or have to be removed by a cosmetic plastic surgeon. The advantages of these sutures are:

  • greater tensile strength – stronger
  • less reactivity – less inflammation and soreness
  • Easier removal – tissue does not integrate with them

Some plastic surgery permanent sutures include:

  1. Nylon
  2. Nurolon
  3. Prolene
  4. Metal wire

Thickness of sutures

All stitches are manufactured in different diameters and with different types of needles.

The numbering system for sutures can seem a bit complicated: 2, 1, 0, 2-0, 3-0, 4-0, 5-0, etc.

The thickest sutures have a numbering system that seems logical. The higher the number, the thicker the suture. A #2 suture is stronger than a #1, which is stronger than a #0.

Sutures smaller than #0 are identified by having “-0” at the end. The thinner a suture, the larger the number! So, a 3-0 suture is thicker than a 6-0, and so on.

 

When to use which  suture thickness

Your cosmetic plastic surgeon will know which sutures to use where based on his or her experience and training. I still change the sutures I use for different procedures based on experience, quality of my surgical results and pragmatic reasons.

For example:

A #1 suture is a thick suture used to keep the abdominal muscles together after an abdominoplasty.

A 4-0 suture is about the thickness of a typical thread used to sew a button. It is used for cuts on a hand or leg that need more strength.

A 6-0 suture is as thin as a hair and used for delicate closures of skin cuts on the face.

A 10-0 suture is used in microsurgery operations.

But,

A 6-0 nylon suture is as strong as a 4-0 catgut! Your plastic surgeon knows…

 

When should sutures be removed from skin?

It depends on what the suture is doing! In the skin of the face where there is little tension on the skin, the sutures may be removed in 5-7 days. In areas where there is movement and tension, such as the arms and legs, sutures may need to be kept for up to a month. Your cosmetic plastic surgeon will have a plan and decide when to take the stitches out. What  is the downside of leaving them in too long? Scarring and difficulty removing them later!

 

This information presented on sutures is intended to give you a general idea about what they are and how cosmetic plastic surgeons use them. Do not start telling your surgeon what type of suture to use—your plastic surgeon knows better than you!

 

Morad Tavallali, M.D., FACS

Cost of Plastic Surgery: Nickel and Diming Cosmetic Patients

Cost of tummy tuck surgery increases with technology

 

We live in an age of exponential growth in information and technology and in the cost of surgery. Even in the past few years, advances in cosmetic plastic surgery techniques have been enormous—and so has the cost of surgery! Some cosmetic plastic surgeons still cling to old methods. That is sad.

Here are a few other posts on these topics:

https://tavmd.com/2012/02/24/plastic-surgery-without-pain/

https://tavmd.com/2011/07/02/new-technique-for-tummy-tuck/

dollar sign

New surgery techniques  come with  a higher cost. How to deal with an increase in the cost of surgery in an era when we are all trying to keep surgery costs down is problematic.

As a cosmetic plastic surgeon, I have a certain cost for my surgeries. Regularly, costs of implants and garments are added to  costs for surgery in addition to hospital/anesthesia fees. Think of it as the cost of performing surgery + materials.

 

Exparel

I have previously written about Exparel.  This slow-release formulation of a common local anesthetic (Bupivacaine) that many plastic surgeons use is set to explode on the market and change the way we practice medicine. The drug  provides for a three-day area of numbness when injected into the surgical field. That means three days of reduced need for narcotics (with all of its problems), not suffering pain and getting back to normal faster!

It adds $285 to the cost of surgery (breast augmentation or tummy tuck).

The hospital doesn’t provide it to plastic surgeons; they do provide regular bupivacaine as part of a global surgery cost. What do they care if you have less pain once you are out the door?  They don’t save any money.

This leaves cosmetic plastic surgeons with the sad choice of telling cosmetic patients that a drug exists that will reduce their pain but add to the cost of surgery. Patients can then choose whether to buy it or not. First-class ticket or economy? I find it hard to practice medicine knowing that a better alternative exists for my patient but that it will not be offered due to cost. That just seems wrong. Reduce my fee and eat the cost? OK; but by the same token why not increase my fee and include Exparel?

Prineo

This is a new wound closure system from  the Ethibond suture company. The combination of Dermabond (tissue glue) and tape makes for a far superior dressing after surgery that stays on patients for about one month. Scars are rare because it decreases incision and tension on the skin for most patients.

My surgery center used to provide it as part of the hospital fee. Not anymore.  I have to either abandon what I know to be a far better closure system and go back to the old, lesser techniques… or have patients pay an extra $250.

Liposuction

For my abdominoplasty/tummy tuck patients, I regularly include abdominal and hip liposuction. It turns out that many plastic surgeons do not include  liposuction, and if they do, they charge patients extra for it… like I used to!

I used to offer patients the option of liposuction at the same time as abdominoplasty because I knew that the cosmetic results were better.  Most would say “no thanks”—the cost was another 20% on top of  tummy tuck fees and that turned out to be too much for most patients. Those who had the liposuction at the same time were happy, and the ones who did not returned later to have it or left unsatisfied despite my best efforts to forewarn them.

I have decided to include the liposuction in all my abdominoplasty operations as standard. I had to cut my fee down for the lipo, but I now get better results. I was able to do this because it was my work and time, not a fixed cost of materials from another company.

Medical economics

The above gives you an example of how the cost of plastic surgery continually rises advances in technology.  New medical advances cost money, which is usually transferred to the patient’s insurance company, which may or may not pay for particular therapies.

In cosmetic surgery patients who pay out of pocket, a new/better treatment modality will cost more. As a cosmetic plastic surgeon, I want the best possible results for my patients, but now I have to offer them a choice between the “best” techniques and simply “good” ones.  If I keep on eating the cost, eventually I will be performing the surgery for free, as my costs will be greater than my income. After all, this is how I make my living.

I can’t decide what to do! I fear that increasing the cost of plastic surgery without telling patients the reasons will frighten away patients who may not understand the nuances of surgery and differences in results.

Or should I be offering a two-tier surgical result—a basic economy tummy tuck and a first-class tummy tuck with all the extras ? Advice is welcome—only first-class advice at no extra cost please!

Morad Tavallali, M.D., FACS

Abdominoplasty Wound Closure, Part 2

Abdominoplasty Wound Closure, Part 2

Tummy tuck incision closure

As I have previously reported, for several months I have been using the Prineo wound closure technique for my plastic surgery abdominoplasty patients. Here is the link to the previous article:
This technique is based on:
  1. Closure of the subcutaneous tissue with sutures
  2. Closure of the deeper skin level with sutures
  3. Closure of the superficial skin with Prineo tape/Dermabond Glue system.
Observations on abdominoplasty wound closure
In short, I have adopted the Prineo system of wound closure in most patients for several reasons. I do not use the system for patients who have thicker abdominal walls. The tape is just not sticky enough to deal with the undulations at the skin surface in patients with a thicker abdominal wall.

Advantages of the Prineo system

  1. The incision is closed rapidly and easily by application of the tape and Dermabond.
  2. No need for sutures to be placed or removed or for the body to dissolve sutures, causing less skin reaction.
  3. Waterproof and bacteria-proof closure and dressing all in one. Like a “fiberglass” covering of the incision.
  4. No need for cosmetic patients to change dressings, apply ointments, etc. as part of post-operative care.
  5. Excellent cosmetic result of scar.
  6. Less pain for patients because there is no need for suture removal or dressing changes.
Disadvantages of Prineo wound closure
  1.  Cost added to surgery; this is offset by a lack of need for sutures, dressings and ointments during surgery as well as during the recovery period.
I should add that I have not received any royalties or compensation for my evaluation of this product and am not a hired gun of the manufacturer. The company representative did, however, provide the materials needed for the first three patients free of charge to me and my patients.
For more information on abdominoplasty, please read here: https://tavmd.com/tummy_tuck.html

New Tummy Tuck Technique

New tummy tuck technique for wound closure

As a cosmetic plastic surgeon I am constantly trying to improve my surgical results and, in particular, the quality of the scars cosmetic surgery leaves. A smaller, thinner scar that is less visible is an important goal for any plastic surgeon. Also, if a surgical technique can improve the outcome and be faster it is preferable. After all, the less time you are under anesthesia, the better it is for you and the less your cost will be! See here for a related post: https://tavmd.com/2010/12/14/abdominoplasty-without-drains/

Finally, if the new innovation can make the patient’s and plastic surgeon’s care of a wound easier, so much the better. A new technique in wound closure for long incisions such as tummy tucks and breast surgery may be able to do all of the above.

Here are some photos of abdominoplasty: https://www.tavmd.com/tummy_tuck_abdominoplasty_photos_va.html

New tummy tuck wound closure with glue

For a number of years, plastic surgeons have had glues like Dermabond at their disposal for closing wounds without tension. Unfortunately, most wounds in cosmetic surgery involve removal of some skin and by necessity have tension—as such, they are not ideal for wound closure with glues. The glues have worked very well for closure of small incisions in places such as the cheek or face.

Abdominoplasty closure with Glue

 

Prineo wound closure photo

New technique for wound closure with glue

The new innovation that may be the answer to wound closure that has some tension is the Prineo dermabond system developed by Ethicon. The idea is to approximate the deeper tissues, apply tape to the wound and then place glue on top of the tape. This provides for a stronger closure over a longer distance. The glue once polymerized by contact with the tape provides a strong physical barrier to bacteria and improves sterility. The patient can shower immediately and the dressing is left in place until it naturally falls away after a few weeks.

 

 

 

I have tried the new technique on four patients so far—here are my results!

  • The wound remained closed at the post-operative visit
  • The surgery took less time
  • The post-operative visit was less uncomfortable for the patient
  • The post-operative visit was shorter
  • The patient had an easier post-operative care regimen—no need for changing dressings or applying antibiotic ointment twice a day.

 

Here is the usual care regimen after an abdominoplasty:

https://tavmd.com/2011/03/13/care-after-a-tummy-tuck-abdominoplasty-part-1/

https://tavmd.com/2011/03/17/care-after-a-tummy-tuck-abdominoplasty-part-2/

I will report later on how good the cosmetic result is once a month or so has passed. Meanwhile, I am rather impressed by the advantages of the Prineo dermabond system for wound closure of abdominoplasty incisions. Let’s wait and see.

Here is more information on abdominoplasty: https://www.tavmd.com/surgery-info/tummy-tuck/

P.S. Here is a similar technique being used by dermatologists for closure of cheek wounds; looks like it’s catching on.

http://cosmeticsurgerytimes.modernmedicine.com/cosmeticsurgerytimes/article/articleDetail.jsp?id=726604&sk=95be0863b665d3fcb0557cebf2c9db37

 

Morad Tavallali, M.D., FACS

Instructions After Cosmetic Plastic Surgery, Part 3

Instructions After Cosmetic Plastic Surgery, Part 3

Cosmetic surgery instructions

This is the third and final segment on general post-operative instructions after cosmetic plastic surgery.

Constipation post-surgery

Pain medication will constipate you. Studies show that 80% of women have trouble with constipation anyway, even before taking narcotics. Narcotics will make constipation worse, and it is important to prevent this from occurring as it will just add to your misery. First, make sure you drink lots of fluids. Take stool softeners such as Metamucil fiber and be prepared to take laxatives such as Ex-Lax and suppositories such as Dulcolax in case it does set in. If you still have no relief, you may need a Fleet enema. All of these over-the-counter medications are readily available at any pharmacy.

Washing after surgery

No showers or baths are allowed until you are allowed to take them by your cosmetic plastic surgeon! You can clean your body through cat washes, but do not get your bandages wet. Wounds need at least 48 hours to become waterproof. However, you can wash your hair 24 hours after surgery. Use soap and water to clean above wounds and let the water run down over the incisions, but be careful not to rub your wounds—it will hurt! The first time you take a shower, make sure you have someone helping you or close by. The warm water may cause dilation of blood vessels in the skin and lead to a brief fainting spell as your blood pressure drops. Be prepared and have a stool or chair nearby. Be prepared to moisturize your skin. Surgery makes the skin dry, and any body lotion will help your skin and make you feel better.

Scars

After any cosmetic plastic surgery, you will have scars. Whether you notice them or not depends on several factors, including your particular skin type, placement of the scars, tension on the wound and after care. For the initial period after bandages are removed, I recommend you use an antibiotic cream on scars, such as Neosporin. Any Vaseline-based cream will protect the healing incision from the environment and provide a closed and waterproof yet moist environment for skin cells to grow in. Washing the area with soap and water daily will kill any bacteria around the skin. After a week, or when the wounds are well closed, silicone creams can be placed on the wounds. Silicone has the ability to change the direction of collagen fibers in scars and organize them into a more ordered placement, which leads to a better scar. Use silicone creams for at least two months after surgery. During the six months following cosmetic surgery it is also important to keep the wound away from the sun and to wear sunblock on scars to prevent hyper-pigmentation. If scars do become dark after sun exposure, you will need bleaching creams to improve them.

Finally, scars love to be touched. Massage scars as often as possible but not to the point that you rub the skin off so that you cause bruising (which I have seen patients do!).

Questions

If you are unclear about any instructions, call the office or plastic surgeon directly. It is better to know and be reassured than to remain unsure and worried.

Health

Healing After Cosmetic Plastic Surgery

Healing After Cosmetic Plastic Surgery

The science of cosmetic healing

After your cosmetic plastic surgeon has finished your surgery, you will begin the healing phase. In a previous post I discussed the effects of surgery and healing on your brain and psychology. Here I want to tell you about what happens to your body!

After any cosmetic procedure, or any surgery for that matter, the healing process is the same. Your body goes through a series of predictable, expected and totally normal changes and phases before you will be fully healed. Depending on the type of cosmetic surgery, the time it takes to heal will vary, but the processes are the same. There are three main phases of wound healing.

Phase 1: the inflammatory phase (swelling)

Swelling after any surgery is a normal and desired response! In plastic surgery, though, it is much more noticeable, as most cosmetic procedures are performed on the skin and so on the surface of the body. If you have your appendix out, you also have swelling, but you don’t see it! To a great extent, it is the swelling that causes pain after surgery.

Swelling is the process whereby lymphatic fluid carrying white blood cells, healing proteins, oxygen, etc. leaches out of the blood and into the area of the surgery as a response to the “injury” of the tissues. This is also known as the inflammatory phase.

Swelling starts within a few minutes after an incision has been made and can last, in the case of a tummy tuck, for six months! Obviously, the swelling is initially more noticeable and will decrease slowly over time.

Compression garments or bandages are sometimes used in some areas of the body to mitigate the effects of swelling. In some cosmetic procedures, such as liposuction, garments can actually be deleterious.

Phase 2: the proliferative phase (scar formation)

While on a cellular level all sorts of cells, such as fibroblasts, are busy making collagen and contracting the wound, and blood vessels are reaching into the area of healing, skin cells are also mobilized to go into the area of the incision. The culmination of these processes is the formation of the scar.

For the first eight weeks after surgery, your body is making scar tissue. The wound will actually reach its maximum strength at eight weeks. During these two months, patients will slowly begin to get their sensation back and have less discomfort.

Phase 3: the remodeling phase (scar maturation)

During this phase of healing, the scar that has formed remodels by becoming softer, narrower, less raised, lighter in color and less noticeable. In some cases, the scar does none of these! This is when you have a hypertrophic scar or even a keloid.

This phase can take up to two years to complete, and if your body does not heal well, you may need to have the scar re-excised and start the whole process again from phase 1!