Review Article
Bidirectional Barbed Sutures for Wound Closure: Evolution and Applications

https://doi.org/10.1016/j.jcws.2009.01.002Get rights and content

Abstract

Traditionally, wound closure sutures have in common the need to tie knots with the inherent risk of extrusion, palpability, microinfarcts, breakage, and slippage. Bidirectional barbed sutures have barbs arrayed in a helical fashion in opposing directions on either side of an unbarbed midsegment. This suture is inserted at the midpoint of a wound and pulled through till resistance is encountered from the opposing barbs; each half of the suture is then advanced to the lateral ends of the wound. This design provides a method of evenly distributing tension along the incision line, a faster suture placement and closure time with no need to tie knots, and the possibility of improved cosmesis. Bidirectional barbed sutures, which are available in both absorbable and nonabsorbable forms, can be used for simple closures, multilayered closures, and closure of high-tension wounds in a variety of surgical settings.

Introduction

Fundamentally, little has changed over many decades with regard to the method of approximating tissues that have been separated as a result of trauma or separated surgically (for excision of lesions of the skin and/or for access to deeper structures). For several centuries, wounds were sutured through rudimentary but effective methods. Cardinal events that have occurred in the history of sutures include (1) the ability to sterilize catgut; (2) the development of various polymers that were used for construction of the suture material; (3) the development of absorbable and nonabsorbable suture materials; (4) recognition of the value of monofilament and braided sutures and the relative indications for each; and (5) the ability to swedge needles directly on the end of the suture, eliminating the need to thread the suture through the eye of the needle. More recently, alternate methods of approximating wounds have also been developed, including staples, adhesives, and clips.

One important feature of conventional sutures is that they require the tying of knots to secure the closure. Complications of knot tying are well recognized. Knot tying requires time and training. Knots may break and slip. Knots may extrude. Infection related to knots is frequently seen when braided sutures are used. Wound tension with traditional sutures when the tension is not uniformly distributed throughout the length of the closure can result in tissue ischemia and unfavorable scarring. Excessive tension can also result in reduced wound strength, inflammation, and dehiscence.1 Excessive tension occurs at the individual suture loops, providing an opportunity for focal ischemia. Pressure-induced ischemia and necrosis predispose the wound to infection and are the principal factors leading to wound dehiscence.2

It follows that a suture that does not require the tying of knots would offer significant advantages, avoiding all of the possible complications described above. To this end, various suture modifications (eg, sutures with cones, sutures with large anchor knots) have been studied.3, 4 However, it was the development of barbed sutures that proved to be a particularly important evolutionary step in providing a technology that would avoid the need to tie knots. Early designs that used unidirectional barbs were abandoned because a single knot was still required at one end to secure the suture. This problem was solved with the advent of the bidirectional barbed suture. The bidirectional technology was first adopted by plastic surgeons for use in various minimally invasive percutaneous rejuvenation procedures to lift ptotic tissues, including the brow, midface, and neck.3, 4 While these sutures continue to be used by plastic surgeons for tissue suspension in open aesthetic procedures with extensive dissection, they are rarely used in closed procedures primarily because of the limited longevity of results and a consequent failure to meet patients' expectations. In recent years, it has become apparent that the unique features of the self-anchoring bidirectional barbed suture are particularly well suited for the purposes of wound closure in a number of different surgical applications. The advantages of this design for tissue approximation include no need for an assistant's hand to follow the suture placement, more rapid deployment of the sutures, even distribution of tension along the incision line, and the possibility of improved cosmesis.

In 2007, absorbable and nonabsorbable bidirectional barbed sutures (Quill SRS, Angiotech Pharmaceuticals, Vancouver, British Columbia, Canada) received US Food and Drug Administration clearance for use in approximating soft tissues (Figure 1). Extensive preclinical testing by Gregory Ruff, M.D. and colleagues has ensured that the tensile strength of these materials provides sustained soft tissue approximation and that the absorption curve is compatible with the time that is required to allow collagen deposition, ensuring the integrity of the soft tissue approximation.5 Barb morphology influences holding and tensile strength. It follows that the deeper the barb is cut, the lower the tensile strength. A novel helical design in the placement of the barbs supports the concept of better tissue adherence to the barbs. Gradients of tension and compression are created by using a bidirectional barbed suture (Figure 2).5 In addition, using smaller diameter needles results in better adherence of the soft tissue to the barbs because a wider channel is not produced by a larger diameter needle. Animal studies to investigate closure of dermal and abdominal wall (ie, deep fascial) tissues confirmed that knotless barbed sutures provide the same in vivo wound security as do conventional sutures that are 1 size smaller.6 The suggestion was made by the author that cosmesis may be improved by eliminating knots that could serve as a source for a foreign body reaction. This issue may be of particular relevance to knots placed in the subcutaneous layers, where foreign body reactions are more commonly in evidence.

The one clinical study that has been conducted to date with the bidirectional barbed suture was a prospective, randomized controlled noninferiority study intended for submission to the U.S. Food and Drug Administration.2 A comparison with conventional 3-0 polydioxanone sutures was conducted in 188 evaluable subjects undergoing dermal closure of the Pfannenstiel incision during nonemergent cesarean delivery. In this context, the bidirectional barbed size 0 polydioxanone suture proved to be noninferior to the conventional suture in terms of cosmesis, closure time, and safety outcomes. No other clinical study data with this product have been published. The methodology that follows, summarizing the various wound closure techniques and applications for bidirectional barbed sutures, is based on the personal experience of the author and that of a handful of other surgeons who have published their experiences with this novel product. Illustrations to support the text were downloaded with permission from the manufacturer's Web site for health care professionals.

Section snippets

General Description

The bidirectional suture has barbs that are aligned in a helical pattern and proceed in opposite directions from a small central nonbarbed segment. A needle is attached at each end of the suture. The suture is available in both absorbable (polydioxanone; a polyglycolide-poly-e-caprolactone copolymer) and nonabsorbable (polypropylene; nylon) formats and in various lengths with various needle sizes. When the suture is inserted in the center of the wound and begins its journey to the lateral end

Summary

The introduction of the bidirectional barbed suture has resulted in a paradigm shift in how wounds may be closed. Eliminating knot tying, speeding the placement of the sutures, eliminating the need for an assistant's hand to follow the suture placement, enhancing the equal distribution of tension, and creating the possibility of improved scar cosmesis are compelling validations of this emerging technology, which arguably may be the most important recent advancement in suture technology, with

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    Citation Excerpt :

    Knotless sutures, also termed barbed sutures (Fig. 2), include V-Loc wound closure device (Medtronic), Quill knotless tissue-closure device (Surgical Specialties, Wyomissing, Pennsylvania), and Stratafix spiral knotless tissue control device (Ethicon). These sutures have protruding spurs along the surface of monofilament suture and are gaining widespread interest and use in veterinary medicine due to many purported advantages, including reduced surgical time, absence of terminal knot, consistent tissue apposition, and even distribution of tension along the wound margins, which reduce tissue ischemia.21–25 There are few studies comparing knotless barbed sutures to monofilament sutures for intestinal surgery, although current studies have found that continuous barbed suture closure was performed faster with similar or higher leak pressures compared with monofilament sutures in canine jejunum.26–29

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Conflict of interest and financial disclosure statement: The author is a paid consultant to Angiotech Pharmaceuticals, Inc., the manufacturer of Quill SRS, and receives a monthly stipend.

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