Bidirectional barbed sutures for wound closure: evolution and applications

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.

Keywords: Bidirectional barbed sutures; Wound closure.

Figure 1

Bidirectional Barbed Suture Reprinted with permission from Angiotech Pharmaceuticals, Inc.

Figure 2

A, Linear compression at the point where the barbs change direction. B, Arcuate placement imparts a mound by adding a vertical vector to the horizontal vector. C, U-shaped deployment results in the forces on the barbs being opposed by the bend in the U (rather than the opposing barbs). Reprinted with permission from Elsevier Inc.

Figure 3

Simple Wound Closure With Bidirectional Barbed Suture. A, Start by taking one end of the suture and pulling it through until the transition zone has reached the tissue. Estimation of the center of the device can be aided by taking a single bite of tissue, then aligning the 2 needles until both ends of the suture are of roughly equal lengths. B, Taking one arm of the suture, complete at least 2 loose arcs through the tissue, then take a few tissue bites with the other arm of the device. C, Once at least 2 arcs per side have been deployed, each of the strands can be grasped and the tissue approximated to the desired tension. Continue the bites sinusoidally until the end of the wound is reached. D, Take the last bite 2 cm beyond the end of the wound, exiting through the skin. Repeat the technique on the opposite side. Push down on the tissue and cut the device and needle flush with the skin. Reprinted with permission from the manufacturer.

Figure 4

Deep Multilayered Wound Closure With Bidirectional Barbed Suture. A, Start at the midpoint. Using a helical suturing technique, pass the first needle through the tissue until the midpoint is reached. The midpoint can be approximated by roughly aligning the needles together as illustrated. Do not pass the first needle beyond the midpoint. B, Take at least 1 more pass with the first needle, followed by at least 2 loose passes with the second needle. C, Once each needle has been loosely passed at least twice, approximate the wound by pulling on both ends of the suture. Based on surgeon experience and the particular configuration used, some surgeons may find it unnecessary to loosely pass both needles twice before approximating the wound. D, Continue closing the deep layer with each needle, securing the ends by employing a backstitch within the wound margin. When approximation is complete, simply cut off the excess; there is no need to tie knots. Reprinted with permission from the manufacturer.

Figure 5

High-Tension Closure With Bidirectional Barbed Suture. A, Mark the vector lines of the suture at 5-cm intervals. Insert the needle from either side of the wound through the full thickness of the wound, exiting the skin at least 3 cm from the border of the wound. B, Hold tension on the device and ratchet the wound edges close together. C, Repeat the procedure until the wound is an optimal size. Close the wound in layers as shown in Figure 4, discarding the ends of the suture and the attached needles. Reprinted with permission from the manufacturer

Figure 6

Mean Time to Closure With Bidirectional Barbed Suture and Traditional Suture Techniques. Each procedure required closure of 3 layers: the superficial fascia/deep tissue, deep dermis, and superficial dermis. Closures were performed by a junior plastic surgery resident, a senior plastic surgery resident, and a senior plastic surgery professor, each serving as his own control.