Commentary on: A Novel Application of the Haemostatic Net in Aesthetic Breast Surgery: A Preliminary Report

See the Original Article here.

I am pleased to offer my thoughts on an interesting technical adaptation of the utilization of external quilting sutures described in the article “A Novel Application of the Haemostatic Net in Aesthetic Breast Surgery: A Preliminary Report” by Drs Goddard, Pacifico, Campiglio, and Waterhouse.¹ The technique is based on previously published reports utilizing the “haemostatic net” by Auersvald and others in rhytidectomy and neck lifts.² Utilization in gynecomastia has likewise been described.³ The authors maintain that the procedure is “an option in patients who might otherwise require mastopexy but refuse to accept the scars.” They also offer that the technique can provide “additional stability to the inframammary crease.”

The authors report on their experience employing the external quilting sutures in a wide variety of breast cases, including aesthetic revision, reconstruction revision, mastopexy, areolar adjustment in tubular breasts, symmastia, primary augmentation, and reverse abdominoplasty. The external quilting sutures were left in for 3 to 4 days in 38 of 48 breasts and for 7 days in the remaining 10 breasts. Two complications reported were hypopigmented scars in 1 patient and failure to maintain the position of the inframammary fold in another. In a general discussion of their approach to the patients in this report, the authors describe capsulorrhaphy prior to placing the external quilting sutures, and then additional internal sutures were placed “as required, including infra-mammary crease stabilizing sutures and lateral pocket tailoring.”

The authors provide details on 3 cases. Case 1 involves a patient with unilateral implant failure; thin, soft tissue cover with fold asymmetry; and symmastia. The authors chose to perform a total capsulectomy, which then left them without significant tissue to repair either the fold or medial pocket on the side with implant failure. Per the authors’ report, internal sutures were placed medially, inferiorly, and laterally in addition to the external quilting sutures, which were removed in 4 days. The final result showed improved aesthetics medially and some elevation of the right inframammary fold.

Case 2 is a postabdominoplasty patient with residual laxity of the upper abdominal skin. In addition, she underwent a previous reduction with resulting elongation of the nipple-to-fold distance of 12 and 13 cm. The authors elected to perform a reverse abdominoplasty to correct upper abdominal laxity, stabilize her folds, and correct glandular ptosis. The hemostatic net was employed per the authors to “secure the flap in position and stabilize the infra-mammary folds.” The quilting sutures were removed in 3 days. Three months later, the authors reported glandular ptosis had improved and fold stabilization and upper abdominal skin laxity were corrected.

Case 3 is a postreduction patient with glandular ptosis who elected for an implant in addition to correction of her ptosis. According to the authors, the net was employed to “lift and support the neo-inframammary crease, as well as effectively performing a reverse abdominoplasty.” The inframammary crease was recreated and repositioned with polydioxanone sutures. Finally, the hemostatic net was employed to “stabilize the IMC position and to obliterate the undermined caudal dead space.” The net sutures were removed at 1 week postoperatively. In this patient, hypopigmentation from the net sutures was seen at 1 year postoperatively.

In their discussion, the authors claim that utilization of the hemostatic net offers “an option of controlling skin in a way that was hitherto impossible.” I would respectively disagree. As is the case in many challenges we face as aesthetic and reconstructive surgeons, there are often multiple ways to achieve surgical goals. In each of the cases described by the authors, an alternative method could have been employed without the utilization of external quilting sutures.

In Case 1, leaving a small portion of the capsule inferiorly and medially would have provided strong tissue to utilize for capsulorrhaphy. Additionally, either acellular dermal matrix or absorbable mesh could have been employed to provide reinforcement and soft tissue support. The utilization of fat grafting could also be considered to soften the contours medially and inferiorly. In Case 2, excising an ellipse of the excess transverse lower pole skin in addition to the reverse abdominoplasty could have been utilized, again with possible utilization of absorbable mesh to support the lower pole. Progressive tension sutures could be employed to advance and stabilize the reverse abdominoplasty flaps as well as to eliminate dead space.⁴ Securing the reverse abdominoplasty would also serve to eliminate downward tension on the inframammary fold repair. Finally, in Case 3, alternative techniques as described for Case 2, minus the undermining on the abdomen, could achieve an excellent correction as well.

The utilization of the external quilting sutures as described and depicted requires significant justification. It simply has not been demonstrated that the hemostatic net truly altered the outcomes in these cases. The series that the authors report is extremely heterogeneous. Multiple surgical techniques were employed, most notably the utilization of internal suturing to correct the pockets. Additionally, it is hard to imagine what real impact the quilting sutures could have to control skin redraping and soft tissue support when in most cases they were only left in for 3 to 4 days. The authors state that “external net sutures can also reinforce internal sutures… reducing the risk of early rupture of internal sutures and relapse.” The wound healing process had just barely begun when the sutures were removed. This, I am afraid, is an example of confirmational bias with no demonstrated proof. The utilization of foam tape for external support for 2 weeks or more would provide more potential support than the transient external sutures.

The other consideration in the utilization of these external quilting sutures is the obvious significant impact on the patient of the appearance of these sutures. In this age of social media posts, I cannot imagine the impact of a distraught patient posting a photo of her early postoperative result. In all honesty, I have to admit that I was a bit taken aback when I first viewed the photos in this report.

The initial reported utilization of the hemostatic net in face and neck lifts and gynecomastia resection was primarily an attempt to prevent hematoma collections. In these cases, the temporary utilization is satisfactory to achieve the hemostatic goal. The utilization the authors describe in the breast, however, is purportedly to support long-term skin redraping and soft tissue support, which simply cannot be meaningfully achieved within 3 to 4 days. With suture marks being visible in 3 of 24 patients and hypopigmented scars being seen in 1 patient at 1 year, the consequences of the utilization of this technique must be justified. Based on the information provided, I simply do not see a proven benefit in the utilization of the hemostatic net in revisional breast surgery. Excellent outcomes may be obtained without the risk of possible scarring and the associated anxiety regarding the appearance of the net sutures.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

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