Gregory Ruff

Evaluation of a novel technique for wound closure using a barbed suture

Background: Suture knots present several disadvantages in wound closure, because they are tedious to tie and place ischemic demands on tissue. Bulky knots may be a nidus for infection, and they may extrude through skin weeks after surgery. Needle manipulations during knot-tying predispose the surgeon to glove perforation. A barbed suture was developed that is self-anchoring, requiring no knots or slack management for wound closure. The elimination of knot tying may have advantages over conventional wound closure methods. Methods: This prospective, randomized, controlled trial was designed to show that the use of barbed suture in dermal closure of the Pfannenstiel incision during nonemergent cesarean delivery surgery produces scar cosmesis at 5 weeks that is no worse than that observed with conventional closure using 3-0 polydioxanone suture. Cosmesis was assessed by review of postoperative photographs by a blinded, independent plastic surgeon using the modified Hollander cosmesis score. Secondary endpoints included infection, dehiscence, pain, closure time, and other adverse events. Results: The study enrolled 195 patients, of whom 188 were eligible for analysis. Cosmesis scores did not significantly differ between the barbed suture group and the control group. Rates of infection, dehiscence, and other adverse events did not significantly differ between the two groups. Closure time and pain scores were comparable between the groups. Conclusions: The barbed suture represents an innovative option for wound closure. With a cosmesis and safety profile that is similar to that of conventional suture technique, it avoids the drawbacks inherent to suture knots.

Technique and Uses for Absorbable Barbed Sutures

The author describes barbed sutures as a unique wound closure tool. Their advantages include the closure of wounds without any knots or the need for a third hand. They are also capable of shifting tissues differentially along the suture to redistribute tensile and compressive forces. The author discusses the development of these tools and their application.

Soft-tissue fungal infections: Surgical management of 12 immunocompromised patients

&NA; Isolated fungal soft‐tissue infections are uncommon but may cause severe morbidity or mortality among transplant recipients and other immunosuppressed patients. Twelve immunocompromised patients illustrating three patterns of infection were treated recently at the Duke University Medical Center. These groups comprised (I) locally aggressive infections, (II) indolent infections, and (III) cutaneous manifestations of systemic infection. Patient diagnoses included organ transplant, leukemia, prematurity, chronic obstructive pulmonary disease, and rheumatoid arthritis. Time from immunosuppression to biopsy ranged from 5.5 to 31 weeks. Organisms included Aspergillus, Rhizopus, Fusarium, Paecilomyces, Exophiala, and Curvularia. Patients presented with necrotic ulcerations or nodules. Surgical treatment ranged from radical debridement to excisional biopsy to none. Antifungal chemotherapy also was employed in some cases. The mortality rate was 33 percent, two patients dying without evidence of fungal infection. Six of the eight survivors cleared their infections. Necrotic skin lesions with surrounding erythema in this population call for prompt examination, biopsy, and culture. Group I lesions mandate radical excision with rapid intraoperative microscopic control and systemic antifungal medication. Group II requires surgical control with or without antifungal therapy. Group III requires systemic antifungal therapy for metastatic infection. In our opinion, treatment of fungal soft‐tissue infection should be tailored to infection type and requires a team approach of surgeon and expert infectious disease consultation. (Plast. Reconstr. Surg. 97: 1391, 1996.)

The use of particulate hydroxyapatite and plaster of paris in aesthetic and reconstructive surgery

The authors describe their early investigative results of using a mixture of hydroxyapatite (HA) and plaster of Paris (PP) in skull and frontal sinus defects in a large series of cats. Histologically, bone was found to form and infiltrate the HA-PP implant over a period of months, with gradual resorption of the plaster in 6–8 weeks. Clinically, the HA-PP combination has been used in 24 patients over the past seven years for various skull, zygomatic, and mandibular defects.

Surgical facial rejuvenation in younger patients

Gordon H. Sasaki, MD Nicanor G. Isse, MD Thomas A. B. Bell, MD Gregory L. Ruff, MD Dr. Sasaki: I am pleased to moderate this panel about surgical facial rejuvenation in younger patients. We will focus solely on surgical procedures, ignoring treatments such as radiofrequency, laser, chemical peels, soft tissue fillers, and Botox. Aesthetic plastic surgeons are seeing an increased number of younger patients for surgical facial rejuvenation. This trend is related to greater personal and societal acceptance of aesthetic surgical procedures and to more acceptable and available surgical options for the younger patient. Another factor has been the increase in discretionary income to meet such goals. Younger patients present unique demands, including the request for procedures that produce less visible scars and have a quicker recovery time. They may also expect the less invasive procedures to yield the same long-lasting effects that are observed after more extended procedures. These patients are also concerned about the impact of surgeries performed when they are young on their aging and on future surgical procedures. The first patient is a 31-year-old woman who has concerns about her angry appearance, lower lid puffiness, midface irregularities, and weak chin (Figure 1). She has had no prior surgical procedures, Botox, or soft tissue fillers. Dr. Isse, how would you evaluate and treat this patient? Figure 1 This 31-year-old woman has had no previous surgeries. She is concerned with her angry appearance, lower lid puffiness and hollow deepening of the nasolabial line, flattened cheeks, and lack of chin definition. Dr. Isse: In general, the patient has symmetrical facial structures. The “angry” appearance results from a low-medial brow position in relation to the central and lateral brow. This condition is due to overactive glabella muscles (medial portion of orbicularis oculi muscle, depressor supercilli, and procerus). My treatment of choice would …