Outcome animal hair and recently, synthetic sutures. Despite the

Outcome of use of barbed sutures in augmentation mastopexy; prospective studyIntroduction  In surgery, wide variety of materials were used to close wounds, ranged from metal wires (gold, silver and steel), dried gut, silk, animal hair and recently, synthetic sutures. Despite the presence of wide Varity of different wound closure materials, the perfect suture for all situations still not exist. Lately, a new type of suture material (barbed suture) has been introduced into the surgeon’s armamentarium. (1)Barbed sutures are manufactured from monofilament materials. Although different technologies have been used to produce barbed sutures, the mechanism of their action involves hooking the tissues onto barbs of the thread so that they subsequently become encased in fibrous tissues, initiating a biologic response. (2) Applications of barbed sutures in plastic surgery are rapidly growing and surgeons are becoming more familiar with this new suture technology (3). Barbed suture devices were first used for minimally invasive facial rejuvenation techniques. With increased number of body contouring procedures to address the significant skin redundancies and breast ptosis related to weight loss. In an effort to improve operative efficiency, the use of barbed sutures has increased to facilitate the closure of large skin wounds and also the breast, particularly breast reductions and mastopexy procedures (4). A well-known advantage of this way of tissue closure is the speed and ease of placement. Another pros of barbed sutures are that, deeper suture layer is not often required or fewer deep approximation points are necessary, reduces the operative closure time. In addition, complications  associated with more conventional suture material suture extrusion and infection may be reduced. Furthermore, tension may also be more uniformly distributed along the wound, and the barbed nature of the suture prevents tissue sliding with more than 20 points of fixation per square inch (5). Some authors have even suggested that the final scar result is subjectively improved from a clinical perspective as a result of a reduction of tissue related ischemia, less suture extrusion (6).     Barbed suture material can be used in all types of breast reduction and augmentation with mastopexy which remains one of the most frequently litigated operations in plastic surgery, although its success in improving the aesthetic appearance of the breast, it is advised to be cautious when using this procedure for a specific patient 7. infection, implant and nipple malposition, exposure and extrusion of the implant, loss of nipple sensation, and misshapen breasts; insufficient soft -tissue coverage, skin flap or nipple loss (partial or total), ptosis, tissue atrophy and poor scarring 8,9.pregnancy and lactation  affect  the mammary gland by both hypoplasia and ptosis. The presence of both pathologies in a single patient is a common situation. Augmentation mastopexy procedure was designed to address these two problems in one surgical procedure . Though stared long time ago 50 years by Gonzalez-Ulloa (11,12)   In recent years, the procedure has gained (positive and negative) attention. We need literature supporting the procedure’s benefits and the risks inherent in a combined operation. Pros assume that combining these procedures does not increase such risks in properly selected patients. One of the common problems in early bottoming out of the breast (12).  In this prospective study ,15 cases with grade II and more breast ptosis according to Regnault classification ,single  stage augmentation mastopexy was done using the unidirectional barbed ,2-0 suture,  and the post-operative results were assessed both objective by the operating surgeons and  subjective by the patients who answered self-satisfaction questionnaire. Patients and methodsSurgery was performed on 15 women who were presented with breast ptosis and mammary hypotrophy ,  augmentation  mastopexy was required at the same surgical time. Data recorded for each patient included age, body mass index (BMI), smoking status, co-morbidities, and the type of mastopexy (crescent, circumareolar, vertical, or inverted-T).Of the 15  cases 3 cases were recurrent ptosis after previous augmentation mastopexy surgery done more than 3 years ago. Inclusion criteria were medically fit cases without medical co morbidities which contraindicate anesthesia (ASA) III.Exclusion criteria are medically unfit cases, cases with unrealistic expectations and those who did not accept the possibility of revision surgery.Informed consent was taken from each case with pre operative digital photographs. Preoperative markings rely on the nipple areola complex (NAC) to suprasternal notch distance, nipple to the inframammary fold (IMF) distance. Every patient who underwent the procedure received standardized care, including general inhalation anesthesia, perioperative antibiotics and application of lower-extremity compression.Surgical techniquePreoperative marking was done for all patients in standing position four areas are marked: the inframammary fold, the midclavicular line, the suprasternal notch, and new (NAC) in its proposed position.  Patients were in supine position with 30 degrees elevation of the upper part of the table with arms abducted 90 degrees during the procedure.All cases in this study were with (NAC) ptosis 3 cm or more below the (IMF) so vertical lift  pattern was done. Local tissue infiltration with 40 ml of mixture of saline adrenaline 1: 200000 concentration along the markings of incisions. By number 15 blade the vertical limb skin incision from the lower border of the areola down to point 2-3 cm above the (IMF) was done, then by electro cautery cutting mode the breast tissue was dissected down to the pectoral fascia which was elevated with the mammary gland to create subfascial pocket extended from 1 cm parasternal side to the anterior axillary line, proper hemostasis was done. A previously determined sizer was inserted in the pocket to accurately choose the suitable implant for each case then by using skin stapler ,the pillars were approximated to take a primary idea about the projection and symmetry of both breasts. The sizers were removed then the implants were inserted after washing them with saline antibiotic (Gentamycin) solution.Nipple areola complex was repositioned to the new correct distance after excess skin depithelialization. In cases with excess lower pole skin or glandular tissue which were minimal in this study, was removed to achieve symmetry. Pillars were approximated by barbed sutures, 2/0 size, 5/8 rounded needle, unidirectional starting from medial pillar to the pectoralis muscle then  to the lateral pillar 3-4 stiches were taken for each side.No drains were needed for the primary (12) cases, but for the secondary (3) cases capsulectomy  were done so we preferred to put one suction drain size 14 F in each side to come out from the midaxillary point at the level of the (IMF) to avoid any possible seroma collection. A second layer of continuous sutures was inserted between the pillars through the glandular tissue by barbed suture 3/0 unidirectional half circle rounded tip needle above the deeper sutures. The periareolar pattern was closed by bidirectional absorbable suture 3/0 sutures run 2 times circumareolar to properly approximate the wound edges in this area. The skin closure was done by 3/0 monofilimintous absorbable cutting tip needle. The appropriate pressure garment was applied for each patient. Post-operative care: Close observation vital signs, drains collection and on discharge they were instructed to keep wearing the pressure garment for 4 weeks and received the post-operative medications e.g. (pain killers) and follow up appointments. All data were collected, tabulated and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, IL, USA). Quantitative data were expressed as mean & standard deviation (X±SD). Qualitative data were expressed as number and percentage (No & %).Results:             This study included 15 patients suffering from mammary ptosis and hypotrophy between October 2016 and September 2017. The patients age ranged between 29 – 46 years, the mean age 37.6 years. As regard the assessment of the degree of ptosis we used the distance between the suprasternal notch to nipple (SSN-N). This distance ranged between 26 to33 cm with mean 28.9 cm and the (NAC) position was 3 cm or below in relation to the (IMF). All patients were subjected to augmentation with vertical mastopexy technique using textured round high profile gel filled implants (Sebbin) brand which was inserted beneath the pectoral fascia in 7 cases and the 3 secondary cases was inserted sub (glandular/submuscular) as none of these cases has had capsular contracture. The size of the implants was determined according to the preoperative measurements and this was confirmed intraoperatively by the use of sizers, where 4 cases we uses 300 cc, 3 cases 350 cc, 1 case 325 cc and 2 cases 275 cc implants were uses. In all cases wound closure was vertical pattern and there was no need to do inverted T closure.  The mean operative time was 93 minutes with range of 85 – 102 minutes. The post-operative complications were stich sinus in 2 cases which were treated conservatively by dressing.Every patient (at 6 months postoperatively) was asked to answer a patient satisfaction questionnaire and to give a score from 1(very disappointed) to 10 (very pleased) regarding each item of the following (breast size, breast shape, breast symmetry, scars) this revealed high overall satisfaction rate up to 96.7%.              Discussion The presence of ptosis and mammary hypoplasia in the same patient is a common problem. The incidence of this issue has increased lately due to increased concern of women about weight loss which leads to breast ptosis and loss of volume (9).The condition is also associated with multiple pregnancies, or with marked increase in breast size during lactation. there is no general agreement on how it should be treated, or whether simultaneous surgical treatment is recommended (13). Pitfalls of combined augmentation mastopexy  procedure include technicalchallenges and unpredictable results. However, the author who reported those pitfalls later described, along with his colleagues, satisfactory results with one stage augmentation mastopexy. Many surgeons currently perform this procedure with acceptable aesthetic results (14,15). Spear (2003) has noted the greater likelihood of “major disasters” with the 1-stage procedure, including nipple loss and skin flap necrosis. However, we have not encountered these serious complications. Our most common complications were one case with stich sinus and one case was unhappy with the postoperative scar (13).  We chose subpectoral fascia plane of augmentation and not the dual plane placement to get the advantage of projection and avoid the motion artifact and possible lateralization of the implants associated with dual plane and relied on the barbed sutures to hold the pillars and provide adequate support of the implant. This choice rational  was similar to Dancey A and colleagues in their study (16).  W Grant Stevens and his colleagues (2014), demonstrated that, the risks of one stage procedure are not more significant than those of two procedures performed separately. Therefore, they believe that one stage augmentation- mastopexy can be performed safely and with no greater risks than 2-stage procedures, which involve repeated surgery and anesthesia (17). Ryan T.M. and his colleagues (2015) used barbed sutures in wound closure of different aesthetic surgery procedures and concluded that, application of barbed sutures increased speed and efficiency of closures through smaller access incisions are the main applications and benefits of using these devices.     Hammond in his experience (2013) said that, barbed sutures offer obvious benefits, including even distribution of tension along the wound, ease and accuracy of suture placement, elimination of the “third hand” during wound closure, avoidance of knots, shorter operative times, and the ability to provide fine-line and inconspicuous scars. So the use of this technology is recommended for enhancing the surgical outcome for many plastic surgery patients. Hurwitz and Reuben (2013) in their retrospective study of 900 body contouring surgeries found that, use of 2 layers barbed sutures closure is statistically significant lower rate of wound-healing complications as compared with prior experience with traditional running braided absorbable sutures more rapid closure, improved security of closure, and increased surgeon satisfaction with the process and wound-healing results (18)We found that use of barbed absorbable sutures as support system of breast tissue in augmentation mastopexy is reliable and provide long lasting satisfying outcome for both patients and surgeons with no added risk of complications than other routine augmentation mastopexy techniques. References Ryan T.M. Mitchell, MD, FRCSCa, Bradley P. Bengtson, MDa. Clinical Applications ofBarbed Suture in Aesthetic Breast Surgery. 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Feasibility of use of a barbed suture (v-loc 180) for quilting the donor site in latissimus dorsi myocutaneous flap breast reconstruction. Arch Plast Surg 2013;40(2):117–22.    Goldwyn RM: Plastic and reconstructive surgery of the breast. Little, Brown and Company, Boston, 1979 Karnes J, Morrison W, Salisbury M, Schaeferle M, Beckham P, Ersek RA: Simultaneous breast augmentation and lift. Aesth Plast Surg 24:148_154, 2000Spear SL: Augmentation/mastopexy: Surgeon, Beware. Plast Reconstr Surg 2006;118(7 Suppl):133S–134SStevens WG Stoker DA Freeman ME Quardt SM Hirsch EM Cohen R. Is one-stage breastaugmentation with mastopexy safe and effective? A review of 186 primary cases.Aesthet Surg J . 2006;26: 674–681. Cannon CLIII Lindsey JT. Conservative augmentation with periareolar mastopexyreduces complications and treats a variety of breast types: a 5-year retrospectivereview of 100 consecutive patients. Ann Plast Surg. 2010; 64:516–521.Dancey A Nassimizadeh A Levick P. Capsular contracture—what are the risk factors?A 14 year series of 1400 consecutive augmentations. J Plast Reconstr Aesthetic Surg .2008;65:213–218.W. Grant Stevens, MD, FACS , Luis H. Macias, MD, Michelle Spring, MD, David A. Stoker, MD, FACS, Carlos O. Chacón, MD, MBA, Seth A. Eberlin, MD: One-Stage Augmentation Mastopexy: A Review of 1192 Simultaneous Breast Augmentation and Mastopexy Procedures in 615 Consecutive Patients. Aesthet Surg J 2014; 34, (5):723–732 Dennis J. Hurwitz and Brian Reuben. Quill Barbed Sutures in Body Contouring Surgery: A 6-Year Comparison with Running Absorbable Braided Sutures Aesthet Surg J (2013) ;33(3S) 44S–56S