Efficacy and Safety of Barbed Sutures for Capsulorrhaphy in Implant-Based Breast Reconstruction

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

Breast cancer is the second most common cancer afflicting women in the United States, with 1 out of every 8 women developing breast cancer in their lifetime.^1,2 In 2023 alone, an estimated 297,790 new cases of invasive breast cancer and 55,720 new cases of ductal carcinoma in situ (DCIS) were diagnosed.¹ The proportion of mastectomies and reconstructions performed to treat breast cancer has increased substantially in the US, emerging as the treatment of choice for most patients.^3-6 The literature suggests that the trend toward mastectomy and reconstruction is due to patient-driven factors, such as a desire for symmetry, peace of mind, and fear of recurrence.^7,8 Implant-based reconstruction is the most common reconstruction approach, and although it is largely successful in restoring breast shape, suboptimal results may occur.^9,10

Implant malposition can be treated or prevented with a capsulorrhaphy procedure that redirects the implant into the desired location. Capsulorrhaphy optimizes the implant location by reshaping and tightening the pocket around the implant.¹¹ Usually, permanent or slowly absorbable sutures are placed in a running fashion during capsulorrhaphy procedures.^11-14 Traditional capsulorrhaphy techniques can be time-consuming, so newer methods are needed to allow for a more precise result that requires less time in the operating room, thereby decreasing the cost for the patient, decreasing patient anesthesia time, and increasing the efficiency for the surgeon.

The use of barbed sutures around the implant in breast surgery is a topic of new interest. Barbed sutures have shown promising results in the literature with regards to other surgical procedures and tissue type by providing better wound cosmesis and decreasing wound closure time.^15-17 To date, there have been no publications of barbed sutured utilization in capsulorrhaphy.

In this study, we aimed to elucidate the safety and efficacy of barbed sutures for capsulorrhaphy. This new technique for secondary breast reconstruction could lead to more efficient, timely, and acceptable results.

Patient Selection

A retrospective cohort study was performed for patients undergoing capsulorrhaphy after implant-based breast reconstruction. Inclusion criteria consisted of all consecutive patients who underwent implant-based breast reconstruction capsulorrhaphy in a similar running fashion, differing only in suture material used. The senior author utilized 2-0 polydioxanone (PDS) barbed sutures (D.D.), while the other senior author (P.S.) utilized 2-0 PDS smooth sutures between 2018 and 2021 at a single institution.

Technique

The ideal patient for suture capsulorrhaphy is someone who has inferior and/or lateral displacement of a breast implant (Figure 1). In the preoperative holding area, the patient is marked in the upright standing position with standard breast border markings (inframammary fold, superior breast border at the level of superior axillary fold, midline) as well as the desired inferior and lateral breast borders. Intraoperatively, an anterior capsulotomy is performed, and the implant is removed (Figure 2). The patient is sat up to 45 degrees, and a lighted breast retractor is used to visualize the inferolateral capsule while mimicking the projection of the breast implant. Bovie electrocautery is utilized to score the capsule along the area of planned imbrication along the inferior and/or lateral pocket. The capsulorrhaphy is then performed with a 2-0 PDS barbed sutured in a running fashion in 2 layers. There are no suture knots with the use of the barbed sutures. The barbed suture is pulled taut with each throw, and when placed correctly, there is no visible suture in the pocket. Sizers are then placed to confirm adequate repair (Figure 3). If more pocket tightening is desired, another barbed running suture can be placed to further imbricate the capsule. Mirror image capsulotomy is typically performed to accommodate the implant and reduce tension on the capsulorrhaphy repair. Once the ideal pocket is made, the permanent implants are placed, and the capsulotomy is closed in standard fashion. Patients are followed on a routine outpatient basis for implant-related complications (Figure 4).

Figure 1. Preoperative photo showing inferior and lateral displacement of left breast implant following implant-based breast reconstruction.

Figure 2. Intraoperative photo taken immediately after anterior capsulotomy and implant removal was performed. The planned inferior and lateral capsulorrhaphy are marked.

Figure 3. Intraoperative photo taken after barbed suture capsulorrhaphy was performed with the implant sizer in place to evaluate the implant pocket.

Figure 4. Postoperative photo taken 2 months following barbed suture capsulorrhaphy, which shows stable implant position.

In the control group, the capsulorrhaphy is performed in the same fashion but using a smooth 2-0 PDS suture with buried suture knots at the superior and inferior extent of the suture line.

Statistical Analysis

Data were collected including body mass index (BMI), age, date of surgery, implant size, implant rupture, revisional surgeries, follow-up duration, and postoperative complications. Complications were categorized into minor and major complications. Minor complications included wound formation, infection not requiring return to the operating room, and hematoma not requiring return to the operating room, while major complications included return to the operating room due to failed capsulorrhaphy, hematoma requiring return to the operating room, and infection requiring return to the operating room. Infection requiring return to the operating room was defined as an infection that did not resolve after 24 hours of intravenous antibiotics. Descriptive statistics, t tests, Mann-Whitney U test, chi-square tests, and logistic regressions were performed using SAS 9.4 (SAS Institute, Inc), accessed from the University of South Florida.

A total of 28 patients (36 breasts) underwent capsulorrhaphy with barbed suture and 20 patients (34 breasts) with smooth suture. The average age at surgery was 54 ± 12 years and the average body mass index was 25.9 ± 4.5 kg/m² (Table 1). The mean follow-up time was 342 days. The only variable that was statistically different between the 2 groups was implant size; the average size for the barbed suture group was 601 ± 159 mL, and for the smooth suture group was 452 ± 134 mL, P < .01 (Table 1).

The overall complication rate was 13.9% for the barbed suture group and 8.8% for the smooth suture group, P = .71 (Table 2). In the barbed suture group, 5 breasts had a postoperative complication, including 2 cases of implant malposition that required a return to the operating room, 2 hematomas requiring return to the operating room, and 1 infection requiring return to the operating room. In the smooth suture group, 3 breasts had a postoperative complication; 2 breasts had a postoperative wound and implant malposition requiring return to the operating room, and the third breast had an infection requiring return to the operating room. There were no statistically significant differences between the 2 groups and the minor and major complications (Table 2). There were no detected implant ruptures in either group.

Patients with barbed sutures had no increased odds of complications compared with those with smooth sutures for capsulorrhaphy (OR 1.67 [0.37-7.59), P = .51).

Barbed sutures have several unique qualities that make them an ideal choice for many plastic surgery procedures. They have evenly spaced barbed material that allows for a more expedient knotless closure with its self-anchoring quality.¹⁸ This allows for a single surgeon to suture expeditiously in a running fashion without loss of tissue reapproximation or displacement.¹⁹ The knotless nature of these sutures eliminates several of the challenges and complications associated with smooth sutures that require knot-tying, such as suture breakage, tissue ischemia, inflammation, decreased tensile strength, and operator-dependent variability in knot strength.²⁰ Barbed sutures also decrease tissue sliding, as the suture is placed in the opposite direction of the barb.¹⁹ When the suture is pulled in the opposite direction, the suture barbs gain a stronger grip on the tissue.¹⁹ Compared with traditional, smooth sutures that require knot-tying, this allows for decreased tissue sliding and a stronger hold on the underlying tissues.¹⁹ Additionally, the equal distribution of tension between knots is challenging using traditional smooth sutures, while barbed sutures exhibit very even tension along the suture line with their even spacing and strong anchoring.²¹ Lastly, barbed sutures allow for shorter suturing time and significantly shorter operative time.¹⁹

Several studies analyzing the use of barbed sutures for various other procedures have shown promising results. Short-term postsurgical complications, wound infection, wound dehiscence, seroma, and hematoma have been decreased using barbed sutures as opposed to standard sutures in abdominal closure during deep inferior epigastric perforator breast flap reconstruction.¹⁸ Barbed sutures are becoming increasingly adopted in laparoscopic gastrointestinal operations because they eliminate the need for knot tying in difficult, intracorporeal anastomosis.²² In their 2022 meta-analysis, Velotti et al found comparable rates of leaks, bleedings, and stenosis in both colorectal and gastric surgeries performed with conventional versus barbed sutures.²² The use of barbed sutures in minimally invasive hysterectomies resulted in similar complication rates and reduced suturing time compared with traditional sutures.²³ This pattern of reducing operating time and reducing or maintaining complication rates compared to conventional suture has been reported in a number of different surgical operations, including C-sections,²⁴ myomectomy,²⁵ primary total hip and knee arthroplasty,^26,27 and pyeloplasty.²⁸

The unique properties of barbed sutures make them an ideal choice for capsulorrhaphy where strength and security of repair are essential to prevent recurrent implant displacement. Our study showed that capsulorrhaphy performed with barbed sutures demonstrated a similar safety profile as with smooth sutures. There were no incidents of detectable implant rupture despite the theoretical concern that the sharp barbs could cause rupture over time. Furthermore, capsulorrhaphy with barbed sutures provided effective, long-lasting repair. Even with an overall larger implant used, patients in our barbed suture group did not have significantly increased minor or major complications.

A limitation of this study is the retrospective design and small sample size. Additionally, our study was conducted at a tertiary cancer referral center including only breast reconstruction patients, so this may not be as representative of the general population undergoing capsulorrhaphy procedures for cosmetic purposes. We also have no comparative data on surgical time of suture placement between the smooth and barbed suture groups.

Future directions include performing a larger and prospective study to better understand the benefits of barbed sutures in both aesthetic and reconstructive breast patients. In future research, it would be interesting to analyze the cost of sutures, number of sutures needed, and time to complete the procedure, and then compare these variables between barbed sutures and smooth sutures to elucidate a better understanding of the pros and cons of each suture type in breast capsulorrhaphy. Nonetheless, this cohort study provides valuable insight into the efficacy of barbed sutures in breast reconstruction, paving the way for broader research into this method.

This cohort study aimed to elucidate the safety and efficacy of barbed sutures for capsulorrhaphy in breast reconstruction patients through a comparison of barbed sutures and smooth sutures at our tertiary cancer referral center. Our study showed that capsulorrhaphy performed with barbed sutures has a similar safety profile to that of capsulorrhaphy performed with smooth sutures. With this data, next steps will include a larger, prospective study to further analyze and explain the use and safety of barbed sutures for breast capsulorrhaphy procedures.