Modified Progressive Tension Sutures for Closing the Wounds of Large Subcutaneous Tumor in Upper Back

Abstract

Large subcutaneous tumor removal in the upper back could leave “dead space” and increase postoperative complications. The progressive tension suture (PTS) has long been used in abdominoplasty to close dead space and reduce the complications rate. We aimed to explore the effectiveness of the modified PTS to reduce the complication of the large subcutaneous tumor removal in the upper back. Fity-nine patients with large subcutaneous upper back tumors (maximal length over 5 cm) were included in our prospective study and were randomly divided into the PTS group (n = 32) and the non-PTS group (n = 27). Based on the exposure of the deep fascia and the thickness of the flap, we modified the PTS technique and compared the outcomes (including necrosis, hematoma, and seroma) between the two groups. The tumor size, flap thickness, and the total surgical duration were comparable between the two groups. The incidence of flap necrosis (6.30% versus 25.90%, P = 0.0659) and seroma (0.00% versus 33.30%, P = 0.004) in the PTS group was lower than that in the non-PTS group. The length of hospital stay in the PTS group was shorter than that in the non-PTS group (6.4 ± 1.3 versus 9.4 ± 2.1 days, P < 0.0001). The modified PTS technique can effectively close the dead space after surgical removal of large upper back tumor and reduce the complications compared to the conventional approach.

Takeaways

Question: Upper back large subcutaneous tumors are prone to postoperative seroma and hematoma. We aimed to use modified progressive tension suture (PTS) to reduce the complications.

Findings: Fifty-nine patients with upper back large subcutaneous tumors were divided into PTS group and non-PTS group. The seroma and flap necrosis rate were lower in the PTS group with shortened hospitalization duration when compared with the non-PTS group. The PTS technique should be modified according to the deep fascia exposure and skin flap thickness.

Meaning: The modified progressive tension suture technique could effectively reduce the complications for upper back large subcutaneous tumor removal.

INTRODUCTION

The large subcutaneous tumors in the upper back area^1,2 pose characteristic challenges: The surgical removal leaves “dead space,” and the mobility of the upper back area increases the risk of hematoma. The conventional techniques to avoid the complications include compressive dressings combined with subcutaneous drainage.³ However, without secure adhesion between the flaps and deep fascia, the efficacy is undermined.

Progressive tension sutures (PTS) were first introduced to close the dead space and remove the tension after wide undermining during abdominoplasty^4,5 without the necessity of drainage. For the excision of a subcutaneous tumor on the upper back, unlike abdominoplasty, the deep fascia may not be fully exposed, or the flap is thin without sufficient subcutaneous fascia. We need to make appropriate modifications to the PTS technique to ensure a tension-free and tight closure. In the present study, we aimed to verify the effectiveness and consistency of a modified PTS technique in reducing complications after resection of large subcutaneous tumors in the upper back.

PATIENTS AND METHODS

Study Design

Our study adheres to the codes of the ethics committee and the Helsinki Declaration. Institutional review board approval was granted for this study.

This was a prospective study for patients diagnosed with a subcutaneous tumor with the maximal length greater than 5 cm on the upper back, from 2018 January to 2021 December. The patients were excluded if the tumor was less than 5 cm in maximum diameter or the tumor infiltrated the deep fascia.

The patients were divided into two groups by randomization. We randomized patients according to a computer-generated, random-number table, on a 1:1 ratio. Randomization was performed by a physician not involved in patient care, using SPSS for Windows: PTS group: the wounds were closed with the modified PTS without drainage; non-PTS group: the wounds were closed in a conventional approach with drainage.

The Conventional Approach

A lazy S-shaped incision was marked, and the skin incision was made with a No. 11 blade. The tumor was exposed and dissected under minimal traction. One negative drain was left. The subcutaneous tissue was closed with a 4-0 Vicryl suture, and the epidermis was closed using a 4-0 Prolene suture. The surgeon checked the negative pressure for the drain before the closure was finished.

Modified PTS Technique

The sole surgeon (C.C.) performed all the wound closures in our study. The PTS were performed as described² with modifications: The assistant pulls the flap in the direction of the wound margin to reduce the tension. From both sides to the middle, the subcutaneous fascia and the deep fascia are sutured at an angle of about 45 degrees, as shown in Supplemental Digital Content 1A–C. [See figure, Supplemental Digital Content 1, which displays the algorithm of modified progressive tension sutures technique. When the thickness of the subcutaneous fascia of the flap was moderate and the deep fascia was fully exposed (A), the flap was sutured progressively medially down at a 45-degree angle, with the deep fascia was sutured (B, C). If the deep fascia is not fully exposed (D), the marked superficial tissue above the deep fascia is removed (E), and the flaps are progressively sutured using the PTS technique (F). When the skin flap is thin without sufficient subcutaneous fascia for sutures, 2 cm of deep fascia is removed (G), the deep fascia is advanced medially and sutured (F), redundant skin is removed, and the wound is closed using the PTS technique (I). http://links.lww.com/PRSGO/C496.] The width of the suture bite is approximately 1 cm. As the underlying dead space has been closed, the drainage tube is not required before the wound closure.

If the deep fascia is not fully exposed, we expose the deep fascia by removing the superficial tissue (Supplemental Digital Content 1D–F, http://links.lww.com/PRSGO/C496). If the skin flap is thin without sufficient subcutaneous fascia for sutures, we advance the deep fascia following removal of a 2 cm width deep fascia (Supplemental Digital Content 1D–F, http://links.lww.com/PRSGO/C496). The redundant skin at the flap margin is removed to achieve tension-free and cosmetic closure.

Data Collection and Analysis

The evaluation included the flap thickness, the maximal length of the tumor, and whether the underlying deep fascia is exposed. Regarding wound closure, we recorded the total time for the whole operation, the time to close the wound, whether limited superficial fascial tissue removal was used, and whether a deep fascia advancement technique was used. The postoperative follow-up time was 30 days. We recorded the time of discharge, the time of removal of the drainage, and the complications, including skin necrosis, hematoma, and seroma. Hematoma was defined as palpable localized blood collection that require the aspiration and validated using ultrasonography. The surgeon evaluated the hematoma and seroma postoperatively.

The quantitative data following a normal distribution was shown as the mean and standard deviation. Student t test was used to compare the quantitative data. The qualitative data was shown as a percentage. The percentage of complications was compared using Fisher exact methods. GraphPad [GraphPad Prism 9 for macOS Version 9.0.0 (86)] was used for the statistical analysis.

RESULTS

Thirty-two patients were in the PTS group, while 27 were in the non-PTS group. Between groups, there are no statistically significant differences in general information as shown in Table 1.

Table 1.

General Information

	PTS (n = 32)	Non-PTS (n = 27)	P
Age	36.4 ± 8.16	40.2 ± 10.44	0.1242
Gender (feminine)	59.38%	48.15%	0.4395
BMI	22.2 ± 2.1	21.9 ± 2	0.611
Hypertension	18.75%	7.41%	0.2692
Diabetes	15.63%	25.93%	0.3528
TG level	1.3 ± 0.2	1.3 ± 0.2	0.452

BMI, body matrix index; TG, triacylglycerol.

The maximal tumor size was comparable between the two groups (7.3 ± 1 cm and 7.0 ± 1.1 cm, respectively). The proportion of incomplete deep fascia exposure, pathological results, and flap thickness is comparable between the groups, as shown in Table 2.

Table 2.

Surgical Details and Complications

	PTS (n = 32)	Non-PTS (n = 27)	P
Wound conditions
Maximal tumor size (cm)	7.3 ± 1.0	7 ± 1.1	0.3658
Covered deep fascia	37.50%	22.22%	0.2618
Flap thickness (mm)	4.0 ± 1.1	4.2 ± 1.1	0.3918
Surgical duration
Total	71.8 ± 13.1	70.3 ± 12.5	0.658
Wound closure	25.5 ± 4.3	21.3 ± 3.3	0.0001
Pathological results
Lipoma	21 (65.6%)	20 (74.1%)
Epidermal cyst	10 (31.3%)	7 (25.9%)
Hemangioma	1 (3.1%)	0 (0%)
Hospitalization	6.4 ± 1.3	9.4 ± 2.1	<0.0001*
Complications
Flap necrosis	6.30%	25.90%	0.0659
Seroma	0.00%	33.30%	0.004*
Hematoma	6.30%	18.50%	0.2293
Infection	3.13%	18.52%	0.0854
Incision dehiscence	0%	11.11%	0.935

^*P < 0.001.

The total duration between the two groups was comparable, as shown in Table 2. The wound closure in the PTS group took 5 more minutes than the non-PTS group’s duration (25.5 ± 4.0 versus 21.3 ± 3.3 min).

In about 34% (11 of 32) of the PTS group, the tissue above the deep fascia is removed to expose the deep fascia for the fixation. In 16% (five of 32) of the PTS group, the deep fascia removal technique is used. The representative pictures for the PTS group are shown in Figure 1.

Fig. 1.

Representative pictures for modified progressive tensions sutures techniques. A 40-year-old female patient diagnosed with lipoma. The operation day (A). Postoperative day 1 (B). A 52-year-old man diagnosed with epidermoid cyst. The operation day (C). Postoperative day 1 (D).

The flap necrosis rate for the PTS group is lower than that of the non-PTS group (6.3% versus 25.9%, P = 0.0659), as shown in Table 2. The seroma rate is significantly lower than that of the non-PTS group, whereas the hematoma rate was lower than that of non-PTS group but not statistically significant. In our cases, all the hematoma and seroma could be treated with aspirations without the need of any surgical intervention, as shown in Table 2.

DISCUSSION

To summarize, we found that the modified PTS technique could effectively close the dead space after removing a large subcutaneous tumor in the upper back with reduced complication rate.

There is evidence that techniques (including compressive dressing,⁶ NPWT devices,^7,8 and quilting sutures⁹) help close dead space. However, the mobility of the upper back and the deep location of the tumor increase the complication rate. Our improved PTS technique, compared with conventional methods, can effectively reduce complications.

Through years of practice, PTS has been proved to be an effective and straightforward approach in reducing complications.^2,4,5,10 In abdominoplasty, the skin flap is thicker, and the deep fascia is completely exposed, so the PTS technique is relatively straightforward. However, in our case series with not fully exposed deep fascia and thin skin flaps (34% and 16% of the PTS group, respectively), modifications must be made. If the deep fascia is not fully exposed, we remove the superficial tissue to expose it. If the skin flap is thin, we perform the deep fascia advancement to ensure skin flap adhesion. This approach is similar to the previously reported PTS approach¹¹ for posterior trunk wound closure. In our study, we confirmed that these two modifications could effectively ensure the adhesion between the flap and the deep fascia without increasing the complication rate.

Some alternative options include surgical flaps to close the dead space. These flaps depend on the neighboring perforators,¹² and complex techniques such as de-epithelialization^12,13 are required. In our cases, we found the modified PTS technique is effective and straightforward in achieving the same goal without increasing the complications.

There are some limitations of our study: This is a single center study with a relatively small sample size. The control groups did not include other compressive approaches such as quilting sutures. There is a variability in the depths of the wound, which require different modifications of the techniques.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.