Small incisions between quilting sutures for preventing haematoma during hyperhidrosis operations

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Small incisions between quilting sutures for preventing haematoma during
hyperhidrosis operations
Miao-Erh Chang, MD, Shih-Cheng Hsu, MD, Wen-Tsao Ho, MD
PII: S2352-5878(17)30019-0
DOI: 10.1016/j.jpra.2017.03.003
Reference: JPRA 103
To appear in: JPRAS Open
Received Date: 4 January 2017
Revised Date: 21 February 2017
Accepted Date: 8 March 2017
Please cite this article as: Chang ME, Hsu SC, Ho WT, Small incisions between quilting sutures
for preventing haematoma during hyperhidrosis operations, JPRAS Open (2017), doi: 10.1016/
j.jpra.2017.03.003.
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Small incisions between quilting sutures for preventing haematoma during
hyperhidrosis operations
Initials and names of each author
Miao-Erh Chang, MD, Shih-Cheng Hsu, MD, Wen-Tsao Ho, MD
Name and address of the department or institution to which the work should be
attributed
Department of Dermatology, Ho Wen Tsao Skin Clinic, No. 269, Ren’ai 2nd Rd., Linkou
District, New Taipei City 244, Taiwan (R.O.C.)
Corresponding author
Wen-Tsao Ho, MD
Department of Dermatology, Ho Wen Tsao Skin Clinic, No. 269, Ren’ai 2nd Rd., Linkou
District, New Taipei City 244, Taiwan (R.O.C.)
Phone:
Fax: +886-2-26084385
Email: varec.clinic@gmail.com
Details of any meeting at which the work was presented
Keywords: quilting sutures, hyperhidrosis operations, haematoma, surgical technique

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Introduction
Clinicians who perform hyperhidrosis operation use various techniques to decrease the risk
of postoperative haematoma and seroma, including tie-over dressings, fibrin glue, drainage
tubes, and quilting sutures. Tie-over dressings compress the dissected flap towards the
subcutaneous tissue to prevent dead space.
1
Applying fibrin glue under the skin flap has been
considered to mitigate such risks, but this effect has not been observed in randomised,
controlled trials.
2
Drainage tubes for draining blood from the dead space may be useful, but
there are no exact data on risk reduction. Rho et al. recommended quilting sutures for
reducing postoperative haematoma.
3
Although the risk depends on the technique used and
individual surgeon, it is impressive that quilting sutures significantly decreased the incidence
of axillary haematoma from 28.1% to 4.9% in their study. Modified quilting sutures are also
an option.
4
The hyperhidrosis operation we used involved subdermal trimming by making one or two
small incisions. Before reviewing the literature, the most common and best way to prevent
haematoma after hyperhidrosis operation at our clinic was a drainage tube (Penrose drain)
combined with tie-over dressings after apocrine gland removal. The drainage tube was
believed to promote blood drainage to lower the risk of haematoma and seroma. However, a
small risk of drainage tract formation, delayed wound recovery, and residual dead spaces in
areas unconnected to the drainage tube were sometimes observed in our practice. Although

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the haematoma rate was low, we did not know the exact rate, and placement of a Penrose
drain delayed wound recovery and increased the frequency of follow-up, which were
troublesome to surgeons.
Therefore, we began performing a technique reported in the literature that uses quilting
sutures rather than a drainage tube to prevent haematoma. As mentioned in the literature,
there is still a risk of haematoma with this technique. After performing an observational case
series, we found that the haematoma had a particular presentation: single or multiple, not
large, and confined to spaces between the quilting sutures. As the fluid of the haematoma had
no definite shape and it was confined to spaces between the sutures, its pressure was applied
in all directions. Consequently, the skin flap, which was flexible, bulged.
Surgical Technique
To resolve this problem, we developed a simple modification to the established technique. A
no. 15 blade was used to make 3-mm long incisions between the sutures immediately after
they were quilted (Figure 1A). During each incision, the flap was pulled up to avoid injuring
the subcutaneous tissue with the blade, which can cause further bleeding. We observed
significant transudate and fresh blood flowing from the holes immediately after puncturing the
skin. Tie-over dressings were scheduled for removal 3 days postoperatively. Dressings were an
orange-brown to black colour instead of reddish, indicating that active bleeding occurred
mainly in the first 1 to 2 days. The representative patient was advised to minimise his arm

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movements for the first 3 days postoperatively, and the wound was checked daily for 7 days.
The quilting sutures and incision site sutures were removed at 4 and 7 days postoperatively,
respectively.
Conclusions
We shared our experience because we have performed more than 100 axillary lymph node
dissections using this modified technique, and no haematoma developed until now. We
presented the skin flap with the most ecchymosis in Figure 1B at 3 days postoperatively.
Once the dressings were removed, most of the punctured incisions healed without any scarring.
Thus, we can deduce that bandage removal at 3 days postoperatively is the most effective
strategy.
Although we had performed a series of 100 patients without haematoma , we did perform a
retrospective study or not yet encounter the complication. We believe that this modified
procedure will be of great benefit to other surgeons and clinics.
Acknowledgments:
Conflict of interest statement: None.

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References
1. Miyamoto E, Hayashi A, Komoto M, et al. "Sea anemone-shaped fixation": a feasible
tie-over technique for axillary osmidrosis. J Plast Reconstr Aesthet Surg.
2012 ;65:e202-203.
2. Sajid MS1, Hutson KH, Rapisarda IF, et al. Fibrin glue instillation under skin flaps to
prevent seroma-related morbidity following breast and axillary surgery. Cochrane
Database Syst Rev. 2013 May 31;(5):CD009557.
3. Rho NK1, Shin JH, Jung CW, et al. Effect of quilting sutures on hematoma formation after
liposuction with dermal curettage for treatment of axillary hyperhidrosis: a randomized
clinical trial. Dermatol Surg. 2008 ;34:1010-5
4. Shimizu Y, Nagasao T, Kishi K, et al. Alternative continuous quilting suture technique for
preventing hematoma in axillary osmidrosis. Dermatol Surg. 2014;40:1058-1060

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Figure Legend
Figure 1 (A) A no. 15 blade is used to make 3-mm long incisions between the sutures
immediately after they are quilted. (B) The punctured incisions healed without any scarring,
even in the representative patient with a skin flap with the most ecchymosis.

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