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Small incisions between quilting sutures for preventing haematoma during hyperhidrosis operations

Accepted Manuscript
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/
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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
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.)
Fax: +886-2-26084385
Details of any meeting at which the work was presented
Keywords: quilting sutures, hyperhidrosis operations, haematoma, surgical technique
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.
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.
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.
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.
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
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
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,
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
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.
Conflict of interest statement: None.
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
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.
... An increase in the number of quilting sutures could possibly solve this situation, but some patients still suffered hematomas or large blood stasis. Therefore, we tried another method, pressing the gauze firmly with our palm on the patient's skin flap and subcutaneous tissue for 20 minutes to enhance coagulation effects after apocrine gland removal and before quilting suture [3]. Accidently, we found that oozing phenomena were significantly improved and the incidence of hematomas was effectively decreased on clinical observation. ...
Background: Fibrin glue (FG) combines fibrinogen and thrombin, under the presence of factor XIII and calcium chloride, and produces a 'fibrin clot' as would occur through the natural clotting cascade. FG is thought to close over any small vessels including lymphatics that are too small for conventional surgical closure, thereby reducing seroma formation, seroma incidence and related comorbidities. Objectives: To assess the evidence on the effectiveness of FG in people undergoing breast and axillary surgery and to establish whether FG is an efficient modality to prevent postoperative seroma and seroma-related outcomes. Search methods: We searched the Cochrane Breast Cancer Group's (CBCG) Specialised Register (9 December 2011), the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2012), MEDLINE (9 December 2011), EMBASE (9 December 2011), LILACS (22 October 2012), SCI-E (22 October 2012), the World Health Organization's International Clinical Trial Registry (9 December 2011) and (22 October 2012). Selection criteria: Randomised controlled trials (RCTs) comparing the effectiveness of FG in terms of reducing the postoperative seroma incidence and related comorbidities in people undergoing breast and axillary surgery. Data collection and analysis: At least two review authors independently scrutinised search results, selected eligible studies and extracted the data. The pooled analysis of the extracted data was achieved by the statistical analysis on Review Manager software. The quality of studies was assessed using The Cochrane Collaboration's 'Risk of bias' tool. Main results: The search of four standard electronic databases yielded 119 potentially relevant studies but only 18 RCTs involving 1252 people were found suitable for statistical analysis. There was significant heterogeneity among trials and the majority of trials were of poor quality. The use of FG under skin flaps following breast and axillary surgery failed to reduce the incidence of postoperative seroma (risk ratio (RR) 1.02; 95% Confidence Interval (CI) 0.90 to 1.16, P value = 0.73), mean volume of seroma (standardised mean difference (SMD) -0.25; 95% CI -0.92 to 0.42, P value = 0.46), wound infection (RR 1.05; 95% CI 0.63 to 1.77, P value = 0.84), postoperative complications (RR 1.13; 95% CI 0.63 to 2.04, P value = 0.68) and length of hospital stay (SMD -0.2; 95% CI -0.78 to 0.39, P value = 0.51). FG reduced the total volume of drained seroma (SMD -0.75, 95% CI -1.24 to -0.26, P value = 0.003) and duration of persistent seromas requiring frequent aspirations (SMD -0.59; CI 95% -0.95 to -0.23, P value = 0.001). Authors' conclusions: FG did not influence the incidence of postoperative seroma, the mean volume of seroma, wound infections, complications and the length of hospital stays in people undergoing breast cancer surgery. Due to significant methodological and clinical diversity among the included studies this conclusion may be considered weak and biased. Therefore, a major multicentre and high-quality RCT is required to validate these findings.
Background: Liposuction provides further reduction of axillary sweating and malodor when combined with dermal curettage with sharp rasping cannulas. This aggressive approach is associated with relatively higher rate of hematoma formation when compared to the conventional simple liposuction. Objective: The aim of this prospective, randomized, controlled trial was to evaluate the effect of quilting sutures on the incidence of hematoma formation after liposuction-curettage for treatment of axillary hyperhidrosis (AH). Materials and methods: The trial randomized 59 male patients (118 axillae) undergoing liposuction-curettage for AH to quilting procedures (61 axillae) or control group (57 axillae) for intention-to-treat analysis. Outcome measures included the incidence of hematoma formation, operative time, degree of postoperative pain, and amount of analgesics consumption. Results: Quilting sutures significantly reduced the incidence of axillary hematoma from 28.1% to 4.9%. Quilting was associated with the lengthening of operative time but did not affect the postoperative pain. Conclusion: Considering its efficacy in reducing postoperative hematoma, quilting is recommended in combination with aggressive liposuction-curettage procedure for treating AH and osmidrosis.