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The “Nordstrom Suture” started with our interest in tissue expansion, which resulted in quite several publications and an international textbook in this field. We became very familiar with biological and mechanical creep. Expanders and extenders were our main tools and we tried to find solutions to the problems we had with them. This led us to the development of the Nordström suture. The main indications for us for the suture so far have been (1) enhancement of serial reductions of bald scalp, burn scars, and so on; (2) prevention of scar widening in situations where proper plastic surgery techniques have not been able to prevent disfiguring scar widening. We believe this medical-grade superelastic suture will probably find many other applications in plastic, reconstructive, and general surgery.
I started with hair replacement surgery in 1974 and did my thesis on punch grafting various types of alopecia.1 Although I had very good success with punch grafts, regarding hair survival I was not totally happy with the end result due to the tuftiness of especially the frontal hair line and that led me to the development of very small grafts with usually one to three hairs each, which I named micrografts, for treatment of androgenetic alopecia. This was in 1978 and I published the method and patient results in the 1981 volume of the journal of Aesthetic Plastic Surgery2 as the first publication in the world on micrografts for correction of male pattern baldness. Before this I had presented my method during the previous years at several congresses. Several years later others also found that these small grafts gave a very natural and good result. Nowadays many use them all over the world.
By 1974 I noticed that the hairs grow in clusters and photographed that phenomenon and published it in the above-mentioned publication in 1976.1 Some 10 years later these clusters or groups of hair were called follicular units by Headington.3
In the late 1970s and the early 1980s I were using micrografts, minigrafts, and punch grafts and were also starting scalp reduction.
After seeing tissue expansion for breast reconstruction by Dr. Radovan, I decided to try it on the scalp and found out it to be very successful; my group published these findings in Plastic and Reconstructive Surgery.4 We started to use tissue expansion or scalp expansion in conjunction with scalp reductions and flaps for correction of androgenetic alopecia. We also used tissue expansion for many other purposes all over the body where we needed new tissue. Our group did considerable scientific work on tissue expansion both with expanders and extenders, and we ended up with several publications in this field and one textbook5 We also noted the problems with expanders and extenders and alternative devices we developed. We tried to find solutions to many of the problems with other devices and that is how we developed the “Nordström suture.” It proved to be very efficient in many situations that will be described below.
This medical device is patented in most places of the world and has a CE-number for its commercial use in Europe.
The Nordstrom suture is a medical-grade silicone suture that can be left in the tissues permanently if wanted but can easily also be removed if necessary or wanted.
The suture is very elastic and can be elongated to four times its resting length, and the tension in the suture increases about linearly in this interval. It is a strand that is made with different diameters and probably also in the future with different shapes; it also has different needles for different purposes. Those ones now commercially available have a diameter of 1.5 mm and 1.0 mm (Fig. 1).
Dealing with tissue expansion we became very familiar with mechanical and biological creep, and we also saw the handicaps of expanders and extenders, which we tried to overcome with alternative devices.
The problems with tissue expanders we met included: (1) multiple filling sessions were necessary to achieve the desired inflation volume; (2) the expanders resulted in considerable aesthetic deformities with associated social problems, especially when they were used in the head and neck area; (3) sometimes it was necessary to make custom-made expanders to fit the planned reconstruction; (4) small donor areas were often a problem for expansion. The lesion to be removed expanded more than the desired donor area.
One of the major problems in scalp reductions was “stretch-back”6 and we studied this quite thoroughly. We also studied kinetics of postoperative movements of the scalp.4,5,6,7,8 Dr. Raposio and I performed a study on the effect on scalp extenders to enhance scalp reductions and prevent stretch-back and found the devices effective.7 But the extenders did have some problems, including: (1) an extra operation is necessary to remove the extender; (2) the extenders did not always have sufficient pulling force; (3) they were not extendible to several hundred percent without increasing the tension too much; (4) it was not usually possible to get various directions of pulling forces to different parts of the area to be removed, nor was it possible to get different pulling forces in different directions.
All this could be done with the “Nordstrom Suture.”
Second, and possibly much more important in the future, it gave us a very powerful tool to prevent or minimize scar widening in areas where normal proper plastic surgical techniques of undermining and suturing were not sufficiently effective to prevent scar widening.
The suture is very elastic and can be elongated to four times its resting length and the tension in the suture increases about linearly in this interval.
In 2001 we published a study on 10 successive male pattern baldness patients undergoing scalp reductions in which we used this device.8 To very briefly mention the results, we found that 1 month postoperatively our device not only eliminated the “stretch-back” seen in earlier studies6 but in fact further shrunk the bald area to be removed considerably. This made the procedure about two to three times as effective as without this device, which also made it extremely cost-effective, considering the effect of two or three operations instead of one, with only a few more minutes operating, and the fraction of the cost of the device compared with the cost of one further operation without this device (Figs. 2, ,33).
Doctors Fan and Wang recently published a series of 12 lesions in 11 burn patients.9 The patients had rather big defects mostly in the scalp but also in the abdominal and thigh regions. They found that lesions up to 10.5 cm of width could be approximated and removed in 18 to 37 days (mean, 25 days). They considered the device very effective.
Nowadays in most patients we do follicular unit micrografting with 2000 to 2500 grafts and 4000 to 5000 hairs in the first session and ~1500 to 2000 grafts in the second session. We do these operations daily and results look like that seen in Figs. Figs.4,4, ,5,5, and and66.
We have a team of six specially trained nurses and technicians for cutting the follicular unit micrografts with microscopes and some of them doing the insertion of the grafts, usually with the stick and place technique. We also do all types of aesthetic plastic surgery and many types of reconstructive plastic surgery.
We do about 40 scalp reductions per year, which is a very low number compared with what we used to do many years ago. Many of these are patients with burns or alopecia congenita circumscripta or other scars. Only a few are male pattern baldness patients. In almost all cases of scalp reductions we use the Nordstrom suture.
The suture can either be left in permanently or taken out. In serious scalp reductions it is removed in the subsequent reduction.
When we just want to prevent scar widening or stretch-back we do not insert the tissue so far from the wound edges and do not use so much tension and elongation in the suture. If necessary we can easily remove the suture later (e.g., 3 months after the operation when the scar usually has gained sufficient tensile strength to resist scar widening and stretch-back). The first end can also be tied as a loop with resorbable sutures (e.g., 3–0 Dexon or 3–0 Maxon), which will dissolve in a certain number of weeks, and the loop tied with the elastic suture will then open up. The first loop can also be fixed with a percutaneous permanent suture in such a way that it can be opened from the surface by pulling on one of the ends sticking out (Figs. 7, ,8,8, ,9,9, ,1010).
The last end of the elastic suture can be tied to itself and buried. In case you need to remove it, you just use a little local anesthetic in this spot to get to the knot, cut it, and the suture will come out easily as you slowly pull it. The pull of the elastic suture will decrease its diameter and it will loosen from the channel in which it lies; it will come out reasonably easily. The channel is capsule formed by collagen. Such a capsule is formed around any foreign body inserted in the tissues. The material of the elastic suture is very similar to the silicone of the shells of breast implants and a similar type of capsule that forms around breast implants will also surround this suture. I am not talking about capsular contracture.
The last end of the elastic suture can also be taken out through the surface and kept in place by a button, through which the suture is pulled and prevented from slipping back in by a knot on the outer side.
The suture can also be left in as a permanent suture like nonresorbable polypropylene or nylon.
The weakest point of the device is the junction between the needle and the silicone strand. Due to this you should not pull the silicone strand from the needle but grasp the silicone strand with your hands and pull it with your fingers to the tension you want in it. Do not touch it with a sharp instrument because it causes tears in the surface, which easily result in breakage of the suture.
We use the suture to prevent scar widening all over the body. As this issue is on scalp surgery I will here present the use of this suture to prevent scar widening of the donor area after harvesting donor strips (e.g., follicular unit micrografting).
Every now and then we see a patient develop a widened scar, especially after repeated harvesting of strips from the occipital area for follicular unit micrografting. In these patients we either use the Nordström suture to correct the wide scar or use it in subsequent operations when further strips are harvested to prevent or minimize scar widening.
We did a study, not yet published, on 30 subsequent patients. The donor area was sutured in two layers. The surface was sutured with a thin running polypropylene suture. But in the occipital area one half was sutured with the Nordström suture and the other half with 0-Dexon. We could see a considerable difference in scar width later (e.g., 3 months after the operation) in favor of the Nordström suture.
We have also used it in more than 50 hair transplantation patients for correction after strip harvesting in the occipital area. We have not yet published these results but we found quite an effect in most cases, although we have not seen it to totally prevent scar widening in all cases. But we feel that we have been able to achieve quite an improvement in most cases. In most of these cases, despite excision of the widened scar, proper undermining, and proper suturing in two or three layers with the best plastic surgery techniques, patients still developed a disturbingly widened scar.
We have been using the Nordström suture totally buried in more than 200 patients and we have not seen any infection that has necessitated any removal of the device so far.
I feel that there is some increased risk of infection, due to the foreign body inserted in the tissues. We have not seen any local negative reaction to it in the tissues. In our cases we have not seen any other type of reaction or any reaction that would have necessitated the removal of the device. Technically it is important to insert it deep enough in the tissues so that the tension used in the suture does not pull it through the tissues out through the surface. Normal good sterility in handling the device and proper gentle tissue handling is essential to decrease the risk of infections.
The material is very sensitive to sharp edges so you have to be very careful not to hit it with a needle or knife when it is placed as it will very easily tear from such a trauma to its surface.
When suturing or closing tissues under tension the sutures will migrate. This also happens with the Nordström suture. The collagen and the tissues on the tension side will resorb and there will be a deposition of collagen on the other side. In this situation there is always a migration of the sutures even with permanent sutures in a tension situation, and when the migration has started to pull the surface enough it leads to scar widening. Only when the scar has gained sufficient tensile strength, before the deeper sutures have migrated enough to create scar widening, will the scar not widen. The Nordström suture also migrates but when it migrates, due to its elasticity, it still retains tension that keeps the wound and scar area together as it has been stretched out for 100 to 300% percent. In this way it still supports the scar during its healing period for much longer time, and in many and most of the cases when it is properly used, it helps the scar to gain sufficient tensile strength to prevent scar widening before it has migrated too much. The period necessary for the surface to resist scar widening might be 6 weeks or more.
The author has the patent in most countries of the world for this suture and has a CE-number for commercial distribution in Europe.