Dr. Joel Aronowitz - Full Surgery - Removal of Suture Granuloma - Foreign Body after Tummy Tuck Abdominoplasty
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| Dr. Joel Aronowitz |
Lexi: "I think so too."
Dr. Joel Aronowitz: "Okay, all right, we'll see. All right, so we're going to jump back through this original incision. And we'll open up just enough of this to be able to lift the skin flap up. There we go. Mm-hmm, powdery please, and a double hook. So here's the suture that was used, and you can see when I'm pulling, it's it's coming from way up here, so we'll leave that so we can find that again. And let's see if we can clean this up a little bit, and let me have a needle drive."
Lexi: "Hmm, this is interesting."
Dr. Joel Aronowitz: "Pottery please."
Lexi: "Okay.You think there's more in there?”
Dr. Joel Aronowitz: “Well, I only, you know, I took out that segment, but I didn't get the knot. I don't know. You want to come back here with me?"
Lexi: "Yeah."
Dr. Joel Aronowitz: "Pottery. So, I need to find the... Let's talk about the treatment in this case. Why didn't I just make an incision over each one of the sutures and take out the suture itself? Well, I thought about that, and I discussed it with the, but because I knew ahead of time that it was likely there were suture material and knots all the way up and down the midline, from the sternal, sorry, from the xiphoid all the way down to the umbilicus, and from the umbilicus down to the pubic symphysis, I knew that I would need access to that whole suture line, all the way up and down, and the only way to do that would be to make a series of vertical incisions in the midline, or open up the whole incision as I did, because the patient didn't want further incisions, she wanted the best cosmetic result. I chose to open her from using the original abdominoplasty incision, and even though I needed to make a longer incision, it was through an existing scar, and therefore there was less healing, there were no new scars. Usually, suture granulomas occur near the surface, and they will form a small papule, it will start pointing, and then a small amount of white creamy substance that is pus will come out, and the suture itself may come out as well, but you may have to pull that suture out with a forceps without teeth. The deeper suture, though, will present classically the way that this patient presented, with a chronic nodule, there may be a tenderness because of the chronic inflammation, there may be redness because of the chronic inflammation and swelling, and also the hyperpigmentation that you see in her tummy, in several locations, that hyperpigmentation is called post-inflammatory hyperpigmentation, it's, it occurs in all skin types, but the darker the person is, obviously, the more hyperpigmentation is going to occur because of chronic inflammation. So, as we dissect, here's the umbilicus, we get close to the umbilicus here, we're encountering another, our granuloma coming into view, you can see it sticking up right here, what we should do is, um, we have a knife, open up this side."
Lexi: "Uh."
Lexi: "Okay.You think there's more in there?”
Dr. Joel Aronowitz: “Well, I only, you know, I took out that segment, but I didn't get the knot. I don't know. You want to come back here with me?"
Lexi: "Yeah."
Dr. Joel Aronowitz: "Pottery. So, I need to find the... Let's talk about the treatment in this case. Why didn't I just make an incision over each one of the sutures and take out the suture itself? Well, I thought about that, and I discussed it with the, but because I knew ahead of time that it was likely there were suture material and knots all the way up and down the midline, from the sternal, sorry, from the xiphoid all the way down to the umbilicus, and from the umbilicus down to the pubic symphysis, I knew that I would need access to that whole suture line, all the way up and down, and the only way to do that would be to make a series of vertical incisions in the midline, or open up the whole incision as I did, because the patient didn't want further incisions, she wanted the best cosmetic result. I chose to open her from using the original abdominoplasty incision, and even though I needed to make a longer incision, it was through an existing scar, and therefore there was less healing, there were no new scars. Usually, suture granulomas occur near the surface, and they will form a small papule, it will start pointing, and then a small amount of white creamy substance that is pus will come out, and the suture itself may come out as well, but you may have to pull that suture out with a forceps without teeth. The deeper suture, though, will present classically the way that this patient presented, with a chronic nodule, there may be a tenderness because of the chronic inflammation, there may be redness because of the chronic inflammation and swelling, and also the hyperpigmentation that you see in her tummy, in several locations, that hyperpigmentation is called post-inflammatory hyperpigmentation, it's, it occurs in all skin types, but the darker the person is, obviously, the more hyperpigmentation is going to occur because of chronic inflammation. So, as we dissect, here's the umbilicus, we get close to the umbilicus here, we're encountering another, our granuloma coming into view, you can see it sticking up right here, what we should do is, um, we have a knife, open up this side."
Lexi: "Uh."
Dr. Joel Aronowitz: "I want to point out something. If you are a student, or a aspiring medical student, or a, or you are a resident watching me, and you're thinking, 'I want to do surgery,' you can tell the people that really are going to end up in surgery, because what they're thinking secretly, as they're thinking to me, is first, they're thinking, 'That looks like fun,' and then they're thinking, 'I think I could do that better.' So, if you're thinking, 'I could do that better,' good, stay with that, and work hard and become a surgeon because you'll, you'll do fine. Is that right? Let's see, only a few days or weeks after surgery, and the suture granuloma presents as a red, painful papule. It may even be draining already along the suture line, but if it's a deeper suture, such as in this case, it can be quite mysterious. And one of the things that we should always rule out when we're presented with a wound that won't heal is the presence of a foreign body. So, if the patient has had previous surgery, especially a surgery in which a permanent suture material such as mercelin may have been used, it's always a good idea to go back to the original operative note and refer to that to see: was a mercelin or other braided permanent suture used? So that it can give you a hint that, yes, a deep suture granuloma may be in the differential diagnosis. Okay, so here we have a granuloma at the just under the umbilicus, and we had the one you saw before. Now, let's see, so we need to find the end of that suture.
Dr. Joel Aronowitz: “So I'll take the image of that next. I think we're going to be better off just opening this. That little piece of this.”
Lexi: “Do you know if it was a continuous?”
Dr. Joel Aronowitz: “I don't know. Yeah, see the green coming into view right here? There's one layer of proline and one layer of braided suture. I'll take the hemostep, please. Let's go ahead and cut that. Do you want to do the honors?”
Lexi: “That was so satisfying. Is that a barbed suture?”
Dr. Joel Aronowitz: “Feel that. It's not smooth. I think it just got torn in the whole process.”
Lexi: “These look like interruptions. Do you want to cut it?”
Dr. Joel Aronowitz: “Yep.”
Lexi: “There it is. There you go.”
Dr. Joel Aronowitz: “Cutting. There. Let's continue up here a little bit. You want to hold that back for me? Here's the culprit on this end. You can see there's a big knot here. I'm going to cut this one end of this. We have a big knot. This is a proline stitch. Here's myrcelline mixed with the proline. When you tie the proline, which is a monofilament so much, it becomes a braided stitch basically. That's what was causing that reaction. Now we just need to clean up this necrotic tissue cuttering. Then repair this defect. You have the umbilicus on your side.”
Lexi: “Yeah.”
Dr. Joel Aronowitz: “Now we're going to close up the midline here where we had to open to get those old sutures out. We're going to use a relatively small monofilament suture called monocryl. This should disappear within a few short weeks. Unlike the permanent sutures, it should not have much possibility of creating a similar problem for her. That's the removal of permanent suture granuloma. We see these even after decades. The braided permanent suture can cause this kind of festering problem that doesn't resolve until the foreign body is actually removed. One of the things to think about before you use myrceline."
Dr. Joel Aronowitz: “So I'll take the image of that next. I think we're going to be better off just opening this. That little piece of this.”
Lexi: “Do you know if it was a continuous?”
Dr. Joel Aronowitz: “I don't know. Yeah, see the green coming into view right here? There's one layer of proline and one layer of braided suture. I'll take the hemostep, please. Let's go ahead and cut that. Do you want to do the honors?”
Lexi: “That was so satisfying. Is that a barbed suture?”
Dr. Joel Aronowitz: “Feel that. It's not smooth. I think it just got torn in the whole process.”
Lexi: “These look like interruptions. Do you want to cut it?”
Dr. Joel Aronowitz: “Yep.”
Lexi: “There it is. There you go.”
Dr. Joel Aronowitz: “Cutting. There. Let's continue up here a little bit. You want to hold that back for me? Here's the culprit on this end. You can see there's a big knot here. I'm going to cut this one end of this. We have a big knot. This is a proline stitch. Here's myrcelline mixed with the proline. When you tie the proline, which is a monofilament so much, it becomes a braided stitch basically. That's what was causing that reaction. Now we just need to clean up this necrotic tissue cuttering. Then repair this defect. You have the umbilicus on your side.”
Lexi: “Yeah.”
Dr. Joel Aronowitz: “Now we're going to close up the midline here where we had to open to get those old sutures out. We're going to use a relatively small monofilament suture called monocryl. This should disappear within a few short weeks. Unlike the permanent sutures, it should not have much possibility of creating a similar problem for her. That's the removal of permanent suture granuloma. We see these even after decades. The braided permanent suture can cause this kind of festering problem that doesn't resolve until the foreign body is actually removed. One of the things to think about before you use myrceline."
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