In this episode of Carpools & Cannulas, Dr. Katerina Gallus of Restore SD Plastic Surgery in San Diego, CA, and Dr. Jennifer Greer of Greer Plastic Surgery in Cleveland, OH, discuss all the ways they suture skin with an aesthetic eye during each procedure. Want to learn more about how your incisions are closed? Listen in as the experts share their experience!
Transcript
Dr. Gallus: Hey, everyone. It’s Dr. Gallus with Restore SD Plastic Surgery, and we’re back for another round of “Carpools & Cannulas.” I was playing with some of the filters on here, but they’re weird and make me look super fake, but let me get Dr. Greer on here and we were gonna talk about incision decisions. View request. Oh, cool. My wi-fi is super slow. There we go. All right please hold for the one and only, Dr. Greer. There you go.
Dr. Greer: Hello? Oh, sure.
Dr. Gallus: Oh my God, thank God someone’s doing the lawn right now. So helpful.
Dr. Greer: Fantastic. You guys get me with like no makeup on because I was in the OR today and then I just get back from the barn and yeah.
Dr. Gallus: Well, I feel like my lighting must be good because I have OR like nothing. I put some lipstick on.
Dr. Greer: Nice. Yeah, and I was like wearing a mask. I don’t know why my face is all red. Just ignore that, everyone.
Dr. Gallus: You’re just sensitive.
Dr. Greer: I am actually, my skin gets so red so easily.
Dr. Gallus: Cool.
Dr. Greer: That’s why I love the Alumier MD, the Calm-R serum is awesome.
Dr. Gallus: Yeah. A couple of girls in my office use it because they have sensitive skin.
Dr. Greer: Yeah.
Dr. Greer: It’s also the only retinol I can actually use without my skin freaking out.
Dr. Gallus: Nice. Yeah. I do like their stuff. Hey Quinn, how’s it going? Oh, you have a cat? My dog is behind me.
Dr. Greer: Yeah, she also will, like, knock over plants while I’m on calls too. It’s very helpful.
Dr. Gallus: Cool. Well, I’m excited about this topic because somebody actually called the office and was asking about tummy tucks and then was like, “How does Dr. Gallus close the incision?” And I thought, mm.
Dr. Greer: Like I have a whole Instagram line coming up. Just you wait.
Dr: Gallus: Yeah. She should tune in and hear. I think she wanted to know specifically the number of layers that I closed in. So, I figure she must have gone to a consult where somebody made that a selling point. I don’t know.
Dr. Greer: It is interesting though, you kind of forget that not everybody does everything the way we do it. Like I remember being on my gyn. surgery rotation and they were just throwing some random sutures in the fat, not like Scarpas, not like dermis just, some fat. I’m like, “Huh.”
Dr. Greer: There goes that layer.
Dr. Gallus: Yeah. They’re just… They do close things differently and usually get away with it so… And no one’s, like, coming back and complaining about their C-section scar, right?
Dr. Greer: Right.
Dr. Gallus: I mean they are…
Dr: Gallus: C-section scars heal beautifully.
Dr. Gallus: Yeah. For the most part. So, yeah, I do think most plastic surgeons close in layers, which means from deep to more superficial. And then yet we’re always trying to find the most efficient way of closing. So…
Dr. Greer: Right. Because that, I mean if you think about it, we open and we close. Like that’s the whole surgery. It’s a lot of suturing. It is though, I mean plastics is kind of funny that way but…and especially I work at a surgery center where the assists don’t close, they just retract. So…
Dr. Gallus: Yeah, same. In California, it’s actually, you’re not supposed to have scrub tech suture for you. And so, although again, I’m aware of some places where that happens. I’m kind of a rule follower so I do all my closing.
Dr. Greer: My cat is literally licking the screen, like, two feet from my face, and I… Stop. It’s loud. It’s so weird.
Dr. Gallus: Not as loud as the lawn stuff going on here.
Dr. Greer: Fair enough.
Dr. Gallus: So yeah, I remember being a resident and we did a huge body contouring case, the kind you could do when you have multiple people operating. So I feel like it was a panniculectomy and maybe a thigh lift and maybe something on the chest. It was this pretty large man. And we stapled everything close and it was the end of a long day because we were Tailor Tacking which I think we should explain in a second. But basically, you staple the skin closed and then anesthesia, the resident was, like, “Oh wow, you guys are done.” And we’re, like, “Oh no, nope. No, we’re just closing. That’s actually the operation is gonna be closing.”
Dr. Greer: It takes forever. Although it’s funny because you think about it like I remember having three residents closing a breast reduction one time, and it’s like, “How do you all fit in there? And I think you slow each other down.”
Dr. Gallus: Yeah.
Dr. Greer: And me, with somebody following me, and we’ll explain what following means, and cutting my sutures like so much faster.
Dr: Gallus: Exactly. So, all right, so why don’t you explain to everybody what Tailor Tucking is?
Dr. Greer: So, Tailor Tacking, I mean it’s just like you’re tailoring because a lot of… This cat. A lot of what we’re doing is tailoring skin, especially in patients who have lost a ton of weight. We’re literally, like, tailoring it to them. So what people do is you’ll kind of tuck this skin and staple it in place and then mark it and then trim it and it’s a bit of a process. And that’s one of the areas where you really can gain a lot of efficiency when you… Oh, hey. All my patients are on here tonight. You guys are awesome. That is one of the areas where I’ve gained a lot of efficiency by not doing it as much. Like just trying the marks, trimming the skin, and not Tailor Tacking and marking everything and then taking all the staples out and trimming it.
Dr. Gallus: Right. So yeah, I would say I don’t do it in every operation. There’s certainly like revision breast surgery, I almost always have to, right? Because I get in there, you get whatever implant was out, and then you’re not sure what you’re gonna have once you take the capsule out and all of those things. But I do remember doing that for breast reductions and for the most part you don’t need to if you…
Dr. Greer: You kind learned, like, to have to eyeball at what things to pick…
Dr. Gallus: What’s gonna work? Right. But…
Dr. Greer: Even for my…Yeah sorry, go ahead.
Dr. Gallus: It’s helpful to pull the skin together. You use a skin stapler, make sure it looks like you want it to look, mark everything, take the staples out, and then you close in layers, which is the actual closure and it takes a minute. So…
Dr. Greer: Yeah. Especially you know those massive weight loss patients, I’ve measured the length of incisions just for fun, and sometimes it’s like six linear feet of incisions we’re closing by ourselves. And I get a little callous on my thumb from the needle driver right here. My thumb hurts at the end of the day because it’s a lot of work.
Dr. Gallus: Again, you have sensitive skin.
Dr. Greer: I’m a delicate flower.
Dr. Gallus: That’s right. That’s right.
Dr. Greer: Yeah. So I keep telling people.
Dr. Gallus: That’s why you have the needle driver tattooed on your arm, right?
Dr. Greer: Yes. Oh here, I’ll show it again because you guys know I love showing off tattoos. And this was life size actually. This is about the size of the Webster needle driver I use. But I think the needles loaded, like, a little bit too far back. I was very picky. I was like, “You don’t have it loaded right.” He’s like, “Hmm. Well, that’s what you get.” Yeah. So this is what we used to suture. By the way, I have a very miniature one of my key chain. It’s so cute. I’ve had it for years. Yeah, and you try not to stick your fingers all the way through the hole so, like, your fingertips are resting on it. Because you have to really be able to rotate your wrists. That’s the key to suturing with those curved needles. And I just remember the plastics attendees harping on all of the other off-service rotators like neurosurgery and general surgery. They’re like, “Supinate your hand. You gotta rotate the wrist.”
Dr. Gallus: Yes. Rotate the wrist. That is part of the game. And then I’m left left-handed so…
Dr. Greer: Oh, I’m sorry.
Dr: Gallus: …so open and close the needle driver with your left hand.
Dr. Greer: I’m not sorry that you’re left-handed. It’s just that left-handed instruments. So, have you guys ever tried to cut with scissors? If you’re left-handed it’s super hard because the leverage on the blades, you’re not pushing them together when you use your left hand, you’re pulling them apart. So you have to cut differently and the needle drivers open and close differently. And yes, they do make special left-handed instruments but since no hospital ever has them, it’s not like you learn with them when you train.
Dr. Gallus: Right. So I had a partner in the Navy who was excited and when we arrived, got a set of left-handed instruments because me and the other attending that started were left-handed. So there were gonna be three left-handed surgeons. And I was like, “I don’t know that that’s gonna work because we’ve spent a decade learning with the right-handed instrument.” So…
Dr. Greer: Right. It’s like trying to write with the opposite hand or…
Dr. Gallus: Yeah, it was…
Dr. Greer: … like my brother trying to play left-handed golf. He is left-handed. He just learned on right-handed clubs.
Dr. Gallus: Yeah. It was terrible. We didn’t use them. I was, like, you feel like you’re having to start all over again.
Dr. Greer: That was not good.
Dr. Gallus: Hard pass. I don’t have special… And like who needs to be that much of a diva and have your own instruments all the time? Nobody got time for that.
Dr. Greer: You know that that’s like plastic surgeons by definition, right?
Dr. Gallus: Well, we’re divas, but there’s an extra level. It’s a bell curve.
Dr. Greer: Fair enough. But… God, this cat. I mean like Guyuron made his own, like, chin retractor thing. He’s like, “Give me my retractor.” All right.
Dr. Gallus: Yeah. People do love to have a retractor named after them.
Dr. Greer: Because it’s fancy. Whereas I’m like, “Do we have… What’s that clampy thing? I’ll use it. It’s fine.”
Dr. Gallus: Yes. Yeah, the Navy…
Dr. Greer: Yes. Thank you, Joel. That is my Allergan rep. I do… Actually. So the gold, because I’m always asking for the gold-handled Adsons. They’re gold-handled marks that they have a different…this cat. A different pickup surface. They’re like tongs and carbide. They’re firmer.
Dr. Gallus: Yes. They’re broader.
Dr. Greer: It’s like a better instrument quality.
Dr. Gallus: A hundred percent.
Dr. Greer: Yeah. Yeah. So with the needle drivers, the gold-handled signals that they have a tongs carbide platform that lasts longer, and the gold-handled Adsons have a finer tips. So they’re just different.
Dr. Gallus: And just a superior product period. Honestly.
Dr. Greer: Yeah. I mean I like… Yeah, I use the goldens all the time. So you’re right. I am a diva kind of.
Dr. Gallus: Gold handled stuff. So. All right, so before we get into the nitty-gritty of how to close in layers, how about name like have you ever used, like, an alternative system to close that’s supposed to be faster and then didn’t work? Because I definitely have.
Dr. Greer: You mean like absorbable staples or anything
Dr. Gallus: Absorbed. Yeah.
Dr. Greer: I remember the first time I used quill suture in residency, and we were like, “We don’t edit.” But I think when you’re in residency you put… So, okay, so let me explain, interrupted versus running suture so this makes sense for you all. Interrupted, you put in a stitch, you tie it off. You put in a stitch, you tie it off. So it’s like lots of individual stitches. Running, it’s like a baseball stitch or a whip stitch. So…
Dr. Gallus: You just keep going.
Dr. Greer: …we would do all the interrupted buried dermal Vycrils and then we’d come through with the Quill and then we’d come through with the Monocryl. So we’re just, like, adding a step. And the key is you really have to put in almost no dermal sutures and run the Quill and then you’re good.
Dr. Gallus: Right. Which was the argument for Dermabond as well.
Dr. Greer: Yeah. Except Dermbond, like, if you don’t close the deep layers area, which… What are you doing? Oh, he’s trying to log onto my computer now. Yeah, so that’s another important point of why we close in layers. You have to evert the wound edges a little bit or those layers will separate and then then you end up with a depressed scar. Which is not the goal.
Dr. Gallus: Exactly. So there have kind of invented to either speed it along or ideally help improve the incision, like how the incision heals, right? And so, INSORB, one of the surgeons that I worked with when I joined then has brand new attending use them. So, then, of course, you know the techs are all like, “You wanna try it, you wanna try it.” And it’s basically a subcutaneous plastic staple that you put in and it everts the skin and it lives under the skin. The thing is it’s a little bit bulky and then if it sticks out at all or doesn’t dissolve quick enough, you’re picking, like, basically little plastic bits out of the incision forever, which has to do with the choice of suture you use. So I was not a fan of the INSORB. I think we know Deb White who practices in Phoenix. I think in Phoenix or Scottsdale.
Dr. Greer: I think Scottsdale. But yeah.
Dr. Gallus: He really likes them. But I think they’ve been kind of revamped since then. And in the right patient it can be helpful I guess. But yeah, that was my take on that. Quill suture I think is nice but it needs to replace a layer. It can’t add another layer. So if you can run a layer you use them in… Don’t you use some version of that for your drainless tummy tucks, right?
Dr. Greer: Yeah, I use Stratafix.
Dr. Gallus: Okay.
Dr. Greer: Okay. Yeah…
Dr. Gallus: It’s a barbed suture.
Dr. Greer: So they’re barbed. So they have little barbs, and the idea behind that is you run it and if part of it breaks, the rest of it stays in place. Which is why it can replace all those deep dermal sutures. So I started using Stratafix, actually my breast reductions several years ago. And the key to being really fast with that is very minimal deep dermals, just to line it up or you can even do staples. And then instead of running a Monocryl subcuticular, which is right under the top layer of the skin, instead of running that I use Prineo, which is a skin glue product.
Dr. Gallus: Right.
Dr. Greer: So the Prineo is technically the final layer. And that, I think that cut 30 minutes off my breast reductions, which at that point we’re like three hours. So that’s a good chunk of time.
Dr. Gallus: Yeah. And I do like the Prineo tape as well. So those are other shortcuts. So that’s Dermabond glue but in tape format. So the tape is sticky, put it on, and then you activate it. The only reason I don’t use that very often is it’s expensive and if you have an allergic reaction to it, it’s just so miserable for people. And I feel like there weren’t many, and now there’s more frequent reactions. Your cat
Dr. Greer: It’s like maybe I should have fed him before we came up. I have only had, I wanna say, like, two patients with allergic reactions, but I will say it sticks to itself. So if you do like a break your plasty and it’s in the XL at all in the…
Dr. Gallus: Oh, yeah.
Dr. Greer: Your arm will stick to itself and under the breast crease it sticks to itself. So it’s a little annoying for people, but I love that it stays on for a month and they don’t have to do anything. We have a… There’s another plastic surgeon who uses it just as a dressing so it, like, saves no time.
Dr. Gallus: Yeah. That’s how I used it. I know. So, right. So it’s just extra cost. Can the last absorbable suture be ripped off? No, no, don’t.
Dr. Greer: Well, if it’s under the skin then no. I mean if you use, like, a fast gut suture on top, then yeah. But that would stop…
Dr. Gallus: And I do think that these are things I don’t think of. Hi, Paula. But even my patient today was asking the… As she was going to sleep was asking, like, she was already nervous about having her sutures removed after surgery. And I was like, “Uh, what sutures? There are no sutures to remove. They’re all gonna be dissolvable and under your skin.” So yeah, I think people assume that there’s gonna be something to take out and most of us close without anything to take out down the road.
Dr. Greer: It takes time and it hurts and it’s not fun. The only non-dissolvable sutures I use are when I make a new umbilicus for relieved abdominoplasty. There’s three nylon sutures in there and my nurse Tana gets to dig them out. She loves it.
Dr. Gallus: Right. That’s the other thing. Don’t put ’em in if you’re not willing to get ’em out later.
Dr. Greer: Yeah. I know a lot of people will do permanence on facelifts and I’m just never wanted to.
Dr. Gallus: I did. I did ’em here and there like in certain areas and I’m like what am I… Why? Why am I doing it? And the same thing actually when I was in training we did a lot of clef lips and the cleft lips we closed with nylon sutures. And then…
Dr. Greer: You did them on babies. Oh, gosh.
Dr. Gallus: We had to bring them back. We bring them back, this is how old I am, and then they put ’em to sleep for a second, you know, and so back to the OR, and then we would take the sutures out. And then eventually we’re like, why are we… Like, why aren’t we using? So we used derma bond or whatever the equivalent was and then absorbable sutures and it does look like they have little snack crusty noses. But…
Dr. Greer: Say what?
Dr. Gallus: …you’re done, like…
Dr. Greer: I know I hate taking sutures out. I used to do on my blephs, I would do like a pullout proline, but it hurts pulling that out. So now I do that, then I glue it and then I pull out the proline before the patient’s awake
Dr. Gallus: Nice. Yeah. I was doing the pullout proline too and nobody likes it. Or the proline breaks and then it’s just…
Dr. Greer: Yeah. Oh, and it breaks and Oh that’s miserable. You’re like, “Oh. it’ll come out in like three months. It’s fine.”
Dr. Gallus: 15 office visits as each little piece circulates. Ugh. I know. I like, I’m like what? I feel like there’s somebody who pulls ’em out on Instagram all the time and I’m like, no, no.
Dr. Greer: Reasonable. Yeah, and…
Dr. Gallus: It will work if it’s not your eyelid.
Dr. Greer: And like we never staple things either, by the way. Although in residency we had, it was actually our chairman, he would staple panniculectomy in very large breast reductions. He would staple
Dr. Gallus: No. Goodness.
Dr. Greer: Yeah. Yes. And he’s like, this scar heals the same and then we’d rotate with the cosmetic practice across town and they’re like, “No, they all come here for revision.”
Dr. Gallus: Oof. Yeah, it doesn’t… So then you end up with something called train… We call ’em train tracks, right? Because as the incision heals you can see each of the little points on either side of the incision where the staple was, little dents.
Dr. Greer: I almost said track marks and I remember that’s something different. Train track marks.
Dr. Gallus: I mean that is a problem in Ohio I’ve heard but.
Dr. Greer: I mean I’m pretty sure it’s a problem in California too. Kat, but. Yeah, but you get the little train track marks. And that’s why we don’t use permanent sutures either. If you do, you use very, very fine ones. But then like I’ve seen Ortho, they’ll use, like, Monocryl outside the skin which dissolves. But it takes plenty long enough to leave little suture marks.
Dr. Gallus: Yeah, yeah. You have to take that out.
Dr. Greer: Yeah. So stitches all dissolve at different rates by the way. And when you’re surgery resident, it’s really fun learning all the different sutures because there’s monofilament which are kind of like fishing line, and then there’s braided which are more like string, but then there’s different monofilaments that last different lengths of time. And the braided, there’s arguments about whether you should use those in dirty wounds. And honestly, it does matter. Like when I used Stratafix, first, I was having a problem with it’s spitting all the time and I was using a 3-0 PDS Stratafix. So I switched to a 4-0 Monocryl so it dissolves faster.
Dr. Gallus: Right.
Dr: Greer: Yeah. Oh, which…
Dr. Gallus: The sutures kind of hold… Oh sorry, go ahead.
Dr. Greer: I was gonna say the sizes of sutures, that’s another fun thing to talk about because they come in different sizes. O is the biggest then 102 or 3-0. I don’t know how they came up with the names. But it actually measures tensile strength, not the diameter of the suture. Which is interesting and something you get pinned down when you’re in med school.
Dr. Gallus: Right. Yes. And then it goes all the way down to 9-0. Which you technically barely can see if this is not under microscope. And there is a 10-0 too actually, but I’ve only ever used 9-0 under the microscope because…
Dr. Greer: You can’t see it.
Dr. Gallus: It’s so painful. Yeah. Because the poor tech is trying to hand you and you feel like you’re the emperor’s new clothes. They’re like trying to load and hand you…
Dr. Greer: And there’s nothing there. Yeah.
Dr. Gallus: …and you suture, and you’re like, you get under the microscope and you’re like, “There’s nothing here.” Like you hand me anything because you can’t see it. Sorry. But yes, so there’s different types of suture. Again, when I was in training and did a lot of county hospital facial lacerations, you know, I would say the gold standard is to close with a suture that isn’t gonna absorb. And you have the patient come back in three to five days to have it removed from the face because you don’t wanna leave any marks. But people consistently didn’t come back so we closed with suture that was gonna absorb and fall out either a chromic or fast absorbing because people came back with like the X fixes in their hands and stuff stuck on like…
Dr. Greer: Oh, yeah. Like a month, two months later. Yeah.
Dr. Gallus: Yeah.
Dr. Greer: I always use Vascryl or chromic if it’s in mucosa because again they don’t come back or they come back in like two weeks and then it looks terrible.
Dr. Gallus: It’s too late.
Dr: Greer: Yeah. The absorbable suture was a wonderful invention. Also, you know, the fact that well suture itself because they used to use horse hair to close cleft lips, like, from horse tails. Like, I remember the older attendings again, same chairman in St. Louis. His dad started the program there and like they would go to Forrest Park and pluck, like, hair from the tales of the police horses and they had some of it like in our library.
Dr. Gallus: That’s crazy. Well also cut gut, it’s, I mean gut suture is made from gut like…
Dr. Greer: Yeah. What is or was appropriate of the small intestine? Why do I know that? Where does that stuff come from in my mind?
Dr. Gallus: I don’t know. You were like a suture savant.
Dr. Greer: Apparently, I do have a passion for suturing. I mean you don’t go into plastics if you don’t like suturing.
Dr. Galllus: No, it would be a no-go. I know it’s so like… It’s like, I mean I don’t knit but I imagine it’s a little bit like knitting in terms of like you’re just kind of in your group and you close and you’re just like, I’m gonna, you know… So nice.
Dr. Greer: It is a lot like that.
Dr. Gallus: Perfectly and everything’s pretty. So, yeah. So, do you generally, let’s say tummy tucks, do you close in three layers or two layers, or what’s your deal?
Dr. Greer: I do close in three layers. So I do Scarpas, fascia, which is, you have superficial fat and deep fat and they’re divided by a fascial layer, which is actually fairly tough and we’ll hold stitches. So we like to do that. So, I’ll close Scarpas then deep dermis, although… Yeah and then skin with Prineo. But I switched, I used to use Interrupted 2-0 Vicryl to close Scarpa. And now since I do progressive tension sutures, like, down the abdomen with the 2-0 Stratafix, then I just run along with Scarpas. Yeah, it’s great. So fast. And the other thing I love about it is you can kind of adjust the tension. So you run it and there’s weird little puckers and you just pull on a tissue and it kind of settles right out.
Dr. Gallus: Yeah, that’s nice. Yeah, I close in three layers too. I’ll sometimes do 2-0 Vicryl for the deep layer like you’ve talked and then sometimes I’ll run the deep dermal and so interrupted because it’s if everything’s laying together really nice and it just holds. And then I did use Stratafix or Quill or one of those versions for the deep dermal at some point. But I had spitting problems. Nothing’s worse than having, you know, the suture react. And then Monocryl. And then I just do Steri-Strips. The place I’m at now doesn’t really love…doesn’t do Dermabond. It’s nice. But I’ve decided that it doesn’t… Now that I’m used to not using it, I’m not sure I like really need it. And the one in however many allergic reactions that you get is annoying. So…
Dr. Greer: I’m thinking too… Is it Betsy? Why am I…
Dr. Gallus: Now with DuraSorb [SP]? Somebody said the first case with DuraSorb?
Dr. Greer: Oh, DuraSorb. Those are like the INSORB staples, Joel? I think. Oh, but you know Betsy Hall Finley just uses the brown paper tape. Like that’s all she uses in her incisions.
Dr. Gallus: Yeah, I use…
Dr. Greer: It does stays on for like a month. If they leave it…
Dr. Gallus: It does. No Mastisol. If it’s clean and dry when you put it on. I think if you’re gonna use Dermabond, it makes sense to…
Dr. Greer: Hold on one minute. Is that for like… Is that kind of like a GalaFLEX product? Like a resorbable mesh, which I use GalaFLEX again today. It’s so fun. I like it
Dr. Gallus: I used it the other week since we’ve… Remember I texted you.
Dr. Greer: Yeah, you did. I’m like, “Here’s what I do.”
Dr. Gallus: Because I was like, I don’t wanna have to do a different pedicle. And you’re like…
Dr. Greer: No.
Dr. Gallus: Yeah, no, that was like perfect. It’s nice that we have the same style.
Dr. Greer: Yeah. No, I’ve always used GalaFLEX. I haven’t tried DuraSorb.
Dr. Galllus: Oh, yeah, I’ve heard about it but I haven’t tried it.
Dr. Greer: Yeah, I’m liking GalaFLEX. You just have to get over that, like, first six months where it feels like, you know, the dog toys where they have crappy paper inside. It kind of reminds me of that because you can feel it a little bit and then it resorbs and it’s great. What were we… Oh, so the horse hair sutures, that was making me think of the nurses used to have to thread the needles too back in the day. Like there was a hole in the needle and they had to like thread the suture through, but now it’s swedge jamming, meaning it’s just fastened to the needle and they come out of packets. So…
Dr. Gallus: Yeah, I do think the stapler helped speed up burn surgery.
Dr. Greer: Oh my gosh. That was magic.
Dr. Gallus: Because you had the staple on and when I was there they’re like, “Oh, not that long ago, we had to suture everything in place.” And I was like, “Oh God, you’d be there forever and patient’s sick so you need to go.” Yeah.
Dr. Greer: And the nurses would be taking out the staples for ages. There’s like hundreds of them.
Dr. Gallus: Yes, I know. Yeah, so… Oh, so, well the only other thing I’m gonna add about suture is that depending on the type monofilament are braided, it has to do with, it creates an inflammatory process which you want the suture to do. That helps, right? You want it to last long enough for your body to like heal and form a strong enough wound that when the suture is gone it’s, you know, stays knitted together essentially.
Dr. Greer: Right.
Dr. Gallus: But I found, I had an old partner that would close the deep dermal with 3-0 Vicryl, and I feel like it was inflammatory and it would spit suture. So trying to find something that lasted the length of time you needed. And so most people I think closed with 3-0 Monocryl because of that. So…
Dr. Greer: I actually do use 3-0 Monocryl.
Dr. Gallus: You do?
Dr. Greer: I do. Not very many of them but…
Dr. Gallus: Dermal or?
Dr. Greer: For the deep dermal, yeah. And then I do the 4-0 Stratafix. But yeah, I’ve always done a lot of 3-0 Vicryl. I’ve only had a couple spit. I mean once or twice they’ll spit. I do have one patient who literally cannot dissolve any sutures. Because some people can’t. Like they don’t, there’s a particular enzyme or something that breaks them down. And she literally spits everything. It’s amazing.
Dr. Gallus: Yeah. Or they get like an over-inflammatory reaction. So yeah, spitting suture is your body, like, trying to ward it off like a foreign body reaction instead of just doing its healing thing and letting the suture dissolve and breaking it down slowly. So instead of breaking it down, it starts to form like scar around it, and then…
Dr. Greer: And you get like a little pimple. It looks like a pimple that erupts and little pus comes out and then people text you panicking because there’s pus, and you’re like, “It’s totally fine.”
Dr. Gallus: Yeah. Let me just get that nod out for you. Yeah. So yeah, so that’s the breakdown. Closing layers would be the motto.
Dr. Greer: Yeah. Closing layers and evert the tissue because it will settle as it heals.
Dr. Gallus: That’s right. It does settle. A lot of times we’re closing things that… I mean we’re not cutting a straight line and then re-closing it. So a lot of times we’re working one end in, and so, that can look gathered if you will. And we all know that will stretch out as well.
Dr. Greer: Bunching. Like around the nipple you’ll see that a lot or under the breast. That’s areas where it bunches and it settles out. It’s amazing.
Dr. Gallus: Yeah, it works out. Yeah.
Dr. Greer: Yeah. But it’s amazing because like I’ll see a laceration that was close in the emergency room and like say it’ll be this long and there’ll be like four permanent sutures in it just on the outside and you’re, like, “Man I would’ve had like six buried sutures and probably like eight on the skin surface.” I swear plastic surgeons use like three times as many… Gosh, this cat. Three times as many sutures as anyone else.
Dr. Gallus: Yeah. But I do think just putting ’em at the superficial level, you’re not offering any strength to that tissue. So it makes sense that deep sutures are gonna kind of hold it together. And then really the superficial layer is just getting the edges to touch without any tension. It’s all about tension. Yeah.
Dr. Greer: Yep. How did you practice when you were a resident? What did you practice on? Like people get pig feet. I like to practice on banana skins to at least practice my spacing because then you get a little blacked out where the suture goes through so you can see how well spaced out you are.
Dr. Gallus: That’s cute. Yeah. We did like… I’m trying to think. Maybe orange skin. I feel like there were little models we could use to suture. Yeah. It’s more obsessed with fine knots than anything else. Knot tack. So that was…
Dr. Greer: Like we instrument tie so much.
Dr. Gallus: I know this was in general surgery, I had no idea it wasn’t gonna pay off later but…
Dr. Greer: Yeah, kinda like the 2-0 and… urgh, It’s funny, otherwise we’ll…
Dr. Gallus: But I could secure a chest tube like no one’s business.
Dr. Greer: I mean that’s a really critical skill. Those are important.
Dr. Gallus: Right. That is some mad skills if I do need to use my hands instead of an instrument to tie, I’m there for you.
Dr. Greer: I mean, I’m there for you.
Dr. Gallus: Oh, and actually speaking of left, I don’t know if it’s a left-handed. It is in a left-handed thing, but I do love the Olson Hager needle drivers. If I was gonna get a tattoo, the needle…
Dr. Greer: Oh that cut Really?
Dr. Gallus: Yeah.
Dr. Greer: I never got into those because I always accidentally cut myself like I’d cut my stitch.
Dr. Gallus: Yeah. We got to use ’em in plastic surgery training. And if you cut your suture they took them away from you. So we learned quickly not to. But yeah, I freaking love those. And again, the place I currently operate at doesn’t have ’em, but it takes me a while to readjust when they don’t. because I like try to cut with the needle driver and the tech’s like, “What are you doing?”
Dr. Greer: See, I’m such a diva, I don’t even cut my own stitches because since my sister is right there and they can’t suture, they cut for me, and then I’ll sit there sometimes I’m like waiting for somebody to cut. Meanwhile, this is like two inches from my hand, and I’m like, “Anyone? Anyone?”
Dr. Gallus: Yeah, see I’m just not… I’d rather just do… I’m like not patient enough because if they like lose focus for a second, they’re not right there to cut it. So I’m like, “We’re done.”
Dr. Greer: You know, my normal scrub and assist, like my scrub is like a surgeon whisper because I’ll like pause and look up and she’s like, “Dr. Greer needs a chair.” I’m like, “I do.” I mean, Yeah. And then one day I was doing a breast dog and I, like, reached out my hand, said nothing. And she gave me the Bovie and I was like, “How do you know if I need the Bovie or the suction?” And she’s like, “You stare it longer when you need the Bovie and you tilted your head.” I’m like, “That is creepy, Brittany.” She’s awesome. I love her.
Dr. Gallus: That’s great. I think when you work with the same people over and over again, it is really nice when you’re like, “Hey, do you want us to…” Like, there’s another place I operate where the nurse is like never idle and she’s constantly readjusting the lights. Like so you don’t have to reach up and do it. She’ll just look at it and be like, “It be better this way.” It’s just amazing. Yeah, it’s…
Dr. Greer: I know I get so spoiled and then I’ll work with somebody I haven’t worked with and I’m like, “I have to think.”
Dr. Gallus: I know.
Dr. Greer: I just wanna hold out my hand and you’re gonna gimme what I need next. Yeah. I’m very spoiled. I love it.
Dr. Gallus: It’s nice to get that rhythm with people. It really is.
Dr. Greer: It’s fun. It’s like dancing and you all know the steps.
Dr. Gallus: Yeah, for sure.
Dr. Greer: Cool. Well wow, that was actually, we had a lot to talk about there.
Dr. Gallus: I know. Just on suture. We’ll have to think of something else equally mundane, but fascinating to us to hash out for the next one.
Dr. Greer: Maybe like post-operative garments. We haven’t talked about…
Dr. Gallus: Oh, yeah. Yes. We could talk about that for sure.
Dr. Greer: Yeah, Too bad we can’t get… I think Elizabeth Leslie never uses them. We should, like, have her join us.
Dr. Gallus: Yeah. And discuss why they’re a waste of time.
Dr. Greer: Yes.
Dr. Gallus: The third person. All right, cool. Well, have a good rest of your evening.
Dr. Greer: Thanks. You too.
Dr. Gallus: I’m gonna go gather people from ballet and soccer, etc.
Dr. Greer: I’m gonna feed my cat because he still starving to death. Yeah.
Dr. Gallus: All right, cool. All right. Postoperative swelling and garments. All right, well, I think that’s our winner. Yes.
Dr. Greer: Perfect. And then we can always talk about scars next time, especially in babies.
Dr. Gallus: Yes. And scarring and… Yes.
Dr. Greer: All good topics. Thanks.
Dr. Gallus: Yeah. Thanks, Paula. That’s a good one too. All right.
Dr. Greer: All right. See you later.
Dr. Gallus: Okay, bye.
About Restore SD & Dr. Katerina Gallus
As the Director of Restore SD Plastic Surgery, board certified female plastic surgeon Dr. Katerina Gallus has over 15 years of experience helping San Diego patients enjoy head to toe rejuvenation with face, breast and body procedures. After a successful career as a Navy plastic surgeon, Dr. Gallus founded Restore SD Plastic Surgery with the intention of creating a welcoming space for anyone seeking cosmetic enhancement.
Restore SD Plastic Surgery offers popular facial rejuvenation procedures like facelift & neck lift, facial fat grafting, and eyelid lift; breast augmentation with implants, breast lifts or breast reduction; body contouring procedures such as tummy tuck, liposuction, mommy makeover, and Brazilian butt lift (BBL), as well as aesthetician services, BOTOX, injectable fillers, and laser treatments.
Dr. Gallus and her highly-experienced aesthetics team are here to help you look and feel your best! To schedule a personal consultation, please contact us online or call our San Diego office at (858) 224-2281 today.
