Supplemental Article

Aesthetic Surgery Journal

Review Article 33(3S) 12S­–16S
© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
The History of Barbed Sutures Reprints and permission:
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DOI: 10.1177/1090820X13498505
www.aestheticsurgeryjournal.com

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Gregory L. Ruff, MD

Abstract
Ligatures have been used for millennia to close wounds. Sterilization and synthetic polymers that degrade in a commensurate fashion with
wound healing have been the most significant improvements in these age-old devices. However, the constricting loop of a traditional suture and
subsequent ischemia (“approximate, don’t strangulate”) still account for the most common cause of wound dehiscence—necrosis. Inspired by the
quill of the North American porcupine, I envisioned a bidirectional array of barbs that could secure tissue without relying on constricting loops.
One set of barbs could anchor the other. In this article, I document the development process of these barbed sutures from concept to patent
to manufacture and US Food and Drug Administration approval. Knotless, strong, and easy to place, barbed sutures could foreseeably supplant
conventional sutures, particularly as endoscopic procedures become more common. They also offer the intriguing potential to suspend ptotic
tissues without surgical intervention.

Keywords
barbed sutures, self-anchoring, transition zone, bidirectional, loops, knotless, minimally invasive

Accepted for publication March 26, 2012.

Biologically speaking, barbs have arisen in every phylum.
Such convergent evolution has resulted in barbs composed
of a wide array of tissues, from the bones in a woodpeck-
er’s tongue, to the keratin in a porcupine’s quill, to the
cellulose in a sticktight seed. Despite the diverse variety of
nature’s barbs, they share a key characteristic: they are
oriented only in one direction. Barbed sutures, on the
other hand, are offered in both bidirectional and unidirec-
tional formations. Bidirectional sutures have barbs in both
directions, so that one end anchors the other. This enables
tissue approximation without the need for a securing knot.
Unidirectional barbed sutures have barbs in a single direc-
tion, secured by a looped end. The development period of
these devices has been brief compared with the millennia
during which ligatures have been used to close wounds.
Traditional ligatures have arguably had only 2 major
advances over all this time: sterilization and the synthesis
of polymers that degrade in strength commensurate with
wound healing. However, these advances have not resolved
the leading cause of wound dehiscence: ischemic necrosis
of the wound margin abetted by garroting of the tissues
within closed loops.1
The ability of the barbed sutures to approximate tissues
without tying knots merits a discussion of the way their
use differs from conventional closure. In this article, I will
review the brief history of barbed sutures to convey what
is known and speculate on the much larger unknown
potential of these sutures to advance wound closure and
tissue movement.
Early Development
Dr John Alcamo, a general surgeon, was granted a US pat-
ent for barbed sutures in 1964.2 He depicted many elegant
barb designs (all unidirectional) along with techniques to
Dr Ruff is a plastic surgeon in private practice in Chapel Hill, North
Carolina.
Corresponding Author:
Dr Gregory Ruff, 55 Vilcom Center, Suite 310, Chapel Hill, NC 27514,
USA.
E-mail: gregruffmd@gmail.com
Ruff
employ these designs. However, the single direction of the
barbs restricted their use because the surgeon had to
“double back” to secure the closure. Alcamo foresaw the
sutures being placed in a sinuous pattern and anticipated
that the grasp of the barbs would be sufficient to close the
wound.
Shortly thereafter, Dr Alan McKenzie, an orthopedic
surgeon, conceived of a device with multiple barbs in both
directions, postulating that it might provide better tendon
repair.3 He cut 4 channels in a cylindrical monofilament,
so that its cross section resembled a “+” sign. He cut out
the barbs himself under a dissecting microscope. He
wrote, “I could find no way to round off the base of the
barb as in a conventional saw blade.” Perhaps because a
saw is a suboptimal means to grasp tissue, his results were
disappointing. While he saw potential in the concept, he
told me that he abandoned the project because his sutures
took too much time to construct alongside the responsi-
bilities of his orthopedic practice. McKenzie also lamented
the lack of support from his sponsor, Ethicon.
McKenzie subsequently adopted a more readily available
model while using the ubiquitous native New Zealand sheep
to study treatment of articular loose bodies. McKenzie’s work
was patented in the United Kingdom4 but was not cited by
the next relevant American inventor, Tanner, who patented a
device in 1972 with barbs in 2 directions but only located at
the terminal ends of the shaft.5 Likewise, my own patent
search in 1992 failed to disclose McKenzie’s efforts.
My First Patents
The design of barbed sutures to rejuvenate the face arose
empirically, perhaps because barbs are so ubiquitous and
familiar that their design seems intuitive. In 1991, I was
thinking about ligatures and wondered if barbs along an
axis, like a porcupine’s quill, could grasp the tissue
securely. If so, a filament with barbs in both directions
could conceivably be devised to close a wound. The tis-
sues would move toward the point where the barbs
changed direction and, given the multitude of barbs along
the axis, the tissues could be gathered differentially like a
curtain. The wound edges would then compress each
other. Since such barbed sutures could thereby be used to
redistribute tissue, perhaps they could reconfigure the skin
without any incisions. I envisioned 2 ways to deploy these
devices: (1) a model with “sufficiently sharp ends” (ie,
needles) or (2) a model within a cannula, which would
shield the barbs and allow one-way insertion.
After constructing a prototype from weed whacker cord
and testing it in a raw New York strip steak, I was
impressed by its holding strength. I proceeded to cut barbs
in sterile PDS sutures (Ethicon, Inc, Somerville, New
Jersey) on the back table in the operating room. The initial
cases I performed employed these hand-cut barbs and
were subject to doctor-patient confidentiality. I placed the
barbed sutures to support conventional repairs at first,
then closed wounds and later lifted brows, faces, and
13S
necks for cosmetic purposes. I applied for patents on the
cannulated device for single-direction insertion as well as
the bidirectional design in 1993. These were granted in
1994 and 2001, respectively.6,7
Evolution of Bidirectional
Devices
Other inventors also described devices with barbs in 2
directions. In Russia, in 1997, Dr Marlen Sulamanidze cre-
ated a barbed polypropylene thread intended to reposition
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the facial skin for rejuvenation. Placed in the subdermis
with a trocar, it acted like a hammock being tightened to
keep the tissue from sagging. He used the acronym
APTOS, for Anti-Ptosis threads. After being granted a
Russian patent, Dr Sulamanidze lectured worldwide and
popularized the idea that barbed sutures could reverse
facial aging.8
The other inventor who envisioned bidirectional sutures
is the renowned Dr Harry Buncke. His patent described
closing wounds, including those for tendon repair and
facelifting, as well as methods of manufacture.9 Although
he described both sets of barbs along a single axis, he was
not granted a patent for this device. The government
claimed that an already patented barbed staple would,
when straightened out, be a preexisting conceptual equiv-
alent! Although Buncke’s examiner was an associate on
one of my patents, he apparently forgot the previous work,
and my patent was not cited in Buncke’s listing of predi-
cates. Buncke’s second design had a set of barbs intro-
duced through each side of the wound that mirrored one
another, requiring that they be joined together within the
wound via a knot or some other fusion. Buncke’s patent
was issued in 1999, but he was stymied in production.
Over lunch in San Francisco, we agreed to collaborate, and
he assigned his patent to our company, Quill Medical.
Interestingly, he was inspired, as I was, by nature. He had
encountered the pesky sticktight seeds I mentioned earlier
near his cottage in the Sierra Nevadas.
In 2001, Dr Woffles Wu sought to improve on the
APTOS thread. He greatly increased the number of barbs
in each direction and also deployed the suture in a
V-shaped pattern rather than the slight arch of the APTOS.
The V eliminated the tendency for migration and extrusion
seen with the latter. However, the laxity still remained
dependent at the apex of the V. Also, the trochar delivery
compromised holding strength compared with a thinner
swaged needle.10
After speaking with Wu in 2003, Dr Nicanor Isse
devised a different approach, flipping the suture around so
that the barbs were pointed up. This allowed the laxity to
be transferred to the temple area, where he anchored each
unidirectional thread with knots. Concerned about cheese-
wiring in the deep fascia, he added a silastic sheet for
support. He also inserted the thread through a trochar.
None of these sutures had regulatory clearance by the US
Food and Drug Administration (FDA).
14S Aesthetic Surgery Journal 33(3S)
Wound Closure Versus Facial
Rejuvenation
Our collaborative efforts at Quill Medical focused on better
wound closure, although I anecdotally demonstrated the
aesthetic potential by lifting the face and neck with these
devices. In 2004, the American Society for Aesthetic
Plastic Surgery’s (ASAPS’s) Aesthetic Meeting in Vancouver,
British Columbia, included a “Hot Topics” report on facial
rejuvenation using barbed threads. I was eager to present
our work and was graciously given time on the dais to
describe it. The next day, the commercial exhibits opened
and Surgical Specialties announced that it was rapidly
nearing FDA approval for use of bidirectional polypropyl-
ene barbed sutures to perform a Featherlift (Angiotech
Pharmaceuticals, Vancouver, British Columbia, Canada).
Our start-up venture, Quill Medical, persuaded Surgical
Specialties to join with us in an exclusive collaboration to
manufacture and market a 2-0 polypropylene suture for
face- and necklifting. This product was named the Contour
Thread.
In September 2004, Surgical Specialties received FDA
clearance for the first barbed suture that was licensed from
Quill Medical; it was a unidirectional 2-0 polypropylene
thread with a swaged straight needle for midface suspen-
sion. One month later, the bidirectional design made of
absorbable polydioxanone, with a curved needle on each
end, was allowed for wound closure. Curiously, the FDA
required that the facial version demonstrate that it could
suspend tissue for 5 minutes yet insisted that the wound
closure version be supported with a clinical study of 100
patients followed for more than a month to document
adequate healing in order to approve the suture for soft
tissue approximation. Surgical Specialties provided the
data on the facial thread, and Quill Medical oversaw the
wound closure trials.
After FDA clearance, more than 2000 physicians were
trained to use Contour Threads. Meanwhile, Quill sought
commercialization options for wound closure variations of
the barbed suture technology. One prospect arose when
Angiotech Pharmaceuticals purchased Surgical Specialties
and then offered to acquire Quill so that it could develop
both the aesthetic and reconstructive barbed devices. Not
long after this acquisition, however, Angiotech withdrew
Contour Threads from the market. Despite the large num-
ber of US physicians trained to use the Contour Threads,
the product was discontinued, in part to allocate resources
to the broadly applicable Quill suture, which has been
adopted by many surgical disciplines.11-13 Already, it had
been found to be particularly useful where knots are dif-
ficult to tie, such as in endoscopic procedures.
Speculation on the decision to drop Contour Threads
from production also included reports of patient dissatis-
faction and use of the product by inadequately trained
practitioners. Despite the apparent simplicity of using a
7-inch needle, experience is required to improve one’s
ability to maintain the appropriate depth while oscillating
the tip in a plane parallel to the skin, so as to increase
holding strength. Having placed more than 3000 of these
sutures in the face and neck, I have never had even tem-
porary compromise of motor nerves, although I have had
4 patients with transient hypesthesia of one ear due to the
thread engaging the great auricular nerve. Only one thread
has ever been infected. I removed several dozen because
they were visible with facial animation—usually raising of
the eyebrows—and I removed 3 in the forehead of a
patient who developed headaches. The bottom line was
that, in my first 350 cases, 24% of patients were dissatis-
fied due to minimal improvement. Accordingly, I now
often perform limited undermining sufficient to excise
redundant skin along with use of either a Contour Thread
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or a polydioxanone Quill. Like conventional superficial
musculoaponeurotic system (SMAS) plication, the barbed
suture advances the target tissues before the requisite ten-
sion is placed on the skin margin. The corrugated gather-
ing of the SMAS does not require the added maneuvers
needed to soften the outline of a purse string. Using this
method, only 8% of my first 129 patients were dissatisfied.
Properties and Benefits of Barbed
Sutures
Currently, there are 2 FDA-approved barbed devices for
wound closure, Quill and V-Loc (Covidien, Mansfield,
Massachusetts). The latter relies on a looped end to
anchor the suture line. Because there are not 2 sets of
barbs to anchor one another, the first bite of tissue still has
the potential for ischemic necrosis and consequent wound
dehiscence. Nonetheless, both products are experiencing
accelerated sales and have been embraced by many sub-
specialties. While effective, there are attributes of barbed
sutures that need further research to optimize their perfor-
mance. Early laboratory work has revealed important
principles about the behavior of barbed sutures, but many
nuanced questions remain.
The strength of any wound closure device is para-
mount. With barbed sutures, the barbs, rather than a
knot, secure the closure; the mechanism of action is obvi-
ously to “snag” tissue, predominantly via collagen fila-
ments. The morphology of each barb may be the primary
consideration but, analogous to a protein structure, the
secondary factor is the distribution of the barbs and the
tertiary dimension described by the path of the axis in
3 dimensions.
Of course, the collagen matrix influences holding
strength, implying there may be an optimum suture for a
given tissue. A barb is characterized by the depth and
angle of its cut. In one model, a change in the cut angle
from 28 degrees to 18 degrees raised not only the tensile
strength but also the holding strength.14 Distributing the
barbs in a tighter helix has also dramatically improved
holding strength, while only slightly reducing tensile
strength.15 Unsurprisingly, a needle diameter larger than
the suture compromised the ability of the barbs to hold, in
vivo and in vitro.10 Although striking, this effect has not
been assessed at various times after wound closure.
Inflammation was mild, similar to conventional suture,
Ruff
when studied over 4 weeks in the linea alba of rats and 6
weeks in porcine dermis.16 Wound-breaking strength,
which obviously cannot be tested in humans, did not dif-
fer significantly.16,17 The most influential factor in holding
strength is the 3-dimensional configuration of a barbed
suture. A curved path holds better than a straight one.18
This precept has also been documented in porcine ten-
dons. Not only does the absence of knots allow the use of
larger sutures, as in the challenging zone II flexors of the
hand, but there is less distortion of the tendon’s diameter
and hence gliding should be facilitated.19,20
Potentially, the most promising aspect of tendon repair
is the extension of the barbs beyond the zone of injury.
Conventional sutures, regardless of initial strength, were
all torn out at 5 days postoperatively in a thorough study
of canine flexor tendons. Perhaps extending the repair
further from the injury would preclude this.21
A comparison of suture design with regard to various
tissues was conducted by Ingle and King,22 who showed
that dermis and fascia hold sutures differently. This
implies that further research will help customize suture
design.
Another potential use for barbed sutures lies in intesti-
nal anastomosis. Studies in fresh porcine jejunum showed
a holding strength comparable to conventional sutures,
and both leaked at an intraluminal pressure far above arte-
rial (and presumably physiologic) values (personal com-
munication, G. T. Rodeheaver, single layer intestinal
anastomoses, 2005). Zaruby et al23 tested the V-Loc barbed
suture with Quill Monoderm in thick porcine skin over 3
weeks of healing. While this could be viewed as a com-
parison of apples and oranges, the much slower resorption
of the V-Loc failed to enhance wound-breaking strength.
Arguably, the most clinically thorough research con-
ducted thus far of barbed sutures was a rigorous compari-
son of conventional versus Quill subcuticular closure after
a caesarean section. Results for each type of suture were
equivalent in terms of pain, infection, cosmesis, and
dehiscence, but there was a 4 times greater propensity for
a knot to extrude than the end of a barbed suture.24
Dr Karol Gutowski advanced the progressive tension
concept using barbed sutures in abdominoplasty. In 58
patients without drains where the deep subcutaneum was
sewn to the external fascia, only one 10-mL seroma was
found with routine ultrasound follow-up.25 Dr Malcolm
Paul demonstrated impressive time savings for postbariat-
ric closures with barbed sutures.26
The Future
Barbed sutures are rapidly replacing conventional devices
for wound closure. The potential to rejuvenate the face
and neck remains unknown, hampered by lack of suture
availability. In my experience, these sutures applied to
facial rejuvenation have a niche between injectables and
surgery. Further experience and improved design will be
forthcoming and should better answer the question “Why
knot?”
15S
Disclosures
Dr Ruff is a paid consultant to Angiotech Pharmaceuticals, Inc
(Vancouver, British Colombia, Canada), which manufactures
and distributes the Quill brand of barbed sutures mentioned
in this supplement. He is also a paid consultant to Johnson &
Johnson (Somerville, New Jersey), which distributes the
Stratafix brand of barbed sutures.
Funding
Publication of the articles in this supplement was supported
Downloaded from https://academic.oup.com/asj/article/33/3_Supplement/12S/176214 by guest on 25 June 2023
by a grant from Surgical Specialties Corporation, but the
authors did not receive any direct compensation for writing
the manuscripts.
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