The "Barbed Roman Blinds" technique: a step forward

Dear Editor, The recently developed "Roman Blinds" technique, firstly described a few months ago in this journal 1, whose main appeals consist in lack of resection, reversibility, repeatability, low cost and minimal discomfort, appears to be effective in the treatment of snorers and patients with mild obstructive sleep apnoea 1. The technique achieves the widening and stiffening of the meso-pharyngeal inlet without any tissue sacrifice through insertion of three threads through the fibro-muscular tissues of the soft palate and the posterior tonsillar pillars, which are then tightened and eventually tied in knots around three steady holds: the posterior nasal spine and the two hamuli pterygoidei 1. In order to overcome the two drawbacks of intra-oral thread-knotting namely i) low patient acceptance requiring general anaesthesia, and ii) possibility of secondary trans-mucosal knot extrusion), in 2011 we introduced barbed sutures (QUILL® Knotless Tissue Closure Device, Angiotech Pharmaceutical Inc., Vancouver, CA), which are conceived to distribute tension along the full length of the thread route and to create dynamic vectors inside the soft tissue without the necessity of knots and avoiding subsequent ischaemic damage. This less traumatic and faster technology has been previously used in general, gynaecologic, urologic, orthopaedic and plastic surgery 2-4; its potential to work in difficult places made it also useful in laparoscopic, endoscopic and arthroscopic procedures 2-4. A further advantage offered by this novel suturing system in the oro-pharyngeal area is the possibility to use only one thread introduced along an ergonomically conceived route, in order to obtain the desired action on velar and posterior pillars soft tissues. Our preliminary experience with this new suturing material has been effective both regarding trans-mucosal extrusion (none to date) and snoring outcome. Considering that the placement of just one "barbed suture" is less traumatic and faster than the traditional three stitches in the "Roman Blinds" technique, it is foreseeable that the new procedure could become feasible in an outpatient setting under local anaesthesia.