Closure of round cutaneous postoperative wounds with the purse string suture.

To the Editor: The intradermal (1-3) and cuticular (4) purse string sutures are inexpensive, rapid procedures which are easily learned and can be useful for the complete (1,2) or partial (3,4) closure of cutaneous surgical wounds. They are especially suited for the repair of round, postoperative defects following local excision of a melanoma, (2,4) nonmelanomatous skin cancer (such as basal cell carcinoma and squamous cell carcinoma), (1,3,4) and benign cutaneous neoplasms. (4) Indeed, the purse string suture is ideal for postsurgical wounds that are large and might otherwise necessitate either a skin graft with a resulting large donor site, a large local flap, or side-to-side closure with accompanying removal of extensive Burow triangles (Fig. 1A). (5)

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The intradermal (or subcuticular) purse string suture can provide complete closure of the surgical defect and is performed by passing the running suture horizontally in the dermis before it is pulled taut. (1-3) The cuticular purse string suture is a recently described modification of the closure technique whereby the running suture is introduced from the epidermis into the dermis, passes through the dermis, and exits from the epidermis before being reintroduced into an adjacent epidermal site (Fig. 1B). (4) The purse string suture not only enhances hemostasis of the entire wound edge, but also stimulates angiogenesis and promotes wound healing by providing uniform tension along the border of the defect. (1-5)

Partial closure of a surgical defect using the cuticular purse string suture is effective in minimizing the area requiring granulation and subsequent healing by second intention; it is particularly useful in locations that have thin skin. (4,5) Both the intradermal purse string suture and the cuticular purse string suture are excellent alternatives when the patient is elderly and has loose, sun-damaged skin, is unable to care for a more complicated reconstruction, is on anticoagulant and/or antiplatelet agents, or is planning to continue an active lifestyle immediately following surgery. (2-5) The purse string suture is also preferential for large chest and back defects, for distal leg and foot wounds which have limited skin laxity (Fig. 1C), and for neck and postauricular surgical defects. (4,5)

The incidence of complications following purse string closure is similar to that noted for postsurgical wounds following other methods of reconstruction. Previously reported complications following placement of the purse string suture include allergic contact dermatitis (to allergens such as antibiotic ointments [Polysporin] or liquid adhesive [Mastisol]), alopecia of the area enclosed by the suture, postoperative bacterial wound infection, exuberant granulation tissue (of the central area following partial wound closure), hypertrophic scar, erythema of the skin adjacent to and beneath the suture, and wound dehiscence (after suture removal following a complete closure). In addition, pain may be present at the suture site following closure; the severity of tenderness is variable and is usually not caused by tension placed on the tissue by the suture but is related to either the defect depth or the surgical site. (4,5)

An advantage of the purse string suture technique--especially for patients with viral diseases or potentially contagious bloodborne pathogens--is that it minimizes the number of suture needle passes required for repairing the defect. Removal of the purse string suture is simple and asymptomatic: the suture is gently pulled from the skin in a continuous manner after the knot has been grasped and the suture has been cut. Also, of particular importance to the patients, the long-term cosmetic and functional results following closure with the purse string suture can be similar to or even better than those following other methods of wound repair (Fig. 1D). (4,5)

Philip R. Cohen, MD

Dermatologic Surgery Center of Houston

Department of Dermatology

University of Texas-Houston Medical School and University of Houston Health Center

Houston, Texas

Paul T. Martinelli, MD

Keith E. Schulze, MD

Bruce R. Nelson, MD

Dermatologic Surgery Center of Houston

Houston, Texas

References

1. Romiti R, Randle HW. Complete closure by purse-string suture after Mohs micrographic surgery on thin, sun-damaged skin. Dermatol Surg 2002;28:1070-1072.

2. Mather MK, Harrington AC, Montemarano A, et al. Surgical pearl: purse string suture in the management of poorly delineated melanomas. J Am Acad Dermatol 1998;38:99-101.

3. Weisberg NK, Greenbaum SS. Revisiting the purse-string closure: some new methods and modifications. Dermatol Surg 2003;29:672-676.

4. Cohen PR, Martinelli PT, Schulze KE, et al. The cuticular purse string suture: a modified purse string suture for the partial closure of round postoperative wounds. Int J Dermatol, in press.

5. Cohen PR, Martinelli PT, Schulze KE. The purse string suture revisited: a useful technique for the closure of cutaneous surgical wounds. Int J Dermatol, in press.