Purse-String Suture Technique in Reducing Surgical Defect Size

A 91-year-old female with 5.0 x 4.5–cm squamous cell carcinoma (SCC) on the right arm was referred for excision of the tumor (Figure 1a). After the lesion was removed with frozen section, the surgical defect measured 7.0 x 6.5 cm (Figure 1b), and the decision was made to use the purse-string suture (PSS) with 3-0 Monocryl to aid in reducing the defect size for acellular dermal matrix placement (Figure 1c). A bolster dressing was subsequently applied (Figure 1d). The patient tolerated the procedure well with no intraoperative complications and was discharged the same day. At the 1-week follow-up, the bolster dressed was removed (Figure 1e). At 7 weeks’ follow-up, the wound was well healed with some mild pleating of the edges (Figure 1f). The remainder of the postoperative course was uneventful, and the patient had excellent closure of the defect with satisfactory cosmetic results.

The PSS was first used as a method to address primary cutaneous surgical defects by Greenbaum and Radonich in 1996.¹ However, this type of technique was used as early as the 1950s, credited to Cannon who was able to apply the pursing strategy after excision of a malar sebaceous cyst. True to the origins of its initial application, surgeons today use the PSS primarily in cutaneous surgery to achieve partial or complete closure of round defects.² The technique is achieved by inserting a needle through the epidermis and threading the suture both parallel to the wound edge and several millimeters away from the edge of the defect. The needle is then pulled from the tissue and the process is repeated adjacent to the previous entrance site. The surgeon repeats the entire process around the circumference of the wound until the needle exits the skin near the original entrance site. The suture material is then pulled taut to close the defect.³ This ability to decrease the surface area of a defect has led to increasing popularity with surgeons in many different specialties.

There are several surgical specialties and indications in which the PSS can be an effective method for primary wound closure. This method is especially useful in areas of esthetic concerns, such as the face and neck, where preservation of adjacent healthy tissue and minimal scarring are imperative. In patients with increased skin laxity, especially older adults, there is an even greater indication for use as the surgeon will be able to apply increased tension when closing the wound. Considering this technique before escalating to a graft can be of great benefit to the patient, especially of esthetic and monetary concern. An additional utility of PSS can be appreciated in oncologic surgery following local excision of skin cancers where partial closure of the wound allows for not only healing while awaiting final histology results but also subsequent excision if necessary.

Advantages of this technique include avoidance of extensive graft or flap placement, cost reduction, and equal distribution of tension leading to minimal scarring. Although small defects may be repaired with primary closure, larger defects often require further reconstruction with grafts or flaps, and their use may be limited to donor tissue availability and morbidity. However, the application of the PSS technique may overcome this issue, especially in elderly patients where extensive surgical reconstruction may not be a viable option for wound closure given their delayed wound healing abilities, atrophic skin, and existing comorbidities.⁴ Costs for patients are also generally reduced through decreased graft or flap size and dressing or acellular dermal matrix requirements.⁵ Additionally, this approach uniformly disperses the tension across the skin at suture placement sites, allowing for the advancement of the wound edge without distortion of any nearby tissue.⁶ Reported scarring and complications are rare in the present literature, and most patients have esthetically satisfactory outcomes.

Disadvantages are few, but as the central part of the defect is often left exposed for healing by either second intention or graft or flap placement, infection is a possibility.⁷ The initial pleating of the skin is a normal part of wound closure, but patients may be dissatisfied with gross distortion. Nonetheless, most patients are satisfied with the result, and if scarring does occur, secondary revisions are simple to perform and the scar itself is less than that which would have resulted without PSS use.

Over the years, surgeons have modified and expanded the role of the PSS for a variety of clinical applications outside of wound care. In plastic reconstructive surgery specifically, the donut mastopexy is frequently performed during breast surgery to help lift the breast and reduce the areola size. The original design by Gruber had the limitations of recurrent ptosis leading to stretching of the areolar complex and hypertrophic scar development.⁸ In 1990, Benelli applied the subdermal PSS technique to the traditional donut mastopexy concept, which lead to improvements in tension and scarring with effective lift and resizing of the areola.⁹ PSS also can be used to help preserve the nipple and surrounding areolar area during subcutaneous mastectomies with inframammary incisions.

The PSS is an effective technique for reconstruction of large defects that may require additional skin grafting or flap reconstruction. A decrease in the total area that is needed for grafting or flap placement results in a smaller defect size, lower costs for patients, and less morbidity for the patient. For the patient in this study, the decision to proceed with the PSS and acellular dermal matrices placement also accounted for her age-associated impairments in wound healing and condition of the tissue. The PSS is a simple and cost-efficient approach for the closure of large defects with satisfactory cosmetic results and minimal scarring. Despite its demonstrated versatility and success, the technique is still used relatively sparingly, and PSS should be considered as an option in a surgeon’s repertoire of reconstructive techniques.

Affiliations: ¹Jobst Vascular Institute, ProMedica Health Network, Toledo, OH; ²Department of Surgery, University of Toledo, Toledo, OH; ³University of Toledo, College of Medicine and Life Sciences, Toledo, OH

Correspondence:  Richard Simman, MD, FACS, FACCWS; richard.simmanmd@promedica.org   

Disclosures: The authors disclose no financial or other conflicts of interest.