The cuticular purse string suture: a modified purse string suture for the partial closure of round postoperative wounds

BACKGROUND: The purse string suture can be used to provide primary closure for small skin defects or as a partial closure for larger round wounds. The size of the defect is reduced secondary to the tension placed on the suture, which uniformly advances the skin from the entire periphery of the wound. METHODS: We reviewed retrospectively the features of 98 consecutive patients for whom a total of 100 cuticular purse string sutures were used to partially close their postoperative surgical defects. The location and types of the tumors removed were also summarized. RESULTS: Postoperative wounds were created following Mohs' micrographic excision of nonmelanoma skin cancer (basal cell carcinoma, 44; squamous cell carcinoma, 25), wide local excision of melanoma (29), or conservative excision of benign cutaneous neoplasms (two). The incidence of purse string suture for partial closure of each tumor was 4.1% for basal cell carcinoma, 7.3% for squamous cell carcinoma, and 46.3% for melanoma. The tumors were equally distributed on the trunk, head and neck, and extremities; however, purse string closures for basal cell carcinomas were more frequent on the trunk, head, and neck, relative to squamous cell carcinomas and melanomas, which were more common on the extremities. Concurrent medical problems and/or the use of an agent with anticoagulant or antiplatelet effects were noted in more than 50% of patients. Absorbable material of thicker diameter was most frequently used for the suture, and the postoperative wound area decreased by 6-90% (mean, 60%) following purse string partial closure. The suture was usually removed after 3-4 weeks. Postoperative complications occurred in six patients: allergic contact dermatitis in two, wound infection in two, exuberant granulation tissue in one, and hypertrophic scar in one. All of the wounds healed completely with either a round or linear scar. CONCLUSION: The cuticular purse string suture is a rapid and simple procedure that provides complete or partial closure of round skin defects and excellent long-term cosmetic and functional results. This closure provides uniform tension to the wound, enhances hemostasis at the tissue edge, and significantly decreases the size of the defect. Partial wound closure with the purse string suture may be advantageous following the local excision of melanoma, either as definitive surgical wound management or as a temporary partial wound closure prior to subsequent complete repair of the surgical defect. The purse string suture is also useful following nonmelanoma skin cancer removal in patients who insist on maintaining an active lifestyle in the immediate postoperative period, who are receiving one or more systemic anticoagulant and/or antiplatelet agents, and who have large surgical wounds that would require either a skin graft or a local cutaneous flap in order to close the postoperative defect.     

Bilobed flap for reconstruction of defects of the helical rim and posterior ear

When contemplating the repair of defects involving the ear, second intention healing and full or split thickness skin grafts are often considered for reconstructive choices. Closing the combined full thickness helical rim and posterior ear defects, however, represents a reconstructive challenge because of the lack of available freely mobile skin anteriorly, superiorly, and inferiorly to the defect. The choice of the bilobed flap circumvents this challenge by rotating the skin and recruiting the tissue from the post-auricular sulcus, the lower pole of the posterior ear, and, if necessary, from the superior area of the neck adjacent to the posterior ear. This bilobed flap also enables an inconspicuous closure of the donor site and provides sufficient blood supply to ensure flap viability in a simple one-stage repair. Herein, we describe two cases in which we used the bilobed flap to rotate skin from the post-auricular surface to reconstruct full thickness skin defects involving the helical rim and posterior ear, with excellent cosmetic results.     

The Z-plasty transposition flap for reconstruction of the middle cheek

BACKGROUND: Large defects of the middle cheek may prove difficult to repair. Too wide for primary closure, such defects pose challenging reconstructive options because there are no cosmetic unit boundaries in which to camouflage incision lines without resorting to widely undermined flaps. OBJECTIVE: This article summarizes our experience with the Z-plasty and double Z-plasty transposition flaps for reconstruction of the cheek. METHODS: The Z-plasty transposition flap was used immediately after Mohs micrographic surgery to repair 14 defects of the middle cheek caused by basal cell carcinoma (n = 12) or squamous cell carcinoma (n = 2). In all cases, primary closure of the defect would have resulted in excessively long scars, scars oriented perpendicular to relaxed skin tension lines, and/or free-margin distortion. In 4 of these cases, a double Z-plasty was used. RESULTS: The cosmetic and functional outcomes were judged from good to excellent by patient and surgeon. No cases of infection occurred. In one patient, minor superficial tip necrosis healed without incident. A "spit" subcutaneous suture at one flap tip of another patient left a small nodular scar, which was primarily excised and healed well. CONCLUSIONS: The Z-plasty and double Z-plasty transposition flaps offer excellent primary reconstructive modalities for the repair of geographically isolated defects of the cheek that are large or misoriented for primary side-to-side closure. The theoretical and practical geometric characteristics of the Z-plasty transposition require preparation and practice to achieve consistently satisfying results.     

An algorithm for the reconstruction of complex facial defects

Dermatologic surgeons are often faced with the repair of complex facial defects following Mohs micrographic surgery. While the size or absence of critical tissue layers may be daunting, the reconstruction of these complex defects follow similar principles to those for the closure of smaller, simpler defects. There are several issues specific to these closures including whether to delay closure in order to allow wound contraction, thus decreasing the size of the wound. Yet, if the defect is adjacent to a fixed anatomic structure, this may not be an option. The tumescent technique allows for effective anesthesia over large surface areas. Although choosing a method of closure may be specific to the anatomic area, if possible, it is best to choose a 'workhorse' flap, e.g. multiple flaps or a flap and a full thickness skin graft. Occasionally, a tunneled pedicle flap may be appropriate. For large areas an artificial skin substitute may be necessary. While tissue expansion has a number of disadvantages, it may be the only option for large defects in immobile anatomic regions. While it would be optimal to close every Mohs defect, it is important to know when to refer a reconstruction that may require general anesthesia and/or hospitalization.     

Surgical treatment of suppurative axillary hidradenitis: value of a musculocutaneous island flap of the latissimus dorsi. Apropos of 3 cases

We report our experience of the surgical management of severe, extensive, medically intractable axillary Hidradenitis suppurativa in three male patients. Under general anaesthesia, all patients underwent large, deep and full excision of the disease prone areas, i. e. zones of apocrine sweat gland distribution and not only of the skin involved at the time of surgery, for the best possible prevention of recurrence. The operation was bilateral in two patients and unilateral in one. In all cases closure was achieved using the latissimus dorsi flap technique. In the two patients with bilateral lesions surgery was carried out in two steps at about two months' interval. At present, after a follow-up of about two years, none of the patients have relapsed and their shoulder mobility is perfectly preserved with a normal abduction allowed by the total absence of axillary scar contracture. The latissimus dorsi flap technique consists of transplanting into the recipient's axillary defect the pedicellated lateral margin of the latissimus dorsi muscle with (2 patients) or without (1 patient) a cover of attached skin palette vascularized by the underlying muscle tissue. Mainly used hitherto for reconstructive mammary surgery, this technique perfectly fits axillary diseases, such as Hidradenitis suppurativa, which can only be cured by creating wide surgical skin defects. It is particularly reliable: covering of the defect is easy and the immediate muscle interposition effectively protects the otherwise widely exposed neurovascular pedicle. The need for a skin palette cover associated with the latissimus dorsi flap is discussed.     

Direct primary closure without undermining in the repair of vermilionectomy defects of the lower lip

Summary Background Vermilionectomy is an excisional technique for the treatment of lower lip squamous cell carcinoma and actinic cheilitis. The vermilionectomy defect is usually repaired by a labial mucosal advancement flap. Traditionally, the mucosal wound margins are widely undermined but this can be associated with significant postoperative morbidity. Objectives We describe our experience with a modified technique whereby lower lip vermilionectomy defects were repaired by direct primary closure without undermining and present the subsequent cosmetic, functional and sensory results. Methods and materials This is a retrospective case series of 21 patients who underwent vermilionectomy repair by direct closure without undermining. Combined data regarding the presence of any postoperative sensory, functional or cosmetic disturbance are presented. Results Complete data were available for 17 patients. Minimal sensory disturbance was noted in 10·5% of our patients 6 months postoperatively, which is less than previous studies. Similarly, labial scar tension was less frequent in our series; 94% of the patients were satisfied with cosmesis. Conclusions Direct closure without undermining is a simple, reproducible technique for repair of lower lip vermilionectomy defects and leads to excellent cosmetic, functional and sensory results in the majority of patients.     

Angular artery perforator‐based transposition flap for the reconstruction of midface defect

Background Midface defect is often seen due to trauma, neoplasm, and infection. It is important to avoid tension and distortion of the local structures and to provide skin color and texture match. We present the technique of angular artery perforator‐based transposition flap for small to moderate size defect of the midface. Materials and methods Between 2002 and 2009, 17 patients underwent operations for the reconstruction of midface defect. After tumor excision, perforators were found at the medial aspect of the defect along the nasolabial fold. Considering the change of the defect shape and primary closure of the donor site, the width and length of the flap was determined. The flap elevated disto‐proximally and transposed to the defect without tension. The donor site was closed first with partial undermining. Results Besides one patient with partial wound dehiscence of the donor site, all the flaps healed uneventfully. The patients were satisfied with the final result esthetically and functionally. Conclusion The angular artery perforator‐based transposition flap takes advantage of the nasolabial flap and perforator flap, and it is a simple and fast procedure. Therefore, it may be an alternative for the reconstruction of midface defect.     

斧头状皮瓣修复头面部皮肤肿瘤切除后创面

[摘要] 目的： 探讨采用斧头状皮瓣修复头面部皮肤肿瘤切除后形成的继发性创面的应用体会。方法： 42例头面部皮肤软组织缺损中, 面积最小0.8cm×0.7cm, 最大5cm×6cm,在缺损边缘的一侧形成斧头状皮瓣, 面积为创面的1～1. 5倍, 蒂部宽度约为旋转侧宽度的1/3～1/4, 形成深度在面部为SMAS的浅面, 头部为帽状腱膜与颅骨骨膜之间。皮瓣形成后向受区旋转推进修复创面。结果：全部皮瓣存活良好, 创面得以Ⅰ期修复,美容效果满意。结论: 斧头状皮瓣制作简单, 血运可靠, 是修复头面部皮肤软组织缺损的一种理想方法。     

Interpolation flaps

Interpolation flaps provide an excellent method for reconstruction of large or deep defects where adjacent local tissue cannot supply sufficient donor tissue for repair. These flaps use tissue imported from nonadjacent sites with an inherent blood supply (vascular pedicle) to support the flap while attached to the recipient defect until neovascularization has been ensured between the flap and recipient bed. Hence, they can supply the thickness or bulk needed for large or deep defects and can survive on exposed bone or cartilage. The main disadvantage of these flaps is that they require two stages to complete because the delayed second stage releases the pedicle after inosculation and neovascularization render the tissue independent of the pedicle. This article describes three major interpolation flaps useful in repair of the nose and ear. The forehead, melolabial, and postauricular interpolation flaps are excellent methods that will add to the dermatologic surgeon's reconstructive armamentarium for the repair of large or deep defects.     

The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases

BackgroundSkin tumors commonly occur on the legs and are treated in first line by surgery. Several techniques are available to repair lower limb defects: secondary-intention healing, partial closure, primary closure with or without an s-plasty, or a skin graft. The lack of tissue laxity of the surrounding skin does not allow several local flaps (advancement, rotation, or transposition). Closing large skin defects at this site may be challenging.Patients and methodsWe retrospectively reviewed a series of consecutive patients undergoing malignant tumor wide excision on lower limbs, with a keystone flap or its simplified technique (releasing incision) for closure of a skin defect.ResultsTwenty-five patients, 17 women and 8 men, ranging from 19 to 95 years old (mean age: 70 years) were included. Keystone flap reconstruction on the lower limbs was performed in 19 cases and the simplified technique in 6. The excised tumors were as follows: squamous cell carcinoma (n = 6), basal cell carcinoma (n = 9), melanoma (n = 9) and Bowen's disease (n = 1). Three local complications were observed. No cases of recurrence were observed.ConclusionKeystone flap is a reliable surgical method for reconstruction of lower limb skin defects. Aesthetic results are better than when a skin graft is used, complications are uncommon, and prolonged operative time is avoided.     

Nevus sebaceus of Jadassohn revisited with reconstruction options

BACKGROUND: Nevus sebaceus of Jadassohn (NS) has the classic presentation on the head and neck of a yellow-orange-colored, waxy, pebble-like, papule or plaque. Its reported malignant potential varies between 0.8% and 50%. The common location of NS on the temporal hairline leaves a cosmetic defect. METHODS: We retrospectively reviewed a consecutive series of patients with NS located in the temporal scalp region. Thirteen patients were included. Twelve patients were reconstructed with a temporal flap. One patient had a primary linear scalp closure after excision. Clinical, histopathologic, surgical, and photographic records were used to review the clinical, anatomic, and pathologic presentation of the lesions. Reconstructions were rated on a scale of 1-5 by two independent examiners. The cosmetic results were also assessed by the patients. RESULTS: Patients ranged in age from 3 to 40 years. All of the lesions were located in the temporal area of the scalp. All cases were pathologically determined as NS. Two cases contained basal cell carcinoma (15%). Two cases were re-excisions of confirmed NS. One case was excised and closed with difficulty using a linear primary closure. Rotation flaps based on the superior temporal artery were used for the reconstruction of the defects in 12 patients. Nine of the flaps were anterior rotation flaps and three were posterior. The average score for the cosmetic results of the patients was 3.75, with the lowest score being 2, and the highest 5. The score for the linear closure was 2. CONCLUSION: A rotation flap based on the superficial temporal artery is an excellent reconstructive solution for NS located in the temporal scalp region.     

The caudolaterally inserted transposition flap and its variations for reconstruction of defects of the nasal ala

Closure of non‐full‐thickness defects of the nasal ala can be a surgical challenge. While there is a plethora of various reconstructive techniques, not all of them are easy to learn and carry out. Recently, the dermatosurgeon Andreas Lösler from the Department of Dermatology at the Hornheide Medical Center, Germany, developed and published the caudolaterally inserted transposition flap for the reconstruction of alar defects. Given its relative novelty, this technique, which is characterized by a very low complication rate, is still unknown to most dermatosurgeons and has not yet found its way into standard dermatosurgery textbooks. The present review describes the caudolaterally inserted transposition flap and two modifications thereof, which allow for the closure of large alar defects as well as defects of the alar crease. Comparisons are made to the two flaps most commonly employed for alar reconstruction, the bilobed flap and the cranially inserted nasolabial transposition flap (melolabial flap).     

Oblique advancement flap for defects of the lateral nasal supratip

BACKGROUND: Reconstruction of nasal alar defects is difficult because of the complex anatomy of the region. A frequent challenge in this area is repair of small cutaneous defects involving the lateral nasal supratip and the superior alar groove. OBSERVATIONS: An oblique advancement flap that uses laxity from the nasal sidewall is described. Its benefits and limitations are compared with those of alternative closures. Overall, the oblique advancement flap preserves the superior alar groove, while minimizing tissue contortion. It is technically similar to a primary closure but functionally and aesthetically superior. CONCLUSIONS: For selected small lateral nasal supratip defects impinging on the superior alar groove, the oblique advancement flap offers a simple, visually pleasing repair that preserves the alar architecture.     

Burow''s grafts in the facial region

BACKGROUND: Full-thickness skin grafts are an important tissue source for reconstructive surgery. Burow's grafts are full-thickness skin grafts that use adjacent lax skin as the donor site. This technique has also been referred to as island grafts, dog-ear grafts or adjacent-tissue skin grafts. OBJECTIVE: The objective was to describe the technique of Burow's grafts for reconstruction of facial defects taking account of its benefits and limitations. METHODS: The operative technique is simple: after a circular excision of the cutaneous lesion, we enlarged the excision line (towards one or both sides of the defect) following the relaxed tension lines. We created a secondary triangular defect by excising skin that is then used for the graft (as donor site). After adequate undermining, we proceeded to direct linear closure of this secondary defect. Finally, the graft was placed and sutured in the remaining defect. RESULTS: The proximity of the donor site provides an excellent tissue match because colour, hair density, texture, sebaceous features and thickness are similar to the recipient site. A good cosmetic result is therefore ensured. CONCLUSION: Burow's grafts can be a good choice for reconstruction of extensive facial surgical defects because of aesthetic results. In addition, it is a simple technique that can be performed in one sole surgical act, with local anaesthesia and without changing the operative site.     

Three point-advancement closure for skin defects

BACKGROUND: Circular skin defects are common following Mohs' surgery. Traditional closure (primary, flap, or graft) may involve extensive surgery. Multidirectional advancement closures such as the purse-string closure have been advocated as another useful tool in such cases. OBJECTIVE: To describe a variation on purse-string closure that, in certain cases, is an excellent alternative to other reconstructions, and will provide good cosmetic and functional outcome. METHOD: A three-point anchoring suture is placed after undermining to advance the surrounding tissue toward the centre, creating a "Mercedes Benz" or tripod closure following removal of "dog-ears." RESULTS: Circular wounds in designated areas can be more easily closed, creating well-tolerated, favourable scars. CONCLUSION: Large wounds may be closed with the advantage of avoidance of larger flaps, of decreased wound healing compared to second intention, and of minimizing removal of healthy tissue. An initial trial of closure with this method does not limit subsequent use of other repairs should it be less than satisfactory.     

Reverse sural artery flap for distal lower extremity defects

Traumatic and various dermatological conditions resulting in skin and subcutaneous tissue loss on the lower limb cause a therapeutic challenge for the dermatological surgeon, because this anatomical location lacks adequate skin laxity and has limited local soft tissue, especially around the heel. In this report, we present our experience with the reverse sural artery flap on seven patients. The soft tissue defect was traumatic in two patients. We also treated three diabetic patients. There were no immediate or late surgical complications in four cases; flap and donor site healing was uneventful. The remaining three cases were diabetic, and all presented with the following complications: rejection of split skin graft at donor site, infection at the flap border and superficial flap necrosis. The flap necrosis was concluded to be at least in part due to the patient's noncompliance with postoperative measures. We conclude that the reverse sural artery flap is a satisfactory alternative in the reconstruction of lower limb defects, but we also feel that the importance of proper evaluation prior to surgery in terms of vascular impairment and patient compliance should be emphasized to ensure a successful surgical outcome.     

Surgical management of skin cancer and trauma involving the middle third of the auricle

The main causes of acquired auricular defects are surgical treatment of skin tumors and trauma. Due to the complex anatomy of the external ear, surgical reconstruction of defects in this area is challenging for surgeons, especially in case of midhelix‐antihelix involvement with significant loss of soft tissue and cartilage. Our purpose is to illustrate the main reconstructive techniques of large midhelix and antihelix defects, as well as the advantages or disadvantages associated with each surgical procedure. Primary closure/wedge technique is mainly used in elderly, multimorbid subjects where single‐stage procedures are desirable, but several complex chondrocutaneous, retroauricular, temporoparietal full‐thickness flap procedures can also be used to recreate an ear with normal appearance. Auricular reconstruction of large midhelix‐antihelix defects requires a good knowledge of auricular anatomy and the various surgical procedures available for such defects.     

Wertigkeit des externen Hautexpanders (ETE®) beim sekundären Verschluß von Hautdefekten

Background: For surgical closure of large skin defects, elaborate reconstructive plastic surgery or other methods such as internal subcutaneous balloon tissue expanders are required in order to avoid tension on the closure margins. Here we point to the benefits and disadvantages of an improved and simple method of secondary wound closure by secondary sutures. Patients and Methods: We employed a system called External Tissue Extender (ETE?), which consists of silicone strings and plastic stoppers pulling the corresponding surgical sites together and evenly distributing the tension. Possible indications in dermatologic surgery and our experiences with this technique are outlined. Results: Implantation and handling of the ETE? are very easy and fast. The functional results are good and the cosmetic outcome satisfactory. More invasive surgical procedures can be avoided by using this method. A major disadvantage is the possibility of developing necrosis under the plastic stoppers. Conclusion: According to our experience, the ETE? is a useful alternative indicated in certain dermatosurgical situations.     

Reverse latissimus dorsi musculocutaneous flap for reconstruction of lumbar radiation ulcer

The surgical treatment of large, deep defects on the midline of the lower back or lumbar area comprises difficult reconstructive challenges. Various flaps have been designed to reconstruct the defect area. We herein report a 70-year-old Japanese woman with a large, deep ulcer in the midline of the lower back, caused by postoperative radiation therapy for eccrine porocarcinoma. The ulcer was successfully treated with surgical debridement followed by reverse latissimus dorsi musculocutaneous flap. This flap is reliable and useful for reconstruction of a large, deep midline defect of the lower back, having large and bulky tissue with a sufficient blood supply.     

Operative Skalpdefekte

The reconstruction of scalp defects following tumor excisions can be a difficult surgical challenge. The size, location and the depth of the defect, but also the presence or absence of hair, the location of the hairline, the condition of the adjacent tissue and possible co-morbidities must be taken into account in order to choose an appropriate reconstructive technique. Even smaller defects often require local flaps and skin grafts. The increasing number of scalp tumors arising on the basis of actinic field cancerization often lead to large defects with exposed scalp bone. In this context flaps combined with split-thickness skin grafting of the donor site defect, granulation-inducing methods with second intention healing and the application of dermis equivalents are possible options to cover the exposed cranium. Adequate functional as well as aesthetic reconstruction of scalp defects require excellent understanding of the options and limits of the diverse closure techniques, good knowledge of the anatomy and proper preoperative planning.