Purse-String Suture Closure

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Purse-String Suture Closure

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Introduction

The purse-string suture can be used to provide complete or partial closure of round skin defects. This running suture is placed horizontally in the dermis. Skin from the entire periphery of the defect is uniformly advanced by the tension placed on the purse-string suture. Large circular defects may be closed or made smaller by utilizing a running purse-string suture. 
The purse-string suture eliminates the excision of healthy skin adjacent to the wound. It can function as the primary closure for small skin defects. It can also serve as a partial closure for larger defects by reducing the wound surface area, and allowing the remainder of the wound to granulate. Alternatively, the residual defect can be closed using either a skin graft or a transfer of adjacent tissue. 
Standing wedges may be cut in advance of the closure. This converts the round defect into a stellate defect that may be closed with a purse-string or classic multiple corner sutures. This technique obviates the need for placement of secondary sutures in a side-to-side fashion, which could interfere with the healing in the central portion of the repair. These side-to-side buried sutures produce tension that could cut through the central graft. The wound can be further supported temporarily during the initial postoperative period by placing overlying mattress sutures. 
Skin has extensive viscoelastic properties that allow it to stretch and expand when placed under constant tension. When the tension in a skin closure is constant, stress relaxation occurs that causes the tension to gradually decrease. Using the purse-string suture, the wound margin length can be considerably reduced, with no long-term distortions of the surrounding skin and a satisfactory scar. During the time necessary for healing, skin remodeling occurs, eliminating concentric skin folds and tissue distortions. 
In the immediate postoperative period, the suture is usually surrounded by a large number of concentric redundant skin folds, and there may be some distortion of the nearby structures. Both of these problems typically improve spontaneously over a period of a month, as the skin naturally stretches under the constant tension, and often completely disappear by the time the suture is removed in 4 to 6 weeks. The scars also tend to orient themselves along the lines of least skin tension line over the ensuing month. Some scar widening may occur over time, especially when larger sutures (0-1 or more) are used or are left in place longer than 6 weeks. The final scar is always shorter than the original defect. Patients need to be carefully prepared for the initial skin distortion and the extended period that the suture remains in the skin. 

Equipment

  • Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.

  • Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.

Indications

  • Closure of round skin defects that are not amenable to other low-tension closures

  • Temporary reduction of skin defects during malignancy excision procedures

  • Reconstruction of postsurgical wounds in elderly patients with loose or thin, sun-damaged skin

  • Operative defects on the distal legs and feet where there is limited skin laxity

  • Closures in patients who are unable or unwilling to appropriately limit their level of activity following surgery

Contraindications

  • Poor skin vascular supply

  • Diseases causing poor vascular supply to the skin (e.g., atherosclerotic heart disease, diabetes, smoking, collagen vascular disease, prior irradiation, severe anemia, anticoagulation)

  • History of poor wound healing, hypertrophic scarring, or keloid formation

  • Uncooperative patient

  • Presence of cellulitis, bacteremia, or active infection

The Procedure

Standard Purse-String Closure

Step 1
After removal of the skin lesion with an adequate margin, a round or ovoid defect is left. 
Step 2
A 2-0 or larger nylon or Prolene suture is passed into the middermis. 
  • Pitfall: Using a suture smaller than 2-0 may result in suture breakage with tying or the suture pulling through the dermis before it is time for removal.

Step 3
Continue taking 5- to 10-mm bites at the level of the mid-dermis. It is not strictly necessary to undermine the wound edges of the surgical defects, but advantages to undermining include promoting easier wound sealing, facilitating eversion of the wound edges, and minimizing folding of the perimeter of the defect. The needle is again inserted 2 to 10 mm from the dermal exit site, and this sequence is continued until the entire circumference of the wound has been sutured. 
Step 4
If the final purse string is going to be long, it may be difficult to extract the suture at the time of removal. Consider placing an external loop, which can be cut to facilitate removal. 
Step 5
Pulling and tying the suture to close the wound causes the circumferential compression of the margins and the temporary formation of many folds in the surrounding skin. This results in either a decrease of the circumference and partial closure of the wound or complete closure of the wound. 
Step 6
Partially closed wounds can then be packed with an absorbable gelatin sponge (i.e., Gelfoam). Alternatively, a final closure may be completed using a few external interrupted or vertical mattress sutures. Apply an antibiotic ointment and then a nonadherent pad, followed by a pressure dressing. 
  • PEARL: Minimal undermining of the wound margins is necessary, which may help maximize skin vascularity.

Stellate Purse-String Closure

Step 1
After the round defect is created by removal of the skin lesion with an adequate margin, draw and excise four wedges equidistant from each other around the defect. 
Step 2
Then the suture can be placed as described previously with a deep pass crossing the opening of each wedge defect. Alternatively, the suture can be passed only through the base of the defect in a circular pattern in a manner similar to that used to close stellate wounds (see Corner Suture). 
Step 3
Pulling and tying the suture to close the wound causes complete closure of the defect without the folds in the surrounding skin found in the traditional method. 

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Sensory changes (often subside with time)

  • Skin necrosis

  • Dehiscence

  • Hypertrophic scarring (often resolves spontaneously within 12 months)

  • Suture marks

  • Alopecia

  • Widening of the scar (especially on the scalp)

  • Exuberant granulation tissue

  • Postoperative pain

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. It is rare to have to do such wide excisions on pediatric patients, which is fortunate because parents are often less accepting of scars for their children than they are for themselves. 

Postprocedure Instructions

Apply topical antibiotics and a dressing after the procedure. Have the patient keep the bandage on and the wound dry for the first 24 hours. After that, it can be gently washed with soap and water as needed. An antibiotic ointment and bandage should be reapplied after each washing until the patient returns. 
Any external sutures should be removed in 5 to 8 days to avoid any suture marks. The purse-string suture should be left in place for a minimum of 4 weeks, although waiting 6 to 8 weeks produces better results. Educate the patient that suture removal too early (<4 weeks) often results in a worse cosmetic outcome. Have the patient report signs of infection. 

Coding Information

These codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-Y-plasty, rotation flaps, advancement flaps, and double-pedicle flaps. When applied to traumatic wounds, the defect must be developed by the surgeon because the closure requires it, and these codes should not be used for direct closure of a defect that incidentally results in the configuration of one of the flaps or plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes. 

Bibliography

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Berschadsky M. Periareolar subcuticular pursestring suture. Plast Reconstr Surg .  1999;104:1203. [View Abstract]
Ciatti S, Greenbaum SS. Modified purse-string closure for reconstruction of moderate/large surgical defects of the face. Dermatol Surg .  1999;25:215–219. [View Abstract]
Cohen PR, Martinelli PT, Schulze KE, et al. Closure of round cutaneous postoperative wounds with the purse string suture. South Med J .  2006;99(12):1401–1402. [View Abstract]
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 .  2007;46(7):746–753. [View Abstract]
Cohen PR, Martinelli PT, Schulze KE, et al. The purse-string suture revisited: a useful technique for the closure of cutaneous surgical wounds. Int J Dermatol.  2007:46;341–347.
Dang M, Greenbuam SS. Stellate purse-string closure. Dermatol Surg.  2000;26:495–496. [View Abstract]
Dinner MI, Artz JS, Foglietti MA. Application and modification of the circular skin excision and pursestring procedures. Aesthetic Plast Surg .  1993;17(4):301–309. [View Abstract]
Marconi F. The dermal purse-string suture: A new technique for a short inframammary scar in reduction mammoplasty and dermal mastopexy. Ann Plast Surg.  1989;22:484. [View Abstract]
Peled IJ, Zagher U, Wexler MR. Purse-string suture for reduction and closure of skin defects. Ann Plast Surg.  1985;14(5):465–469. [View Abstract]
Shelton RM. Repair of large and difficult-to-close wounds. Dermatol Clin.  2001;19:535–553. [View Abstract]
Tremolada C, Blandini D, Beretta M, et al. The “round block” purse-string suture: a simple method to close skin defects with minimal scarring. Plast Reconstr Surg .  1997;100(1):126–131. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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