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There are four options for treating surgical defects: healing by second intention, primary closure, local skin flap, and skin grafting. Whenever possible, direct closure is the best reconstructive option. When defects are large or the likelihood of movement of adjacent skin is low, design of flaps for reconstruction can be complicated. When a flap is sutured at the margins of a defect with excessive tension, necrosis may result. In large defects, the full-thickness skin graft provides a straightforward repair option. The donor area required might limit the maximum size of the graft. The aesthetic goal in skin grafting is to provide cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity.[1]

We describe a novel procedure to reduce final wound area. This technique aids closure when the reconstruction is performed with a graft, which necessitates a smaller donor area, and with flaps, which are sometimes designed with a lot of tension, so as to reduce the traction of the sides of the defect on the displaced tissue.

This article presents a useful subcuticular suture technique for management of large defects. We call it “guitar-string suture” for its resemblance to the strings of a guitar. It can be used in large skin defects, reducing the size of the skin graft required or the size and number of flaps.

Methods

  1. Top of page
  2. Methods
  3. Results
  4. Discussion
  5. References

The technique consists of identifying the direction in which the approximation of the edges is larger and applying some cross stitches along that axis.

Guitar strings are vertical dermal–subcutaneous sutures. The suture begins in the depth of the wound and rolls toward the surface, reenters the opposite side of the wound in the dermis, and rolls deep. The knot is tied along the long axis of the defect. We prefer the surgeon's knot, which is a double throw followed by a single throw in parallel, as in the square knot. This suture creates uniform tension across the wound and significantly decreases the size of the defect. During the procedure, the wound edges that the guitar-string sutures place under tension relax, and additional tissue movement of the skin occurs.

Although the wound edges that guitar-string sutures place under tension will experience tissue relaxation, necrosis and dehiscence may result from the wound being under extreme tension, although this is infrequent.

The author has used synthetic absorbable suture composed of the homopolymer of glycolic acid in all cases. These sutures retain tensile strength through the fourth postoperative week, with sufficient time for the wound to develop intrinsic strength with a fibrotic band of the scar tissue. At 4 weeks after surgery, there is palpable dense fibrosis at the site of the guitar-string sutures that disappears after 3 to 4 months. The use of absorbable sutures reduces the risk of suture extrusion or leaving a permanent palpable knot or a draining sinus tract.

Results

  1. Top of page
  2. Methods
  3. Results
  4. Discussion
  5. References

Over the last 24 months, we have treated 11 patients with guitar-string sutures (6 male, 5 female, mean age 67, range 43–86). All of the skin defects were located on the scalp, cheek, trunk, and extremities. The average area of the defect was 135 cm2 (range 64–266 cm2). The guitar-string suture reduced the size of the defect by 15% to 45%. The length of the guitar-string sutures ranged from 3.5 to 7 cm (average 5.2 cm). The number of sutures also varied from two to five depending on the patient (average 3 sutures per procedure). In all patients, the reconstruction was performed immediately after placement of the guitar pulley sutures. Five patients underwent reconstruction with grafts (3 on the scalp, 2 on the leg), six with local flaps, and one with a combination of flap and graft. We used skin staples and ligatures to ensure the contact of a skin graft to the bed of the defect by continuous pressure dressing. Prophylactic antibiotics were used for 4 days (amoxicillin/clavulanic acid 500/125, 3 times/day). We removed the dressing 6 days later, without special care of the wound subsequently. In most of these patients, the guitar-string sutures were palpable and visible through the graft at that point. There was no loss of skin graft. Defects in patients undergoing reconstruction with flaps were located on the cheek (Figures 1-4), back, thorax, shoulder, thigh, and leg. Use of the guitar-string sutures did not lead to any adverse events such as biocompatibility problems (granuloma formation and rejection) or infection.

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Figure 1. Large defect of the cheek after excision of recurrent basal cell carcinoma and facial nerve reconstruction. Operative plan for a rotation flap of retromandibular skin.

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Figure 2. Moving the tension-free flap into place: a small flap for a large defect. Due to excessive stress in this design if the flap is sutured to the margins of the defect it can result in necrosis.

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Figure 3. Three guitar-string sutures advance tissue symmetrically into the defect and decrease its size.

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Figure 4. End of operation without margin tension.

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Discussion

  1. Top of page
  2. Methods
  3. Results
  4. Discussion
  5. References

A skin defect can always be made smaller so that closure is simpler. Plicature and forced approximation is a technique that uses a nonabsorbable suture, facilitating migration of keratinocytes deep in the defect and speeding healing by second intention.[2, 3] In round postoperative defects, the purse-string suture creates uniform tension across the wound, enhances hemostasis at the tissue edge, and significantly decreases the size of the defect.[4] On the face, suspension sutures aid closure, avoid tissue distortion, and prevent tenting across concavities.[5]

Although they may appear similar conceptually, there are differences between suspension sutures and guitar-string sutures. Suspension sutures join two tissues, generally one that is fixed and deep to another that is superficial and moveable. In contrast, guitar-string sutures approximate two moveable tissues. The placement of the guitar-string suture 5 mm from the wound margins allows sufficient tissue at the advancing wound margin to place the cutaneous sutures of the graft or flap with ease. The final cosmetic result is good, although the dimpling that guitar-string sutures cause may be visible for weeks after the surgery. The sutures remain sunken, attached to the bottom of the defect, in such a way that there is no possibility of tenting or formation of hollow spaces where secretions may accumulate and infections encouraged.

The placement of guitar-string sutures across large defects is a quick and simple technique that promotes optimal wound contraction with substantial reduction in the size of a large surgical defect before grafting or flap movement. In our experience, it is particularly useful on the scalp, trunk, and extremities and to a lesser extent on the face, where suspension sutures may work better. On the face, the excessive traction that guitar-string sutures produce may distort the tissues around natural orifices, making use of this technique less advisable. In any case, in the one patient presenting with a defect on the cheek reconstructed using a cervical flap, the cosmetic result was highly satisfactory. The potential pitfalls of guitar-string sutures include necrosis of tissue, promotion of infection, and prolonged inflammation as the result of the presence of foreign material. In our experience, no adverse events were noted, and graft and flap survival was excellent.

In conclusion, dermatologic surgeons have an additional tool, guitar-string sutures, available to aid in the closure of sizable wounds. It is a simple, inexpensive, rapid technique for reducing wounds by expanding the surrounding skin.

References

  1. Top of page
  2. Methods
  3. Results
  4. Discussion
  5. References