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Buried Purse-string Suture Step-by-Step
Buried Purse-string Suture Step-by-Step
a. The wound edge at the far end of the round- or oval-shaped wound, parallel to the
incision line, is reflected back. b. With the tail of the suture material resting between the surgeon and the far end of
the wound, the needle is inserted into the underside of the dermis on the far edge of the wound with a trajectory running parallel to the incision. In general, this entry point in the dermis should be approximately 3 to 6 mm set back from the epidermal edge, depending on the thickness of the dermis and the anticipated degree of
tension across the closure. The needle, and therefore the suture, should pass through the deep dermis at a uniform depth. Bite size is dependent on the needle size; though in order to minimize the risk of necrosis, it may be prudent to restrict the size of each bite. The needle should exit the dermis at a point equidistant from the cut edge from where it entered. c. The needle is then grasped with the surgical pickups and simultaneously released
by the hand holding the needle driver. As the needle is freed from the tissue with the pickups, the needle is grasped again by the needle driver in an appropriate position to repeat the above step to the left of the previously placed suture. d. A small amount of suture material is pulled through and the needle is inserted into
the dermis to the left of the previously placed suture, and the same movement is repeated. e. The same technique is repeated moving stepwise around the entire wound until the
needle exits close to the original entry point at the far end of the wound. f. Once the desired number of throws has been placed, the suture material is then
pulled taught, leading to complete or partial closure of the wound, and tied utilizing an instrument tie.
This technique is designed as an efficient method of wound area reduction. In many cases, placing a purse-string suture can affect complete wound closure and it therefore represents an alternative to a layered repair of a fusiform incision.
It has been suggested that some defects on the back and extremities, particularly in elderly patients with loose skin, are better closed with a purse-string approach than with a traditional linear closure, since linear closures often heal with a residual scar and require a significantly longer excision line, while the puckering that may be present immediately postoperatively with purse-string closures is likely to resolve with time.9โ14 That said, in the right hand, linear closures on the trunk and extremities often heal with subtle scarring, even when wounds are closed under tension.
On a pragmatic level, this approach is generally utilized when either a patient is unwilling to undergo a traditional linear closure or when their comorbidities make the additional length of the incision for a linear closure an unrealistic option.
As with linear running dermal techniques, this technique may be used as a modified winch or pulley suture, since the multiple loops help to minimize the tension across any one loop and permit closure of wounds under marked tension. Because each throw is not tied off, it is important to adequately secure the knot.
As with other running dermal techniques, this approach leaves a fair amount of absorbable suture material in the dermis. Therefore, foreign-body reactions, suture abscess formation, and infection are possibilities. That said, since the entire suture line is secured with a single knot, and since most of the bulk of any suture line is in the knots,
rather than the lengths of suture material between knots, this technique may be less susceptible to suture abscess or suture spitting than others.
The pucker effect of this closure resolves rapidly in atrophic skin, though it can persist in other areas; patients should realize that some degree of residual puckering toward the center of the wound is to be expected. Additionally, this technique may be used to help recreate the nippleโareola complex if full reconstruction is not desired and the nipple is lost to a local tumor.
Since the entire closure is held by a single knot, this approach may be associated with a higher rate of wound dehiscence, as knot failure in the suture material at any point leads to an immediate loss of tension on the closure. Given the concern regarding knot breakage, it may be helpful to attempt to better secure the knot. This may be done by paying particularly close attention to knot tying, tying an extra full knot, adding extra throws, or leaving a longer tail than would traditionally be executed.
A recent study has suggested, however, that the postoperative cosmesis of a pursestring closure is no better than a wound allowed to heal with secondary intention healing.15