Progressive Tightening of Pulley Sutures for Primary Repair of Large Scalp Wounds

Abstract

Scalp defects greater than 2 cm in diameter are not usually amenable to primary closure and require local tissue rearrangement, grafting, tissue expansion, or prolonged second intention healing. Scalp flap reconstruction is a significant undertaking that requires elevation of a total flap surface area that is 3-6 times the size of the defect, often involves profuse bleeding, and can be challenging to perform without conscious sedation or general anesthesia. Anticoagulated and medically complex patients pose additional challenges and limit options for treatment. The pulley suture uses the mechanical advantage of the pulley to distribute tension across a wound and is useful in areas of high tension such as scalp wounds. For scalp wounds greater than 2 cm, pulley sutures are placed along the length of the wound. An assistant exerts equal tension on the pulley sutures, and the surgeon sequentially ties the sutures. The sutures are tightened and retied weekly until complete scalp closure is achieved. The pulley sutures can be used for rapid primary closure of scalp wounds up to 2.5-3.0 cm in diameter under local anesthesia. For scalp wounds larger than 3 cm, we have also found that pulley sutures can be progressively tightened yielding additional tissue expansion every week. Scalp wounds greater than 3.0 cm can be easily closed via primary repair and weekly tightening of pulley sutures without the need for flap reconstruction, traditional tissue expander placement, or second intention healing.

Fig. 1.

Pulley suture technique “far-near-near-far.” The needle is placed “far” from the wound edge. The needle is placed “near” starting deep to the galea on the opposite wound edge. The needle is placed “near” on the opposite wound edge. The needle is placed “far” starting deep to the galea on the opposite wound edge.

Video Graphic 1.

See video, Supplemental Digital Content 1, which displays placement of pulley sutures on fake skin. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A618.

Video Graphic 2.

See video, Supplemental Digital Content 2, which displays tightening of pulley sutures on fake skin. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A619.

Fig. 2.

Scalp wound status after staged surgical excision for a recurrent basal cell carcinoma. The wound measures 3.4 × 3.0 cm and has exposed bone at the base.

Fig. 3.

Pulley suture partial scalp wound closure. The wound was completely closed a week later by tightening the original sutures.

Fig. 4.

Progressively advanced pulley suture closure at 4-week follow-up after suture removal.