Technique to Reduce Wound Size: The Double-Opposing Purse-String and Horizontal Continuous Closure Algorithm

Abstract

Background: Surgical reconstruction of complex wounds requires considerable planning to ensure optimal patient outcomes. A conservative approach utilizing the lower tiers of the reconstructive ladder is preferred, especially in patients with comorbidities lending to a higher risk of poor wound healing. A simplified, low-risk solution with a double-opposing purse-string suture (PSS) and horizontal continuous closure technique may be particularly helpful in reducing the need for more complex techniques of wound reconstruction in select patient populations.

Methods: A retrospective chart review was performed on all patients who underwent reconstruction with the double-opposing PSS technique (N = 57) by the senior author (B.J.W.) at the University of Louisville between 2019 and 2022.

Results: A total of 46 patients and 57 wounds underwent the double-opposing PSS and horizontal continuous closure technique as directed by the algorithm. The average defect size before and after was 61 and 12 cm², respectively. A 2-tailed paired t test analysis was performed to explore the relationship between the pre- and post-closure defect size (P = .0003, t (44) = 3.9, 95% CI). A total of 21 wounds required a skin graft, meaning 63% of the wounds were successfully closed without the use of skin graft as a result of the double-opposing PSS technique. In addition, of those 21 wounds, the skin grafts, as well as the donor site sizes, were smaller.

Conclusions: This approach to wound closure demonstrates usefulness in reducing the size of or need for skin grafts in complex wound patients, particularly in those with comorbidities. The majority of patients underwent successful closure of their complex defects in various areas (eg, face, extremities) with this technique. Residual defects requiring skin graft allowed for a smaller graft and, thereby, donor site. Ultimately, this technique reduces the risk of complex complications by simplifying and reducing wound size.

Keywords: Complex Wound Closure; Purse-String; Skin Cancer; Skin Grafting; Surgical Technique; Wound Reconstruction.

Figure 1.

Decision-making flowchart for complex wound reconstruction with PSS and STSG. FTSG = full-thickness skin graft; PSS = purse-string suture; STSG = split-thickness skin graft.

Figure 2.

Cartoon depiction of the double-opposing purse-string suture with bidirectional running horizontal mattress suture. (A) First PSS entering the dermal-epidermal junction at the 12 o'clock position, running in a clockwise direction staying within the dermis, and exiting the dermis again at the 12 o'clock position. (B) Second PSS entering the dermal-epidermal junction at the 6 o'clock position, running in a counterclockwise direction staying within the dermis, and exiting the dermis again at the 6 o'clock position. (C) Fastening both ends of both sutures and burying the knots. (D) Running bidirectional horizontal mattress. PSS = purse-string suture.

Figure 3.

Patient who developed cutaneous angiosarcoma of the left breast following partial mastectomy and radiation therapy for invasive ductal carcinoma. (A) Large defect located on lateral chest wall prior to application of the PSS. Shoulder at the superior aspect of wound and pectoralis major visible superomedially. (B) Defect after double-opposing PSS. (C) Defect after meshed STSG. PSS = purse-string suture; STSG = split-thickness skin graft.

Figure 4.

Patient who presented with a T1a melanoma of the right ankle who underwent wide local excision. (A) A defect located on the right ankle prior to application of PSS. (B) Complete closure of right ankle wound using double-opposing PSS. PSS = purse-string suture.

Figure 5

Patient who presented with a T1b melanoma of left forearm who underwent wide local excision. (A) A 5 × 5-cm defect on the dorsal aspect of the left forearm just proximal to the ulnar styloid. (B) Application of second PSS in opposite direction. (C) Complete closure of left forearm defect using the double-opposing PSS without need for a skin graft. PSS = purse-string suture.

Figure 6.

Patient who presented with a T4 nodular melanoma of the left ankle who underwent wide local excision. (A) A 6 × 7-cm defect of the left medial malleolus measuring an overall area of 36 cm². (B) Close-up image of the defect. (C) Defect measuring 16 cm² in total area after utilization of double opposing PSS. (D) Application of the split-thickness skin graft from the right thigh and secured with 3-0 chromic sutures. PSS = purse-string suture.

Figure 7

Patient who presented with 0.9-cm thick melanoma of the left ankle and underwent wide local excision. (A) 3-cm defect of the left anteromedial ankle. (B) Complete closure of the left ankle defect utilizing the double opposing PSS without need for a skin graft. PSS = purse-string suture.