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Surgical Pearl: Mini-running or “X” suture for closure of punch wounds
PEARLS Stuart J. Salasche, MD Surgical Pearls Editor
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Mini-running or “X” suture for closure of punch wounds Michael B. Reynolds, MD, and John L. Ratz, MD Augusta, Georgia
T
he punch is one of the most common procedures performed by dermatologists. It is used not only as a diagnostic tool, but also as a tool to excise small neoplasms and in certain cosmetic procedures. Several methods can be used to close the defects made by this technique, including second-intention healing, primary closure, and grafting. By far the most common technique is primary closure. We describe a novel technique that can be used to close a punch defect. The procedure is best used on defects that normally would require two sutures for best closure, most commonly 4- or 5-mm punch defects. Ideally, the skin is spread perpendicular to the relaxed skin tension lines (RSTLs) at the time of the punch. This creates a more oval defect that is then closed corresponding to the RSTLs. To perform the closure, the needle is first passed through the epidermis and dermis, through the wound, and then it exits the skin on the opposite side of the wound, equidistant from the wound as the entry point (Fig 1). This is the same as a simple interrupted suture. The suture is pulled through the skin leaving a small tail. The needle is then reinserted into the epidermis adjacent to the initial insertion (and on the same side of the wound as the initial insertion), again passes through the wound, and exits through the epidermis adjacent to the exit point of the initial throw (Fig 2). The suture is pulled through to remove any slack in preparation for knot tying (Fig 3). The knot is then tied, resulting in an “X” configuration of the suture across the wound (Fig 4). The suture is removed according
From the Section of Dermatology, Medical College of Georgia. Reprints not available from authors. Correspondence: John L. Ratz, MD, Section of Dermatology, Medical College of Georgia, 1004 Chafee Ave, Augusta, GA 30904. E-mail: [email protected]. J Am Acad Dermatol 2002;46:423-4. Copyright © 2002 by the American Academy of Dermatology, Inc. 0190-9622/2002/$35.00 + 0 16/74/119564 doi:10.1067/mjd.2002.119564
Fig 1. Needle has been passed through defect as in a simple interrupted stitch. Needle is in position for second bite.
Fig 2. Second bite has been taken, parallel to first.
to standard guidelines; no problems have been encountered relating to suture removal. The main advantage of this technique is its efficiency. Although not a dramatic timesaver, it is 423
424 Pearls
J AM ACAD DERMATOL MARCH 2002
Fig 3. Suture is pulled tight in preparation for knot tying.
Fig 4. Final appearance of stitch after knot has been tied.
quicker than using two simple interrupted sutures because there is only one knot to tie and cut. This is especially helpful in noncooperative patients (such as young children) who are anxious and fidgety, and when performing biopsies on the wards where conditions are not optimal and time is important. In addition, the suture provides excellent hemostasis because it is a somewhat constricting suture. Finally, the suture has some pulley action, which allows for easier closure of wounds under tension. There are some possible disadvantages, and this technique should not be used on all punch wounds. First, in cosmetically sensitive areas such as the face, simple interrupted suturing provides more precise wound apposition compared with the “X” suture. However, cosmetic results using the new technique appear no different than with interrupted sutures.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
Second, although the suture is useful in closing wounds under tension, two separate sutures would theoretically decrease the chance of dehiscence. A “trial-and-error” approach to different wound locations to assess the usefulness of this technique in each area is suggested. BIBLIOGRAPHY O’Sullivan RB, Padilla RS. Excision. In: Ratz JL, editor.Textbook of dermatologic surgery. Baltimore: Lippincott-Raven; 1998. p. 156-8. Siegel DM, Usatine RP. The punch biopsy. In: Usatine RP, Moy RL, Tobinick EL, Siegel DM, editors. Skin surgery. St Louis: Mosby; 1998. p. 101-11.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.
Mark G. Lebwohl, MD Medical Pearls Editor
Surgical Pearl: Mini-running or “X” suture for closure of punch wounds Michael B. Reynolds, MD, and John L. Ratz, MD Augusta, Georgia
T
he punch is one of the most common procedures performed by dermatologists. It is used not only as a diagnostic tool, but also as a tool to excise small neoplasms and in certain cosmetic procedures. Several methods can be used to close the defects made by this technique, including second-intention healing, primary closure, and grafting. By far the most common technique is primary closure. We describe a novel technique that can be used to close a punch defect. The procedure is best used on defects that normally would require two sutures for best closure, most commonly 4- or 5-mm punch defects. Ideally, the skin is spread perpendicular to the relaxed skin tension lines (RSTLs) at the time of the punch. This creates a more oval defect that is then closed corresponding to the RSTLs. To perform the closure, the needle is first passed through the epidermis and dermis, through the wound, and then it exits the skin on the opposite side of the wound, equidistant from the wound as the entry point (Fig 1). This is the same as a simple interrupted suture. The suture is pulled through the skin leaving a small tail. The needle is then reinserted into the epidermis adjacent to the initial insertion (and on the same side of the wound as the initial insertion), again passes through the wound, and exits through the epidermis adjacent to the exit point of the initial throw (Fig 2). The suture is pulled through to remove any slack in preparation for knot tying (Fig 3). The knot is then tied, resulting in an “X” configuration of the suture across the wound (Fig 4). The suture is removed according
From the Section of Dermatology, Medical College of Georgia. Reprints not available from authors. Correspondence: John L. Ratz, MD, Section of Dermatology, Medical College of Georgia, 1004 Chafee Ave, Augusta, GA 30904. E-mail: [email protected]. J Am Acad Dermatol 2002;46:423-4. Copyright © 2002 by the American Academy of Dermatology, Inc. 0190-9622/2002/$35.00 + 0 16/74/119564 doi:10.1067/mjd.2002.119564
Fig 1. Needle has been passed through defect as in a simple interrupted stitch. Needle is in position for second bite.
Fig 2. Second bite has been taken, parallel to first.
to standard guidelines; no problems have been encountered relating to suture removal. The main advantage of this technique is its efficiency. Although not a dramatic timesaver, it is 423
424 Pearls
J AM ACAD DERMATOL MARCH 2002
Fig 3. Suture is pulled tight in preparation for knot tying.
Fig 4. Final appearance of stitch after knot has been tied.
quicker than using two simple interrupted sutures because there is only one knot to tie and cut. This is especially helpful in noncooperative patients (such as young children) who are anxious and fidgety, and when performing biopsies on the wards where conditions are not optimal and time is important. In addition, the suture provides excellent hemostasis because it is a somewhat constricting suture. Finally, the suture has some pulley action, which allows for easier closure of wounds under tension. There are some possible disadvantages, and this technique should not be used on all punch wounds. First, in cosmetically sensitive areas such as the face, simple interrupted suturing provides more precise wound apposition compared with the “X” suture. However, cosmetic results using the new technique appear no different than with interrupted sutures.
Direct all Surgical Pearl submissions to Dr Stuart J. Salasche, 5300 N Montezuma Trail, Tucson, AZ 85750.
Second, although the suture is useful in closing wounds under tension, two separate sutures would theoretically decrease the chance of dehiscence. A “trial-and-error” approach to different wound locations to assess the usefulness of this technique in each area is suggested. BIBLIOGRAPHY O’Sullivan RB, Padilla RS. Excision. In: Ratz JL, editor.Textbook of dermatologic surgery. Baltimore: Lippincott-Raven; 1998. p. 156-8. Siegel DM, Usatine RP. The punch biopsy. In: Usatine RP, Moy RL, Tobinick EL, Siegel DM, editors. Skin surgery. St Louis: Mosby; 1998. p. 101-11.
Direct all Medical Pearl submissions to Dr Mark G. Lebwohl, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1048, New York, NY 10029.