PALM BEACH, FLA. Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.
This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.
Purse-string closure of defects after surgery for skin cancerwith sutures placed around the defect and the skin pulled togetheris cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.
For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).
"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.
The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.
Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.
Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.
"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.
The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.
"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.
The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.
