LETTERS AND COMMUNICATIONS
References 1. Karmody CS, Annino DJ Jr. Embryology and anomalies of the external ear. Facial Plast Surg 1995;11:251–6. 2. Gore SM, Myers SR, Gault D. Mirror ear: a reconstructive technique for substantial tragal anomalies or polyotia. J Plast Reconstr Aesthet Surg 2006;59:499–504. 3. Pan B, Qie S, Zhao Y, Tang X, et al. Surgical management of polyotia. J Plast Reconstr Aesthet Surg 2010;63:1283–8.
Paul X. Benedetto, MD Dermatologic SurgiCenter Philadelphia, Pennsylvania Allison T. Vidimos, MD, RPh Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
4. Ku PK, Tong MC, Yue V. Polyotia—a rare external ear anomaly. Int J Pediatr Otorhinolaryngol 1998;46:117–20. 5. Bajaj Y, Sahni JK, Jain A, Kansal Y. Polyotia. Arch Otolaryngol Head Neck Surg 2001;127:75–7.
The authors have indicated no significant interest with commercial supporters.
A Novel Suture Technique for High-Tension Wound Closure: The Tandem Pulley Stitch Closing surgical defects that require high tension such as larger defects on the back and scalp can be challenging. Commonly used techniques include the horizontal mattress stitch, pulley stitch, and even the use of a towel clamp for mechanical creep. These methods can be useful during initial closure of a wound by offloading tension, thus facilitating placement of buried sutures. The horizontal mattress stitch distributes wound tension over 2 sutures that cross the wound and laterally between them. It is especially useful to redistribute tension and close dead space,1 and variations include the running,2 partially buried,3 fully buried,4 and locked.5 The pulley stitch uses mechanical advantage to distribute forces over a greater length of suture in a single vertical plane across the wound. The authors describe a combination of the horizontal mattress and pulley stitches termed the tandem pulley stitch. In this stitch, forces are distributed in 2 vertical planes and laterally, and the mechanical advantage of 2 pulley stitches is gained. This stitch is especially useful for closures requiring high tension as an initial stitch, off-loading tension, and allowing for easier placement of buried sutures. It can be retained or removed immediately after closure. The authors have used this stitch to close wounds in various anatomic sites including the back, scalp, and extremities with great success. As shown in the schematic diagram (Figure 1), it is a hybrid of a horizontal mattress and 2 pulley stitches.
In the tandem pulley stitch, force vectors are distributed over a cuboidal space as with a horizontal mattress stitch, and the mechanical advantage of 2 parallel pulley stitches results in greater total closure force. Wall-to-wall approximation is obtained compared with more point-to-point contact along a vertical axis as in a single pulley stitch. The tandem pulley stitch also allows for the use of a lower tensile strength suture potentially decreasing the number and types of sutures required for wound closure. Technique for the tandem pulley stitch: (1) Step 1: With a forehand movement, place a farnear near-far pulley stitch using nonabsorbable suture (Figure 1A,B). (2) Step 2: Move the needle parallel to the wound edge (Figure 1B). (3) Step 3: With a backhand movement, place another far-near near-far pulley stitch (Figure 1C,D). (4) Step 4: Tie (Figure 1E). A few practical points from the authors: (1) Place each stitch precisely with symmetric bites for proper alignment of wound edges. (2) If desired, provide space between the 2 parallel pulley stitches to allow for placement of a buried stitch between them. (3) For greatest strength, throws should traverse the entire thickness of the flap into the undermined gap.
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A–E) Schematic diagram of tandem pulley stitch.
(4) For easier removal, cut the transverse component on the side opposite the knot and remove by grasping the knot and pulling. Although the authors cannot provide quantitative evidence, they have observed that this suture is especially useful for closures requiring high tension as an initial stitch, off-loading tension, and allowing for
easier placement of buried sutures. It is the authors’ opinion, based on experience, that the tandem pulley stitch also allows for the use of a lower tensile strength suture potentially decreasing the number and types of sutures required for wound closure (Figure 2). In summary, the superficial and buried tandem pulley stitches combine features of the horizontal mattress and pulley stitches. Tandem pulley stitches are especially useful in closing wounds under higher tension. They generate a large magnitude of force and result in easier wound closure with good wound-edge approximation, off-loading of tension, and dead space elimination.
References 1. Wentzell JM, Lund JJ. The inverting horizontal mattress suture: applications in dermatologic surgery. Dermatol Surg 2012;38:1535–9. 2. Moody BR, McCarthy JE, Linder J, Hruza GJ. Enhanced cosmetic outcome with running horizontal mattress sutures. Dermatol Surg 2005; 31:1313–6.
Figure 2. Clinical photograph of tandem pulley stitch.
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3. See A, Smith HR. Partially buried horizontal mattress suture: modification of the Haneke-Marini suture. Dermatol Surg 2004;30:1491–2.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
4. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol 2004;50:73–6.
Timothy Wang, MD Cutaneous Surgery & Oncology Unit Johns Hopkins University Baltimore, Maryland
5. Hanasono MM, Hotchkiss RN. Locking horizontal mattress suture. Dermatol Surg 2005;31:572–3.
Catherine H. Lee, MD, MSc Newport Dermatology Institute Corona Del Mar, California
The authors have indicated no significant interest with commercial supporters.
Transposition–Advancement Flap for the Reconstruction of Segmental Auricular Defects Here, the authors present the utility of the transposition–advancement flap (TAF) for the single-stage repair of segmental auricular defects. Surgical Technique Example 1 Figure 1 illustrates a complex full-thickness 4 · 3 cm Mohs defect of the left ear. A triangular-shaped transposition flap (TF) is designed in the retroauricular sulcus with the apex of the triangle oriented inferiorly toward the side of the neck designed to align into a preexisting rhytid. The dimensions of the flap must be such that once elevated and transposed 90, the flap is both long enough and wide enough to be “folded” over itself to provide adequate skin coverage for both the posterior and anterior aspects of the ear, that is, the proximal half of the TF resurfaces the posterior aspect of the ear and the distal half the anterior ear. The size of the required TF for such a large defect is significant, and thus, a primary closure of the created secondary defect in the retroauricular sulcus is often not possible. Consequently, linking the TF to a curved advancement limb (CAL), at least 3· the width of the secondary defect, laterally along the parietooccipital scalp not only enables greater tension free movement of the TF itself but also allows direct primary closure of the created secondary defect. The curved nature of this advancement limb (as opposed to a straight limb) enables a greater recruitment of the lax tissue of the occipitoparietal scalp. The degree of curvature adopted may be modified according to each patient’s individual tissue laxity in this region.
The defect shown in Figure 1 was extended to involve the helical rim. An antihelical cartilage stent was then harvested from the contralateral ear and sutured in place to recreate the structural framework of the midhelical rim and maintain the height of the ear. The TAF is dissected extensively in a subcutaneous plane. The key primary stitch, a buried vertical mattress suture, approximates the leading edge of the CAL to the retroauricular sulcus. This movement closes the secondary defect created by the transposition limb and also facilitates the movement of the TF itself. The proximal aspect of the TF is then sutured to resurface the posterior aspect of the ear with the distal aspect of the TF being “wrapped round” the cartilage baton providing coverage for the anterior aspect of the ear, with the tip of the TF lying within the conchal bowl. Great care is taken to ensure the flap is “draped” without tension across the cartilage baton. The CAL within the occipital scalp is then sutured according to the “rule of halves.” Example 2 Figure 2 illustrates a Mohs defect, at the junction of the upper and middle third of the ear, approximately 1 cm wide and 4 cm in length. A small remnant remained at the superior crus of the helix. In this case, the TAF was performed in conjunction with a helical rim advancement flap. The TF limb of the flap in this case was initiated from the most inferoposterior aspect of the surgical defect (the midpoint of the retroauricular sulcus in this case) and elongated to the ipsilateral angle of the jaw to ensure enough length to allow this limb to be “draped” in a vertical fashion (rather than horizontally as in Figure
41:8:AUGUST 2015
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
References 1. Karmody CS, Annino DJ Jr. Embryology and anomalies of the external ear. Facial Plast Surg 1995;11:251–6. 2. Gore SM, Myers SR, Gault D. Mirror ear: a reconstructive technique for substantial tragal anomalies or polyotia. J Plast Reconstr Aesthet Surg 2006;59:499–504. 3. Pan B, Qie S, Zhao Y, Tang X, et al. Surgical management of polyotia. J Plast Reconstr Aesthet Surg 2010;63:1283–8.
Paul X. Benedetto, MD Dermatologic SurgiCenter Philadelphia, Pennsylvania Allison T. Vidimos, MD, RPh Department of Dermatology, Cleveland Clinic Foundation, Cleveland, Ohio
4. Ku PK, Tong MC, Yue V. Polyotia—a rare external ear anomaly. Int J Pediatr Otorhinolaryngol 1998;46:117–20. 5. Bajaj Y, Sahni JK, Jain A, Kansal Y. Polyotia. Arch Otolaryngol Head Neck Surg 2001;127:75–7.
The authors have indicated no significant interest with commercial supporters.
A Novel Suture Technique for High-Tension Wound Closure: The Tandem Pulley Stitch Closing surgical defects that require high tension such as larger defects on the back and scalp can be challenging. Commonly used techniques include the horizontal mattress stitch, pulley stitch, and even the use of a towel clamp for mechanical creep. These methods can be useful during initial closure of a wound by offloading tension, thus facilitating placement of buried sutures. The horizontal mattress stitch distributes wound tension over 2 sutures that cross the wound and laterally between them. It is especially useful to redistribute tension and close dead space,1 and variations include the running,2 partially buried,3 fully buried,4 and locked.5 The pulley stitch uses mechanical advantage to distribute forces over a greater length of suture in a single vertical plane across the wound. The authors describe a combination of the horizontal mattress and pulley stitches termed the tandem pulley stitch. In this stitch, forces are distributed in 2 vertical planes and laterally, and the mechanical advantage of 2 pulley stitches is gained. This stitch is especially useful for closures requiring high tension as an initial stitch, off-loading tension, and allowing for easier placement of buried sutures. It can be retained or removed immediately after closure. The authors have used this stitch to close wounds in various anatomic sites including the back, scalp, and extremities with great success. As shown in the schematic diagram (Figure 1), it is a hybrid of a horizontal mattress and 2 pulley stitches.
In the tandem pulley stitch, force vectors are distributed over a cuboidal space as with a horizontal mattress stitch, and the mechanical advantage of 2 parallel pulley stitches results in greater total closure force. Wall-to-wall approximation is obtained compared with more point-to-point contact along a vertical axis as in a single pulley stitch. The tandem pulley stitch also allows for the use of a lower tensile strength suture potentially decreasing the number and types of sutures required for wound closure. Technique for the tandem pulley stitch: (1) Step 1: With a forehand movement, place a farnear near-far pulley stitch using nonabsorbable suture (Figure 1A,B). (2) Step 2: Move the needle parallel to the wound edge (Figure 1B). (3) Step 3: With a backhand movement, place another far-near near-far pulley stitch (Figure 1C,D). (4) Step 4: Tie (Figure 1E). A few practical points from the authors: (1) Place each stitch precisely with symmetric bites for proper alignment of wound edges. (2) If desired, provide space between the 2 parallel pulley stitches to allow for placement of a buried stitch between them. (3) For greatest strength, throws should traverse the entire thickness of the flap into the undermined gap.
41:8:AUGUST 2015
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A–E) Schematic diagram of tandem pulley stitch.
(4) For easier removal, cut the transverse component on the side opposite the knot and remove by grasping the knot and pulling. Although the authors cannot provide quantitative evidence, they have observed that this suture is especially useful for closures requiring high tension as an initial stitch, off-loading tension, and allowing for
easier placement of buried sutures. It is the authors’ opinion, based on experience, that the tandem pulley stitch also allows for the use of a lower tensile strength suture potentially decreasing the number and types of sutures required for wound closure (Figure 2). In summary, the superficial and buried tandem pulley stitches combine features of the horizontal mattress and pulley stitches. Tandem pulley stitches are especially useful in closing wounds under higher tension. They generate a large magnitude of force and result in easier wound closure with good wound-edge approximation, off-loading of tension, and dead space elimination.
References 1. Wentzell JM, Lund JJ. The inverting horizontal mattress suture: applications in dermatologic surgery. Dermatol Surg 2012;38:1535–9. 2. Moody BR, McCarthy JE, Linder J, Hruza GJ. Enhanced cosmetic outcome with running horizontal mattress sutures. Dermatol Surg 2005; 31:1313–6.
Figure 2. Clinical photograph of tandem pulley stitch.
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3. See A, Smith HR. Partially buried horizontal mattress suture: modification of the Haneke-Marini suture. Dermatol Surg 2004;30:1491–2.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
4. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol 2004;50:73–6.
Timothy Wang, MD Cutaneous Surgery & Oncology Unit Johns Hopkins University Baltimore, Maryland
5. Hanasono MM, Hotchkiss RN. Locking horizontal mattress suture. Dermatol Surg 2005;31:572–3.
Catherine H. Lee, MD, MSc Newport Dermatology Institute Corona Del Mar, California
The authors have indicated no significant interest with commercial supporters.
Transposition–Advancement Flap for the Reconstruction of Segmental Auricular Defects Here, the authors present the utility of the transposition–advancement flap (TAF) for the single-stage repair of segmental auricular defects. Surgical Technique Example 1 Figure 1 illustrates a complex full-thickness 4 · 3 cm Mohs defect of the left ear. A triangular-shaped transposition flap (TF) is designed in the retroauricular sulcus with the apex of the triangle oriented inferiorly toward the side of the neck designed to align into a preexisting rhytid. The dimensions of the flap must be such that once elevated and transposed 90, the flap is both long enough and wide enough to be “folded” over itself to provide adequate skin coverage for both the posterior and anterior aspects of the ear, that is, the proximal half of the TF resurfaces the posterior aspect of the ear and the distal half the anterior ear. The size of the required TF for such a large defect is significant, and thus, a primary closure of the created secondary defect in the retroauricular sulcus is often not possible. Consequently, linking the TF to a curved advancement limb (CAL), at least 3· the width of the secondary defect, laterally along the parietooccipital scalp not only enables greater tension free movement of the TF itself but also allows direct primary closure of the created secondary defect. The curved nature of this advancement limb (as opposed to a straight limb) enables a greater recruitment of the lax tissue of the occipitoparietal scalp. The degree of curvature adopted may be modified according to each patient’s individual tissue laxity in this region.
The defect shown in Figure 1 was extended to involve the helical rim. An antihelical cartilage stent was then harvested from the contralateral ear and sutured in place to recreate the structural framework of the midhelical rim and maintain the height of the ear. The TAF is dissected extensively in a subcutaneous plane. The key primary stitch, a buried vertical mattress suture, approximates the leading edge of the CAL to the retroauricular sulcus. This movement closes the secondary defect created by the transposition limb and also facilitates the movement of the TF itself. The proximal aspect of the TF is then sutured to resurface the posterior aspect of the ear with the distal aspect of the TF being “wrapped round” the cartilage baton providing coverage for the anterior aspect of the ear, with the tip of the TF lying within the conchal bowl. Great care is taken to ensure the flap is “draped” without tension across the cartilage baton. The CAL within the occipital scalp is then sutured according to the “rule of halves.” Example 2 Figure 2 illustrates a Mohs defect, at the junction of the upper and middle third of the ear, approximately 1 cm wide and 4 cm in length. A small remnant remained at the superior crus of the helix. In this case, the TAF was performed in conjunction with a helical rim advancement flap. The TF limb of the flap in this case was initiated from the most inferoposterior aspect of the surgical defect (the midpoint of the retroauricular sulcus in this case) and elongated to the ipsilateral angle of the jaw to ensure enough length to allow this limb to be “draped” in a vertical fashion (rather than horizontally as in Figure
41:8:AUGUST 2015
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
