A retrospective study to evaluate the efficacy and safety of staged purse-string sutures for the reconstruction of surgical defects on skin using computer image analysis program.

Background: Staged purse-string suturing has been recently introduced for the reconstruction of round or oval defects following tumor excision. Objective: The aim of this study was to evaluate the clinical advantage of staged purse-string suturing for the reconstruction of relatively large skin defects. Materials and
Methods: Twenty-one patients who received staged purse-string sutures were included in the study. To evaluate the defects and scar sizes objectively, computer-based image analysis was used. A modified observer scar assessment scale (OSAS) was applied for evaluating the clinical efficacy.
Results: The mean primary postsurgical defect size in the total 21 cases was 1446.2 ± 1187.2 mm2, and the mean final scar size was about 268.1 ± 252.3 mm2. The defect area decreased gradually as staged purse-string suturing was performed. The mean total modified OSAS was 7.96 ± 1.69.
Conclusion: Staged purse-string sutures might be an alternative reconstructive method for relatively large round or oval skin defects. Copyright:

Introduction

Reconstruction of round or oval defects following tumor excision can be accomplished in a variety of ways. To close this type of defect, primary closure, healing by secondary intention, a skin flap or skin graft are usually available.[12] Of these methods, purse-string suturing creates uniform tension to the wound, enhances hemostasis at the tissue edge, and can significantly decrease the size of the defect.[34] Purse-string suture methods have various modifications.[56] Recently, staged purse-string suturing was introduced, which repeats purse-string closures at regular intervals until the wound is fully recovered.[7]

Herein, we aimed to evaluate the clinical efficacy and safety of staged purse-string sutures using computer-based image analysis.

Materials and Methods

Study design

This study was designed as a retrospective study. Chart and clinical photo review was performed on patients with malignant tumors who underwent purse-string closure for reconstructing skin defects during the period from June 1, 2012 to April 30, 2018. Patients under the age of 18, patients who did not follow-up after undergoing the pulse-string closure, patients who were pregnant or lactating, and patients without clinical photos were excluded. This study was approved by the institutional review board at the Dankook University Medical Center (DKUH-2020-03-037).

Surgical technique

First, subcuticular purse-string sutures with monofilament absorbable suture material were made close to the primary round postoperative wound just after tumor removal. The first-stage purse-string suturing was done at the level of the fat layer at first, and secondarily at the dermo-fat junction or lower dermis. Therefore, first-stage purse-string suturing included two kinds of purse-string sutures. If the wound was partially closed by first-stage purse-string suturing, purse-string suturing was repeated several times at regular seven to 10-day intervals until the wound was completely closed or small enough to be healed by secondary intention [Figure 1].

Figure 1

Serial clinical photographs of subcuticular staged purse-string sutures and measurements of the defect area using a computer-based image analysis. (a) A round- to oval-shaped defect was seen after the removal of skin cancer. (b) The defect area size decreased after first-stage subcuticular purse-string suturing. (c) The defect area decreased more with second-stage subcuticular purse-string suturing in 1 week

Efficacy evaluation

To evaluate the size of the defects and scars objectively and quantitatively, we used an image analysis program (TOMORO Scope Eye v3.5, Techsan Community, Seoul, Korea) [Figure 1]. To clinically evaluate the final scar, a modified observer scar assessment scale (OSAS) including the pigmentation, thickness, relief, and surface area was done by independently by three dermatologists.

Safety evaluation

To evaluate the safety of the procedures, infections, bleeding, spitting, dehiscence, hypertrophic scars, and systemic symptoms were identified.

Statistical analysis

The results were expressed as mean ± standard deviations

Results

Characteristics of patients and skin lesions

A total of 21 patients were included in the study. The mean age was 69.1 years. Eleven were male and 10 were female. Of the 21 patients, there were 15 cases of squamous cell carcinoma, two cases of dermatofibrosarcoma protuberance, and one case each of porocarcinoma, atypical xanthomatous dermatofibroma, and basal cell carcinoma or malignant melanoma. There were seven cases of head and neck, seven cases of arm and leg, four cases of trunk, and three cases of hand and foot cancer.

Changes in defect size with staged purse-string sutures

Until the wound was completely healed, five patients (23.8%) needed only first-stage purse-string suturing, nine patients (42.9%) had second-stage purse-string sutures, two patients (9.5%) underwent third-stage purse-string suturing, and five patients (23.8%) had fourth-stage purse-string suturing. The mean area of the primary defect after tumor removal in all 21 patients was about 1446.2 ± 1187.2 mm2. The mean area of the final scar in all 21 patients was 268.1 ± 252.3 mm2 [Table 1]. Compared to the primary defect size, the final scar size after staged purse-string suturing was markedly reduced, and all the patients were satisfied with the cosmetic results [Figure 2].

Table 1

Change of defect area with staged purse-string closure

	n (%)	Mean±SD (range)
		Defect area (mm2)	1st post purse (mm2)	2nd post purse (mm2)	3rd post purse (mm2)	4th post purse (mm2)	Final scar (mm2)
Total patients	21 (100)	1446.2±1187.2 (217.9-4780.3)					268.1±252.3 (19.0-921.3)
The number of times of purse string suture
Sub group
1 time	5 (23.8)	631.7±334.5 (218.5-1096.2)	145.3±134.2 (16.17-338.3)				266.3±279.2 (23.6-748.1)
2 times	9 (42.9)	1252.4±1014.1 (217.9-3658.7)	481.3±464.3 (27.6-1544.7)	282.0±237.9 (20.5-747.5)			272.8±227.2 (19.0-652.9)
3 times	2 (9.5)	1070.2±325.7 (839.9-1300.5)	247.6±199.3 (106.7-388.6)	176.0±194.5 (38.4-313.5)	90.7±92.5 (25.2-156.1)		76.9±73.1 (25.2-128.7)
4 times	5 (23.8)	2668.8±1491.1 (1285.4-4780.3)	581.9±346.9 (250.3-969.3)	356.4±273.9 (80.5-720.4)	255.4±179.7 (39.7-471.4)	180.6±188.2 (19.8-452.7)	191.8±81.3 (82.1-260.0)

Figure 2

The clinical and cosmetic results of staged purse-string suture closure. (a) The patient was diagnosed with squamous cell carcinoma on the foot dorsum. (b) A circular defect developed after Mohs microscopic surgery. The defect size was about 430.69 mm2. (c) In 7 months, the scar size was about 150.36 mm2 after staged purse-string suture closure

The modified observer scar assessment scale

The modified OSAS, a validated surgical outcome, was 7.96 ± 1.69. The mean pigmentation was 2.52 ± 0.66, the mean thickness was 1.69 ± 0.73, the mean relief was 2.06 ± 0.73, and the mean surface area was 1.68 ± 0.61.

Safety profile

No serious side effects developed until the surgical defect area was completely recovered. Five patients complained of mild hypertrophic scars, which were controlled with intralesional triamcinolone injections.

Discussion

For large skin defects, conventional primary closure is not usually recommended, even if it is very simple.[8] Local skin flaps and skin grafts could be effectively used for larger defects and induce good cosmetic results, but they need longer operation times and complicated techniques. Especially in the failure of skin flaps or graft survival, secondary restoration may be very difficult.[9] Secondary intention healing has the advantage of being economical and is simple compared to skin flaps or grafts, and can produce good cosmetic results in areas such as the face and neck.[59] However, it may cause infection and pain due to persistent open wounds, which require wound management and long recovery times.[59] Purse-string closure is useful for repairing round or oval defects in terms of its circumferential approximation.[2] However, it may have difficulties in achieving the complete closure of relatively large defects and need longer times for healing compared to primary closures, skin flaps, or grafts. It also increases the likelihood of postoperative complications, such as infections.[7] To overcome the above limitations of purse-string sutures, staged purse-string suturing has been introduced recently to efficiently reconstruct large defects.[6] It is a modified method of repeated purse-string suturing and can be used to restore relatively large defects faster and provide cosmetically superior results.[7] In this technique, purse-string suturing can be repeated at regular 7- to 10-day intervals until the wound is fully recovered. Staged purse-string suturing can also induce better and faster wound healing based on the theory of circumferential tissue recruitment.[7] In the present study, we investigated the effect of purse-string sutures in reducing the defect size using a computer-based image analysis system. This system provides us various kinds of information about wounds such as size, character, color change, and so on. For example, in the calculation of the defect size or scar size, it calculates automatically the polymorphous wound shape contrary to the previous study, which checks simply long and short axis.

The absolute defect size decreased gradually when purse-string suturing was repeated periodically, and the final scar size of all patients was reduced markedly from the mean initial defect size of 1446.2 ± 1187.2 mm2 to the final defect size of 268.1 ± 252.3 mm2.

Compared to the primary defect size, the reduction in wound size was greatest in first-stage purse-string suturing, and it decreased gradually in the next purse-string suturing. This might be due to the limits of tissue movement and the elasticity of the tissue to return to its original position and shape, even if an additional purse-string suturing was done.

The mean total score of the modified OSAS evaluated by independent three dermatologists was less than 10. This means that the staged purse-string closure method was cosmetically acceptable. The modified OSAS in previous studies, except for vascularity and pliability item scores, were reported as 7.86 points for postoperative linear scars, 11.68 points in secondary intention healing, and 16.61 points in skin grafts.[1011121314]

In the present study, serious adverse events, including infections, bleeding, spitting sutures, and wound dehiscence, did not occur after purse-string closure although the patients cleaned their wounds by themselves according to home dressing guidance during the follow-up.

This might be due to the fact that the operation time in purse-string suturing was relatively shorter, and the technique was simpler than that for skin flaps or grafts. In addition, with the development of easy and safe dressing materials, appropriate home care by the patient could be enough to prevent postoperative complications.[15] This study is limited by its small sample size (21 patients), use of a single center for data, and the absence of controls due to the retrospective nature.

In conclusion, it might be postulated that staged purse-string suturing could be an alternative reconstructive method for relatively larger round or oval skin defects and could be applied easily and safely.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.