Tacking Sutures to Shrink Surgical Defects near Free Margins

Surgical Challenge

When contemplating repair options, free margin distortion must be limited to prevent epiphoria, ptosis, ectropion, vision or hearing impairment, and loss of symmetry.¹ Surrounding actinic damage, ability for recurrence monitoring, tissue match, and the most favorable functional and aesthetic results must also be considered. Purse string repairs effectively shrink surgical defects circumferentially but can cause free margin distortion.

Solution

Interrupted tacking sutures to first shrink the defect allow the surgeon to control the direction of tension and contraction axis, and thus avoid free margin distortion. We recommend this approach for larger temple, forehead, and ear defects (especially in older patients with more laxity), to first shrink the defect, followed by placement of a full-thickness skin graft or porcine xenograft to repair the residual defect (Figure 1). While skin grafting without first placing dermal tacking sutures may be considered, use of a smaller graft offers a lower metabolic requirement, less potential contracture, and better cosmesis.^1,2 To date, we have performed this repair on eight temple/forehead/eyebrow region cases and two helical rim cases (Figure 2). Prior to tacking suture placement, mean of the maximal dimension was 4.6cm (range=2.2-7.0 cm) and mean defect area was 19.3cm² (range=2.8-35.7cm²). After dermal tacking suture placement, mean defect size was reduced to 10.7cm² (range =1-20.4cm²). Mean percent reduction in area was 48.5% (range=20-66%). All cases had an expected postoperative course without complications. By 10-12 weeks, all were fully healed and pleased with their results with no evidence of free margin distortion or functional complications.

Tacking Sutures. Figure 1.

Step-by-Step Guide to Tacking Suture Placement. In each case, the surrounding tissue was widely undermined. (A) Dermis/subcutaneous tissue was grabbed from peripheral wound edge with the needle of polyglactin-910 suture, (B) Tacking suture placed into soft tissue within central aspect of defect, (C) After suture placement, with evidence of shrinkage of defect with single suture (D) Another tacking suture being placed, (E) After suture placement, (F) Dermis/subcutaneous tissue grabbed from peripheral wound edge, (G) Tacking suture placed into central aspect of defect, (H) Dermis/subcutaneous tissue grabbed from peripheral wound edge, (I) Dermal Tacking Complete. Tacking sutures are placed all along the entire periphery of the defect except at the aspect where distortion of the free margin would occur. As shown here, no tacking sutures were placed at the medial-most aspect of the defect to prevent pulling on the upper eyelid. After tacking, a smaller porcine xenograft or full thickness skin graft can be applied.

Tacking Sutures. Figure 2.

Tacking Suture Repair of Temple (A-J), Forehead (K-N), and Ear (O-Q)

Patient 1 (Temple): A. Defect, B. After Dermal Tacking, C. With Porcine Xenograft, D. 1-week post-op, E. 16-months post-op; Patient 2 (Temple/Forehead): F. Defect, G. After Dermal Tacking, H. With Porcine Xenograft, I. 2-weeks post-op, J. 2-months post-op; Patient 3 (Forehead): K. Defect, L. After Dermal Tacking, M. With Porcine Xenograft, N. 5-weeks post-op; Patient 4 (Helical Rim): O. Defect, P. After Dermal Tacking with Full Thickness Skin Graft, Q. 3-months post-op.