© 2000 by the American Society for Dermatologic Surgery, Inc. • Published by Blackwell Science, Inc.ISSN: 1076-0512/00/$15.00/0 • Dermatol Surg 2000;26:495–496

SURGICAL GEM

Stellate Purse-String Closure

Minh Dang, MD and Steven S. Greenbaum, MD

Skin and Laser Surgery Center of Pennsylvania, Philadelphia, Pennsylvania

background.

There are fundamental concepts we use in man-aging surgical defects. Whether planning a primary closure or alocal flap, we frequently modify the basic design to maximizeaesthetic outcomes, taking into consideration a number of fac-tors including the location of the defect and tissue availability.

objective.

We describe the stellate modified purse-string clo-sure, a novel flap modification.

method.

Report of an illustrated case.

result.

A patient with vertex scalp defect was reconstructedusing the stellate purse-string flap.

conclusion.

Certain modifications of commonly used re-constructive techniques can be utilized in specific situations toenhance cosmesis. Advantages of this modification are dis-cussed.

THE PURSE-STRING closure has proven to be a valu-able tool in dermatologic surgery. It is versatile and canbe modified to better suit a given surgical defect.

1,2

Thestellate flap we are describing is a modified circumfer-ential advancement or purse-string closure, where theburied suture is placed subcuticularly. This flap is use-ful for medium-size defects on the scalp, shoulder, orupper back, where the skin is generally inelastic and aside-to-side closure may not be possible or may resultin an extensively long scar. Y-plasty and its variationsresulting in stellate-shaped closures have been com-monly used as a technique for scalp reduction, wherethe defect is reduced by dog-ear excisions and side-to-side closures.

3,4

For very large defects, the stellatepurse-string closure may not be practical because ex-tensive undermining is necessary and there would betoo much tension. Also, the cross-shaped scar that re-sults may not be aesthetically desirable.

The flap involves excising four wedges of tissue atperpendicular angles around the circular defect (Fig-ure 1A,B). This converts a round defect into a four-legged stellate defect. Depending on the location of thewound and the laxity of the surrounding skin, thelength of the tissue wedge can vary from 0.7 to 1.5times the diameter of the primary defect. After suffi-cient undermining, a 2-0 vicryl suture or other alterna-tive absorbable suture is placed circumferentially in arunning subcuticular fashion, with the needle passinghorizontally through the dermis of each leg of the flapat its mid-length (Figure 1C). The two free ends of the

suture are then pulled and secured with a surgeon’sknot. The defect is totally closed, leaving a cross-shaped scar (Figure 1D). Skin sutures can be placed torelieve tension and to reapproximate the skin edges.

The stellate modified purse-string flap is especiallyuseful for large wounds on the scalp. Most scalps donot offer much elasticity due to the galea. A side-to-side closure would result in a very long scar. Oftenonly a partial closure can be done, leaving a small re-sidual defect to heal by secondary intention. Alterna-tively, rotation flaps such as the bilateral rotation flap,O to Z closure, pinwheel flap, or others can be uti-lized. However, they must be designed much largerthan elsewhere on the body and extensive undermin-ing is necessary. The stellate modified purse-string flapallows maximum skin recruitment from all directions,requiring less extensive undermining and allowing eas-ier execution. The resulting stellate-shaped scar is cos-metically excellent, especially on the vertex of baldscalp as the bald area is reduced symmetrically.

The stellate modified purse-string flap is also veryuseful for wounds located on mobile areas such as theshoulders and upper back. Scars in these areas tend tostretch over time. Because the stellate modified purse-string flap is a circumferential advancement flap, onecan postulate that the scar will be stretched less be-cause tension is distributed in all directions. It wouldbe interesting to perform a study to document thispostulate.

Case Report

Our 73-year-old patient presented for a reexcision of a1 cm superficial spreading malignant melanoma, 0.9mm in depth, stage I, level III, on the vertex of hisscalp. A wide and deep excision through the galea was

M. Dang, MD and S.S. Greenbaum, MD have indicated no signifi-cant interest with commercial supporters.Address correspondence and reprint requests to: Minh Dang, MD,5201 Norris Canyon Rd., Suite 130, San Ramon, CA 94583.

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executed. The resulting defect measured 3 cm in diam-eter (Figure 2A).

Four wedges of tissue at perpendicular anglesaround the circular defect were drawn and excised(Figures 2B,C). Each wedge was about 1.5 cm long.Extensive undermining in the subgaleal plane wasthen performed. A 2-0 vicryl suture was placed in asubcuticular fashion circumferentially around the de-fect (Figure 2D). The two ends of the suture were thenpulled and secured with a surgeon’s knot. The wounddefect was totally closed (Figure 2E). The skin edgeswere reapproximated using interrupted 4-0 prolene.

Suture removal at the 2-week follow-up visit

showed a cross-shaped scar of excellent cosmetic ap-pearance (Figure 2F).

References

1. Greenbaum SS, Radonich MA. The purse-string closure. DermatolSurg 1996;22:1054–6.

2. Ciatti S, Greenbaum SS. Modified purse-string closure for recon-struction of moderate/large surgical defects of the face. DermatolSurg 1999;25:215–20.

3. Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in derma-tologic surgery. Chicago: Year Book Medical Publishers, 1989.

4. Roenigk HH. Scalp reduction. In: Roenigk RK, Roenigk HH, eds.Dermatologic Surgery: Principles and Practice, 2nd ed. New York:Marcel Dekker, 1996:1213.

Figure 1. Steps in the stellate modified purse-string closure: A) defect; B and C) excision offour cones at perpendicular angles aroundthe defect; D) placement of purse-string su-ture; E) resulting cross-shaped scar.

Figure 2. Photographs of our patient: A) de-fect; B) stellate flap drawn; C) four wedges oftissue excised; D) buried subcuticular sutureplaced; E) postoperatively; and F) 2 weekspostoperatively.