LAS VEGAS – A simple purse string stitch can provide an elegant closure of challenging lip defects after Mohs surgery.
"It's quite easy to perform. It's useful for numerous areas of the lip. It's low-risk, with low morbidity, and requires little down time," yet provides an excellent aesthetic outcome, Dr. Kenny J. Omlin said at the annual meeting of the American College of Mohs Surgery.
The keys to reconstruction using the purse string stitch start with undermining the entire surgical wound in the subdermal plane to decrease sheering forces.
Photos courtesy Dr. Kenny Omlin
A patient is shown before undergoing a purse string stitch closure.
The same patient is shown after undergoing the procedure.
Next, uniformly place an absorbable suture in the deep dermis using a small needle, with circumferential tissue advancement to distribute the tension uniformly, explained Dr. Omlin, chief of Mohs surgery for Kaiser Permanente Napa-Solano County, Vacaville, Calif.
The same patient is shown before undergoing a complex linear closure.
The patient is shown after undergoing the procedure on her upper lip.
"There is a uniform stitch all the way around the perimeter" of the wound with particular attention to precisely aligning the vermilion/cutaneous lip junction, he said.
The cosmetic outcomes of the two closures appear comparable.
The purse string stitch creates a trestle-like framework that supports normal wound healing.
As with any reconstructions on the lower cosmetic subunits of the face, he tells patients to practice a "ventriloquist act" while healing and not talk much or move their mouths much.
One of his patients provided an excellent case-control comparison of wound closures. She initially presented with a basal cell carcinoma that intersected both the cutaneous and vermilion margins of her left upper lip.
After Mohs surgery, Dr. Omlin did a standard, complex linear closure, followed later by two pulsed-dye laser treatments. At 1-year follow-up, the patient was satisfied with an acceptable cosmetic outcome.
Six months later, she presented with a nearly identical basal cell carcinoma on the right upper lip. This time, Dr. Omlin used a purse string stitch after Mohs surgery. "It takes all of 5-10 minutes," he noted. The aesthetic result was "nearly perfect" a month later, said Dr. Omlin, also of the University of California, Davis.
On the central upper lip, "a lot of our older patients tend to have absent philtral columns or an absent Cupid's bow. Again, this is an excellent place for a purse string stitch," he said.
For patients on warfarin, the purse string stitch is great for hemostasis when repairing Mohs defects of the lip, Dr. Omlin added.
He also likes to use it for defects at the oral commissure. "Sure, you can use an elaborate cross-lip commissuroplasty or other elaborate techniques," but a simple purse string stitch reproduces the accordion-like structure of the oral commissure.
After wound granulation and healing, at 3 months it's hard to tell that a defect was ever there, he said.
In an interview after his presentation, he said he was pleased by the enthusiasm expressed by other attendees at the meeting for his simple surgical pearl.
Dr. Omlin said he has no relevant financial disclosures.