EDITOR'S NOTE: August 26, 2013: This article has been amended since it was first published to make it clear that Dr. Kelley Pagliai Redbord's description of the pulley stitch procedure was taken directly from an article published by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg.2011;37:1503-5). In her presentation, Dr. Redbord credited Dr. Yag-Howard and her article. However, this credit and attribution to Dr. Yag-Howard was not included in the article published.
WASHINGTON – The pulley stitch "is my go-to stitch for defects under tension," said Dr. Kelley Pagliai Redbord.
The pulley stitch allows for considerable reduction in the surface area of a large defect that can’t be closed by side-to-side stitches alone, making it an excellent choice for use on the scalp and legs, Dr. Redbord said at the Atlantic Dermatological Conference.
"When the tension across the wound is decreased, buried dermal sutures can be placed more easily and accurately," she said. "I use it a lot as an intraoperative tissue expander."
Dr. Redbord said that her description of the pulley stitch was taken from an article by Dr. Cyndi Yag-Howard in Dermatologic Surgery (Dermatol. Surg. 2011; 37:1503-5).*
The pulley stitch can serve as a temporary suture that can be left in place or removed, said Dr. Redbord, a dermatologist in group practice in Rockville, Md.
Courtesy of Dr. Kelley Pagliani Redbord
The pulley stitch and its modifications are effective for closing defects under tension.
The technique follows a far-near-near-far pattern, starting the stitch 8 mm from the wound edge (far), then bringing it to the opposite side just 4 mm from the wound edge (near). Dr. Redbord then reenters the stitch 4 mm from the wound edge on the initial side (near), and makes another pass to the opposite side 8 mm from the wound edge (far).
Multiple passes through the tissue create resistance that keeps the suture from slipping. "The loops of the stitch are placed at an oblique angle so that the inner and outer loops are offset and do not override each other," she noted. This technique minimizes potential skin damage from pressure necrosis caused by overriding loop sutures. The pulley stitch has a 2:1 mechanical advantage over an interrupted suture, and the additional friction of a second loop prevents the knot from slipping.
A modification of the pulley stitch is to loop the suture through an external loop on the opposite side of the incision, and pull across. "This new loop functions as a pulley and directs the tension away from the other strands," she said.
Another stitch with excellent eversion, in which the pulley stitch plays a key role, is the subcutaneous inverted cross mattress stitch (SICM). The SCIM is entirely subcutaneous, and combines the buried vertical mattress stitch and the buried pulley stitch.
The SCIM "uses the buried vertical mattress’s ability to evert wound edges and combines it with the pulley stitch’s ability to decrease tension at the wound edge," she said.
The four-step process is as follows:
• 1. Insert the needle into the dermis 3-5 mm lateral to the wound edge. Advance the needle into the upper reticular dermis, and then curve down to exit through the lower reticular dermis.
• 2. Insert the needle into the opposite edge of the wound at the lower reticular dermis and advance into the upper reticular dermis, then curve down and exit intradermally.
• 3. Insert the needle across the defect using an intradermal approach 1-2 mm lateral to the initial needle insertion point. Then, create a second buried vertical mattress stitch.
• 4. Pull the two stitches to close, which "creates a pulley effect with minimal recoil, and tie off," Dr. Redbord said.
"The pulley system locks the wound edges so that a knot can be tied without slipping," she added.
Dr. Redbord said she had no relevant financial disclosures.