Chapter 5.25: The Pulley Suture

The pulley suture technique relies on the pulley effect of multiple loops of suture to permit the closure of wounds under even significant tension. Since this approach may lead to marked tension across the wound surface, it is typically used in scalp reduction surgery or other areas where the final cosmesis is less critical. This approach may also be used as a temporary technique to better approximate wound edges and allow deep sutures to be placed expeditiously, after which the pulley sutures may be removed.

Suture choice is dependent in large part on location, though because this technique is expressly designed for wounds under marked tension, a 3-0 nonabsorbable suture works well on the scalp and back, though when the area is under particularly marked tension a 2-0 nonabsorbable suture may be helpful.

1. The needle is inserted perpendicular to the epidermis, approximately 8-12 mm distant to the wound edge.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits between the incised wound edges.

3. The needle is then reloaded and reinserted from the underside of the dermis on the contralateral wound edge, exiting approximately 4 mm from the wound edge. The exit point is just distal (relative to the surgeon) from the entry point on the original side.

4. The needle is then reloaded and inserted at 90 degrees perpendicular to the epidermis approximately 4 mm from the wound edge on the contralateral side of the incision line (the original entry side).

5. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits between the incised wound edges.

6. The needle is then reloaded and reinserted from the underside of the dermis on the contralateral wound edge, exiting approximately 8-12 mm from the wound edge. The exit point is just proximal (relative to the surgeon) from the entry point.

7. The suture material is then tied off (Figures 5-25A, 5-25B, 5-25C, 5-25D, 5-25E, 5-25F, 5-25G).

This is a useful technique for select wounds, as it permits the wound edges to come together even under marked tension. Since the sutures are transepidermal, however, it may also be associated with significant cross-hatching or residual suture track marks if they are left in place for any amount of time. Therefore, one frequently used approach is to use pulley sutures on a temporary basis intraoperatively to permit placement of other sutures; once the other sutures have been placed, the pulley sutures may be removed before the end of the procedure.

If pulley sutures are left in place, they should probably be removed in a timely fashion, and certainly should be left in place for no longer than 1 week.

The two loops of suture are slightly offset from each other, as the suture traverses the incised wound edge on an oblique angle, which helps lessen the risk of tissue necrosis and tear-through.

This technique may be used to prepare the wound for placement of a buried pulley suture, such as the pulley set-back dermal suture. As long as undermining has been carried out effectively, utilizing a pulley technique with a thicker gauge suture material should allow for effective closure of all but the tightest wounds.

In areas under extreme tension, a three-loop variation of this approach is possible as well, allowing for an even more dramatic pulley effect.

A double variation of this approach, the tandem pulley stitch, has been recently described as well.

The greatest drawbacks of this approach are the possible residual track marks and wound spread that may be seen when wounds under marked tension are closed. This technique may elicit an increased risk of track marks, necrosis, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried pulley techniques. Therefore, sutures should be removed as early as possible (ideally intraoperatively) to minimize these complications, and consideration should be given to adopting other closure techniques in the event that sutures will not be removed in a timely fashion.

Suture removal with this technique may be more involved than with simple interrupted sutures; the inner loop is generally easier to cut at the time of suture removal, though if sutures are left in place for an extended period of time they may have a tendency to be overgrown by the surrounding epidermis.