Chapter 5.28: The Dynamic Winch Stitch

Modified winch stitch

Like the standard winch stitch, this is a niche intraoperative tissue expansion approach. When closing wounds under marked tension, buried or transepidermal pulley sutures may be insufficient to permit closure. Placing a temporary winch stitch, in order to take advantage of mechanical tissue creep, aids in closing these select defects. The suture is removed intraoperatively, after other tension-relieving sutures have been placed.

Since this is a temporary suture, choice of suture material is guided more by resilience and resistance to breakage than by any concern regarding permanent track marks. Therefore, a 2-0 or 3-0 monofilament nonabsorbable suture is generally appropriate in most areas where this technique would be used, such as the trunk and scalp.

1. The needle is inserted perpendicular to the epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits the skin on the contralateral side.

3. The needle body is grasped with surgical forceps in the left hand, with care being taken to avoid grasping the needle tip, which can be easily dulled by repetitive friction against the surgical forceps.

4. The loose tail of suture material is secured in place with the aid of a hemostat.

5. Starting proximal to the prior throw relative to the surgeon, steps (1) through (3) are then repeated sequentially until the desired number of throws is placed.

6. The leading edge of suture is then pulled taut and secured in place with a hemostat.

7. After allowing time for tissue creep to occur, one hemostat is gently pulled, increasing tension across the sutures and bringing the wound edges closer together. At maximal pull, an additional hemostat is then placed at the junction of the skin and the suture material, securing the suture material in position. The hemostat that was pulled is then removed. This step is repeated until the desired degree of tension relief has been accomplished.

8. Once permanent sutures are placed, the hemostats are removed and the suture material is pulled out (Figures 5-28A, 5-28B, 5-28C, 5-28D, 5-28E, 5-28F, 5-28G, 5-28H).

This is a multiple pulley tissue expansion technique that relies on the multiple throws of suture to minimize tension and secure the wound edges in position.

This technique is not an actual closure technique; that is, the sutures are not left in place to permit tension reduction or wound-edge apposition, but rather to allow placement of the actual tension relieving sutures that may not be easily placed in extreme high-tension closures.

The individual bites should be large enough to minimize suture material tear-through; otherwise, wounds under extreme tension, especially those with a relatively atrophic dermis, may not support the suture material which could simply tear through the friable skin, leading to additional defects and associated cosmetic compromise.

Depending on the degree of tension and the thickness and resilience of the dermis, this technique may lead to some epidermal and dermal damage that may not be desirable. Therefore, care should be taken to use this approach only when absolutely needed. The risk of necrosis, while mitigated by the fact that these sutures are only left in place temporarily, is still a possibility, and even in the absence of true tissue necrosis the trauma of crush injury to the delicate dermal vasculature is a possible risk as well.

With any suturing technique, knowledge of the relevant anatomy is critical and it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material. For example, the needle may pierce a vessel leading to increased bleeding.

Given the possible problems associated with this approach, a double or pulley buried suture is preferable for effecting closure in high-tension areas when feasible. This technique remains a useful adjunct, however, in cases of extreme tension where mechanical tissue creep may be relied on to add laxity to a very tight closure.