Chapter 4.29: The Guitar String Suture

This is a niche technique useful for reducing the size of a defect prior to flap or graft repair in wounds under marked tension. It is most commonly employed on the scalp, trunk, and extremities, though its use has been described elsewhere as well. It should probably be avoided on the face, where possible anatomical distortion, as well as the long-term fibrotic bands from the placement of these sutures, are undesirable. Of note, this technique does not entirely close a defect; instead, it serves to pull the wound edges closer together, reducing the size of the defect prior to definitive closure.

Suture choice is dependent in large part on location. Since this technique is designed to hold a fair amount of tension, generally a 3-0 or 2-0 absorbable suture is appropriate. As a large amount of suture material will remain relatively superficially in the bed of the wound, longer-lasting absorbable suture material (such as polydioxanone) should probably be avoided.

1. The desired axis of partial wound closure is visualized, and the wound edge on one side of the desired axis is reflected back using surgical forceps or hooks. Adequate visualization of the underside of the dermis is required.

2. While reflecting back the dermis, the suture needle is inserted at 90 degrees into the underside of the dermis 7-9 mm distant from the incised wound edge.

3. The first bite is executed by traversing the dermis following the curvature of the needle and allowing the needle to exit closer to the incised wound edge. Care should be taken to remain in the dermis to minimize the risk of epidermal dimpling. The needle does not, however, exit through the incised wound edge, but rather 5 mm distant from the incised edge. The size of this first bite is based on the size of the needle and the thickness of the dermis.

4. Keeping the loose end of suture between the surgeon and the patient, the dermis on the side of the first bite is released. The tissue on the opposite edge is then reflected back in a similar fashion as on the first side, assuring complete visualization of the underside of the dermis.

5. The second bite is executed by inserting the needle into the underside of the dermis 5 mm distant from the incised wound edge. Again, this bite should be performed by following the curvature of the needle and avoiding catching the undersurface of the epidermis that could result in epidermal dimpling. It then exits further distal to the wound edge, approximately 6-9 mm distant from the wound edge. This should mirror the first bite taken on the contralateral side of the wound.

6. The suture material is then pulled centrally, reducing the size of the open wound, and the suture material is tied utilizing an instrument tie. Hand tying may be utilized as well. The use of an assistant to hold the wound edges in place as far medially as possible may be helpful (Figures 4-29A, 4-29B, 4-29C, 4-29D, 4-29E.

Like the purse string suture—when it is used solely for reducing defect size—this technique does not alone result in complete defect closure. It is therefore best suited to areas that are under marked tension, areas where a skin graft will be used, or where even a large flap may have difficulty closing a defect. After placement of the guitar string sutures, a full- or partial-thickness skin graft may be used to cover the residual defect.

A double, or pulley, variation of this approach is possible as well, which may aid in adding additional medial tension on the suture material by taking advantage of the pulley effect. The benefits of the pulley effect, however, should be weighed against both the increase in retained suture material as well as the possible increased risk of tissue necrosis from the high-tension closure that may be undertaken utilizing this approach.

This technique’s name, of course, is derived from the appearance of the residual suture material between the wound edges, as the taut suture material has the appearance of guitar strings as it traverses over the underlying subcutaneous fat or fascia.

This technique results in a large volume of suture material being left in the wound for many months. Even after the suture material is hydrolyzed, it leaves behind palpable-fibrotic bands that may take months to absorb entirely, and there is a theoretical risk that these bands will not disappear entirely.

The large volume of foreign-body material that is left in the wound may increase the theoretical risk of infection. Moreover, depending on the depth of these sutures, other complications, such as sinus tract formation, are possible as well. Though these complications have not been described by proponents of this technique, they remain theoretically possible depending on individual patient circumstances and local technique variations.

The tension inherent in this approach also increases the theoretical risk of tissue necrosis and long-term residual dimpling at the lateral borders of the wound. While epidermal dimpling will occasionally occur where the arc of the suture reaches its apex at the dermal-epidermal junction, generally, a small degree of dimpling will resolve with time as the absorbable sutures are gradually resorbed.