untitled CORRESPONDENCE RESEARCH LETTERS The Fascial Plication Suture: An Adjunct to Layered Wound Closure M inimizing surgical wound tension is gener-ally accomplished by combining buried der-mal sutures with an epidermal closure of choice. Several improvements on the buried dermal su- ture have been proposed over the years, from the buried vertical mattress technique1 and its many variants2 to the setback dermal suture.3 Despite the unique nature of wound closure from ex- cisional surgery, most surgeons approach these clo- sures as repairs of simple incisions. The added wound tension resulting from the extirpation of the excised tis- sue, over and above the tension across the surface of the wound that would be expected even from incisional sur- gery, may not be fully alleviated with standard layered- closure techniques. In excisions of large cysts or tu- mors, significant dead space may remain even with wounds closed using dermal sutures, potentially increas- ing the risk of hematoma formation or wound infection. The plication of superficial muscle fascia has been used as a technique of choice in rhytidectomy surgery for de- cades. The popularity of this technique stems from the ability to effect long-lasting tissue drag. Extending the application of this technique to reconstructive proce- dures, Dzubow4 described the use of multiple fascial pli- cation sutures using nonabsorbable sutures in lieu of der- mal sutures for select Mohs defects on the head and neck. Other authors have suggested fascial imbrication for se- lect scalp and forehead defects.5 The fascial plication technique described herein is best suited to high-tension repairs on the trunk, neck, and shoulders—areas where general dermatologists per- form the bulk of their procedures. Further study is needed to assess whether this technique confers a significant ben- efit over standard layered closure techniques. A B C D Figure 1. A, First throw, cross-sectional view; B, second throw, cross-sectional view; C, first throw, surgeon’s-eye view; D, second throw, surgeon’s-eye view. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 12), DEC 2009 WWW.ARCHDERMATOL.COM 1454 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 Methods. After the excision is accomplished, the wound is widely undermined in the level of the superficial fat, and adequate hemostasis is obtained. For all but the deepest ex- cisions, the muscle fascia will not be visible at this point. With absorbable suture (I favor 2-0 Vicryl; Ethicon Inc, Somerville, New Jersey), the first throw is accomplished by inserting the cutting or reverse-cutting needle gently into the fat and through the superficial fascia approximately 2 to 5 mm from the undermined edge of the wound (Figure 1A and B). A successful bite of the fascia may be tested by gently pulling on the suture and watching for char- acteristic uplifting of the area. The second throw is then performed by repeating the procedure on the opposite edge and at the same depth (Figure 1C and D). The knot is then tied, which results in a visible pleat and leads to a more fusiform appearance of the wound (Figure 2 and Figure 3). Placing the sutures at the far lateral under- mined edges should be avoided owing to a tendency for dimpling of the overlying skin. If 1 fascial plication suture is used, this may be placed in the vertical midline of the wound; otherwise, a series of multiple evenly spaced pli- cation sutures may be placed. Comment. While this technique might theoretically in- crease risk of postoperative pain from deep tissue trauma or infection through the breach in the superficial muscle fascia, these issues have not been a problem in my ex- perience. In hundreds of wound closures using this tech- nique on the shoulders and trunk, I have found im- proved outcomes with less spread-scar formation, less dehiscence, and less tendency toward hematoma forma- tion, especially on large defects. A randomized con- trolled trial is needed to determine whether this tech- nique truly offers a clinically and statistically significant benefit over standard layered wound closure tech- niques. This technique shifts the burden of tension from the dermis to the fascia, theoretically resulting in a lower- tension closure, dramatically improved dead-space mini- A B Figure 3. Defect before (A) and after (B) placement of single fascial plication suture; note enhanced fusiform appearance of the wound. Scale bar measures 6 cm in both panels. A B Figure 2. A, Final wound appearance, cross-sectional view; B, final wound appearance, surgeon’s-eye view. (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 12), DEC 2009 WWW.ARCHDERMATOL.COM 1455 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 mization, and, hopefully, a cosmetically and function- ally improved reconstruction. Accepted for Publication: July 14, 2009. Author Affiliation: North Florida Dermatology Associ- ates, Jacksonville, Florida. Correspondence: Dr Kantor, North Florida Dermatol- ogy Associates, 1551 Riverside Ave, Jacksonville, FL 32082 (jonkantor@gmail.com). Financial Disclosure: None reported. 1. Zitelli JA, Moy RL. Buried vertical mattress suture. J Dermatol Surg Oncol. 1989; 15(1):17-19. 2. Alam M, Goldberg LH. Utility of fully buried horizontal mattress sutures. J Am Acad Dermatol. 2004;50(1):73-76. 3. Kantor J. The set-back buried dermal suture: an alternative to the buried ver- tical mattress for layered wound closure. J Am Acad Dermatol. In press. 4. Dzubow LM. The use of fascial plication to facilitate wound closure follow- ing microscopically controlled surgery. J Dermatol Surg Oncol. 1989;15(10): 1063-1066. 5. Radonich MA, Bisaccia E, Scarborough D. Management of large surgical de- fects of the forehead and scalp by imbrication of deep tissues. Dermatol Surg. 2002;28(6):524-526. Lack of Lower Extremity Hair Not a Predictor for Peripheral Arterial Disease P eripheral arterial disease (PAD) afflicts 8 to 12 mil-lion Americans, but nearly 75% of them areasymptomatic.1 Physicians rely on history and physical examination to determine which patients re- quire further evaluation. Physical findings that have been associated with arterial disease include a unilaterally cool extremity, skin atrophy and lack of hair, and abnormal pedal pulses, among others.2 The disease spectrum ranges from exertional calf pain to chronic limb ischemia ne- cessitating amputation. The suspicion of arterial disease often leads to further examination of the lower extrem- ity vascular supply. Measurement of the ankle-brachial index (ABI) is a noninvasive method for detecting PAD and is about 95% sensitive and specific when the diag- nostic cutoff is 0.9.3 In general, the accepted ABI for the presence of PAD is lower than 0.9, and that for severe disease is lower than 0.7. The present observational case-control study was un- dertaken based on the clinical observation that many men seem to have hairless lower extremities. Our goal was to determine whether this physical sign is a predictor of PAD. Methods. After obtaining institutional review board ap- proval, we enrolled 50 subjects from Hershey Medical Cen- ter in the study. Twenty-five control subjects were re- cruited from various outpatient clinics and had documented normal ABI measurements (�0.9). Twenty-five subjects with PAD were recruited from the vascular clinic and had either an ABI lower than 0.9 or abnormal lower extremity arterial duplex findings. Subjects with ABIs lower than 0.9 due to disease other than PAD were excluded. Subjects with diabetes who had abnormal ABIs were included in the disease group. Due to arterial calcifica- tion, the vessels in subjects with diabetes may be less com- pressible and so might generate falsely elevated indices. Thus, the vascular disease of patients with diabetes is likely worse than the measured value. Lower extremity hairs were counted on all subjects. First, a measurement was taken from the anterior tibial tuber- osity to the proximal portion of the lateral malleolus. The distance was divided by 3, and hairs were counted at a lo- cation one-third of the distance proximal to the lateral mal- leolus. Scissors were used to trim hairs at this location to several millimeters in length. Temporary black hair dye was then applied to the area for approximately 1 minute. Ex- cess dye was removed, and we took 2 pictures of the area using a magnified digital photography technique, which involved pressing the camera lens against the skin to make full contact while the photograph was taken. All photo- graphs were taken with a Nikon D80 camera (Nikon USA Inc, Melville, New York), stored on a memory card, and uploaded to a computer where Photoshop (Adobe Sys- tems Inc, San Jose, California) was used to crop them to standard dimensions of 2572 � 1564 pixels. Hair count analyses were performed, and data were categorized as either leg hair present (1 or more hairs pre- sent in the examined field) or leg hair absent (no hairs present in the examined field). This assessment was per- formed on data from each of the 50 subjects. Statistical analysis was then completed using a �2 analysis. Results. Of the 50 patients recruited for this study, 25 had existing PAD, and 25 were healthy controls (Table). Subjects in the control group had a mean age of 65 years (age range, 50-80 years). Those in the PAD group had a mean age of 75 years (age range, 55-88 years). Sixty- four percent of patients with PAD had absent leg hair, and 40% of patients without PAD had absent leg hair (Table). Using �2 analysis, we found no statistically sig- nificant relationship between disease presence and ab- sence of lower extremity hair (P = .09). Comment. Peripheral arterial disease involves atheroscle- rotic occlusions in the arterial system distal to the aortic bifurcation.4 It is mainly a disorder of advancing age, and one’s risk of PAD is increased by cigarette smoking, dia- betes, hypercholesterolemia, and hypertension.4 Because many patients are asymptomatic, physicians must recog- nize the early signs and take appropriate action. The goal of the present study was to determine whether the ab- sence of lower extremity hair is a useful predictor of PAD. No statistically significant difference was found between the numbers of diseased patients without leg hair (n = 16) and control patients without leg hair (n = 10) (P = .09), sug- Table. Presence of Lower Extremity Hair in Patients With and Without PAD Lower Extremity Hair Patients, No .(%) With PAD a (n = 25) Without PAD (n = 25) Present 9 (36) 15 (60) Absent 16 (64) 10 (40) Abbreviation: PAD, peripheral arterial disease. a By �2 analysis, no statistically significant relationship was found between disease presence and absence of lower extremity hair (P = .09). Jonathan Kantor, MD, MSCE (REPRINTED) ARCH DERMATOL/ VOL 145 (NO. 12), DEC 2009 WWW.ARCHDERMATOL.COM 1456 ©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021