PMID: 15996423

Issn Print: 1076-0512

Publication Date: 2005/06/01


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Immediate Skin Stretching with Towel Clips and Needles

Clifford S. Perlis; Raymond G. Dufresne

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Excerpt

ALTHOUGH THE skin naturally stretches over time, approximating wound edges for the initial closure often presents a challenge. Techniques to facilitate primary closure may either use the natural elasticity of the skin or redistribute the tension. Methods to stretch include tissue expander balloons, vertical mattress “pulley” sutures, skin stretching devices, and padded horizontal mattress sutures.1 One recently described method involves using two towel clips to reapproximate wound edges under tension.2 Although this latter, cost-effective method is significantly less time and effort intensive than many others, it is not without its own drawbacks. Towel clips can cause substantial trauma to the skin by focusing the tension on four discrete points. In tight wounds or areas with thinner skin, the clips may easily tear through the skin edges. We offer a cost-effective modification of the towel clip method that more equally distributes tension along the wound to produce nearly immediate tissue expansion.
Two 1.5 inch–long 18-gauge needles are placed along the wound edges, which are then pulled together by a towel clip (Figure 1). Following an excision and achievement of hemostasis, two needles are placed intradermally approximately 1 cm from the wound edges. The needle enters the skin, runs intradermally, and exits the skin distally (Figure 2). A towel clip is placed across the wound and over the two buried needles. The towel clip is pulled together to reapproximate the wound edges in a quick and relatively atraumatic manner (Figure 3).
The wound edges should not be undermined because that may compromise the vascular integrity of the stretched skin. To further protect vascular integrity, the towel clips may be closed tightly but should not blanch or tear the skin. The towel clip may be further tightened after 5 to 10 minutes have elapsed and some initial elasticity has been gained if additional area is required. Leaving the towel clips in place for 10 to 15 minutes is often sufficient to adequately stretch the skin. In a Mohs micrographic surgery practice, this time is used to stretch while the pathology specimens are processed.
Variations on this technique include employing longer needles (ie, spinal needles) and multiple towel clips for larger lesions. An additional towel clip is usually required for every 3 cm of wound length. In addition, this skin stretching method may clearly be combined with several closure techniques, such as partial closures, secondary intention, or local flaps. The stretching method of reapproximating wounds is particularly useful on the scalp, back, and extremities.
It should be noted that this technique does not preclude obtaining further Mohs sections, if needed. In our experience, the procedure does not induce appreciable crush artifact, tissue distortion, or reorientation, which would limit interpretation of subsequent tissue specimens on surgical mapping.
The needle and towel clip method offers several advantages over other techniques for facilitating primary repair of higher-tension wounds. This method relies on inexpensive equipment already present in most dermatologic surgery suites. In addition, the method is quick to place and, if left in place while planning the closure or processing tissue, does not add any significant time to the procedure. Finally, the technique equitably distributes tension along wound edges to decrease asymmetric stretch and the risk of tears. The needle and towel clip method is a rapid, minimally traumatic, and highly effective method for stretching skin to reduce defect size.
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