The "Modified" Winch Stitch
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Jacques Michael Casparian, M.D.
Assistant Professor of Medicine (Dermatology), Pathology, and Otorhinolaryngology
Kansas University Medical Center
4023 Wescoe, Division of Dermatology
3901 Rainbow Boulevard
Kansas City, Kansas 66160

Erin Jane Rodewald, Medical Student
University of Missouri-Kansas City
2411 Holmes
Kansas City, Missouri 64108

Abstract

Background: Methods described to achieve intraoperative tissue expansion have drawbacks.

Objective: We report an intraoperative tissue expansion technique using standard suture material and hemostats to create a “modified” which stitch.

Methods: A continuous running suture is placed with both ends left free. A “fixed” hemostat is placed above the skin at one end. After pulling at the other end with a second hemostat, a third hemostat is placed proximal to this hemostat just above the skin, which is left in place to produce stretching. The second and third hemostats are then used in an alternating pulling and holding fashion.

Results: This suture produces significant tissue expansion. If the desired degree of approximation is achieved, the ends of the suture can be tied together, as in the previously described winch stitch.

Conclusion: The modified winch stitch is a simple and inexpensive means to facilitate closure of wounds under a significant amount of tension.

Intraoperative tissue expansion is often used in closing wounds under significant tension. Some methods in the literature utilize devices such as balloons and the Sure-Closure. These techniques have drawbacks including expense and the need for specialized equipment which is not typically available to a dermatologic surgeon. Other methods using readily accessible equipment include towel clamps, which produce significant trauma to surrounding skin, as well as skin hooks, where the entire mechanical load is dependent on operator effort.

Recently, Casparian and Monheit described a simple, easily available means of intraorperative tissue expansion utilizing a continuous running suture called the “winch stitch.” The winch stitch that we described is a temporary multiple pulley suture which can be left in place for up to about an hour. Moreover, if desired, this temporary stitch can be pulled to achieve a greater stretching force compared with that attained at the time of initial placement.6

This report describes another temporary, multiple pulley suture that is a modification of the winch stitch. This “modified” winch stitch only requires standard suture material, such as 3-0 polypropylene, a needle holder, and three hemostats. As with the other methods outlined above, the modified winch stitch utilizes mechanical creep to achieve approximation of wound edges that are initially under excessive tension. This modified stitch has a number of advantages in producing tissue expansion, in comparison with the previously described techniques, which will be discussed.

The usefulness of permanent two loop pulley sutures to close wounds under tension has been reported in the literature for various types of closures. Snow et al, and others have described the value of two loop pulley sutures in superficial wound closures. Variations of the two-loop pulley stitch have also been reported for dermal and subgaleal closures. While the temporary and modified winch stitches also employ pulleys, the number of loops is greater, typically in the range of three to five, resulting in a greater mechanical advantage.

The previously described, original winch stitch6 is a “holding stitch” that achieves tissue expansion by using multiple pulleys to generate a load on the wound edges. This temporary stitch is performed as a continuous running suture that has the ends tied together at the time of initial placement. If desired, this temporary stitch can be pulled after its initial placement to help achieve further wound edge approximation. The slack on the suture created by tissue expansion limits the usefulness of this suture for more than a short period of time. Typically the temporary winch stitch is removed once other sutures are secured, thereby relegating its role to being a holding suture.

Like the original which stitch, the modified winch stitch is another temporary holding stitch performed using a similar technique. However, while the two ends of the temporary winch stitch are tied together at its initial placement, prior to achieving mechanical creep, this step is not required in performing the modified winch stitch. However, if the surgeon does choose to tie the two ends together, this may be performed as an optional, final step in achieving tissue expansion.

As with the other methods of tissue expansion already discussed, standard procedures to relieve tension such as undermining may be performed prior to placing the modified winch stitch. The stitch is a type of running suture, where the initial free end is not tied off. Instead, this free end is clamped above the skin surface with the first hemostat (the “fixed” hemostat). The suture is then run as a continuous running simple suture. Upon completing the desired number of throws, the suture at the end closest to the needle is then grasped with a second hemostat (the “pulling” hemostat) (Figure 1). At this time, the surgeon uses this second hemostat to pull one end of the suture away from the skin surface. This results in the wound edges being brought closer together. By employing multiple pulleys, less force is needed by virtue of the reciprocal relationship between force and distance; the greater the number of throws, the larger the mechanical advantage.

While taking care to avoid an excessive amount of tension on the wound edges, the surgeon places the third hemostat (the “holding hemostat”) just above the skin surface proximal to the pulling hemostat, and the pulling hemostat is removed (Figure 2). This “holding” hemostat is left in place for several minutes to achieve mechanical creep. After allowing the skin to be stretched, this third hemostat is lifted from the skin surface, thereby becoming the new “pulling” hemostat. The action of the second and third hemostats is then alternated analogous to the way a tug of war participant alternates his hands in a “pulling” and “holding” fashion (Figure 3).

During the period of time a holding hemostat is left in place, the tension on the wound edges diminishes because of additional mechanical creep, created by the multiple loops of the suture. The process of pulling and repositioning the hemostats can be repeated numerous times; using the second and third hemostats in a reciprocal fashion produces further closure of the wound. Similarly, one can alternate hemostats at the initial end of the wound as well, involving the first “fixed” hemostat along with another “pulling” hemostat, to achieve more uniform wound edge approximation. It is imperative to avoid the use of excessive force which may result in strangulation, as may occur with any pulley or running stitch. For this reason, this suture is typically employed selectively on wounds located on the scalp, and rarely at other sites such as the trunk and proximal limbs.

The gradual advancement of tissue also allows the surgeon to place buried sutures at each side of the winch, towards the tips of the wound. If desired, the actual securing of these sutures may be delayed until the wound edges are further approximated by virtue of additional mechanical creep. Additionally, staples or superficial sutures can be secured between the throws of the winch stitch to enhance approximation. These additional closure methods serve to further relieve the tension experienced by the winch stitch, thereby facilitating wound closure. An optional final step is to bring the two ends of the suture together across the loops of the running stitch, where they are tied together (Figure 4). In this way, the modified winch stitch can be converted to the original winch stitch once tissue expansion is at or near maximal. However, this final step has the drawback of making it more difficult to place sutures or staples between the throws of the suture, because of the diagonal component.

We do not recommend that the modified winch stitch be made left in placer longer than as a temporary “holding” suture under most circumstances, however. There may be ischemic complications associated with this multiple loop suture. Moreover, If this suture were to remain in place for days, the cosmetic result may be impaired as a result of the diagonal component contributing to suture track marks.

There are numerous advantages of the modified winch stitch compared with the original form. Because the suture need not be tied together until the end of the stretching procedure, the surgeon is able to place one or more additional throws to create more pulleys, if they are needed to facilitate wound approximation. The hemostats permit a more controlled mechanical load to be placed on the tissue. Furthermore, the fixed and holding hemostats create a passive load on the skin, without requiring active pulling to achieve stretching. Consequently, the surgeon can leave the field for a few minutes, pull on one end of the suture, and place a holding hemostat, thereby achieving greater control and efficiency in the tissue expansion process.

In summary, the modified winch stitch is a simple, inexpensive, efficient, easily assessable and readily controllable means of achieving intraoperative tissue expansion.