Palmieri’s double suture skin repair: a new double suture approach to cases of skin cancer and ulcerative lesions

We describe two case reports to assess the efficacy of a new method suitable to close small-sized pressure ulcers and cancer-related skin lesions.

synthetic, mid-term absorption suture with precision point cutting edge 3/8 needle) thin contiguous stitches to reduce the amount of bulky collagen reaction, with final strong overlapping fusion of the skin margins.

First case presentation
A 42-year-old woman underwent delayed nipple-sparing mastectomy, tissue expanders and submuscular and partial subcutaneous prosthesis. She developed a small pressure ulcer (4 × 4 mm) caused by friction in the lower inner left quadrant of her left breast ( Figure 1A) oozing some serous fluid which was cultured and did not display any bacterial growth. This pressure ulcer was due to the weight of the silicon prosthesis applied to the patient's tense breast skin.
The patient came to the Poliambulatorio del Secondo Parere (Modena, Italy), signed the informed consent and was immediately scheduled for prosthesis change in 2 weeks' time to undergo a primary closure of pressure ulcer with our 'fine thread technique' and evaluate the intraoperatively harvested newly-formed scar by histological analysis of hematoxylin and eosin (H&E) standard tissue stain.
Suturing technique (Palmieri's suture) A 6/0 suture (GLICOFIL® LAC, Assut Europe, Italy) with a double precision cutting point needle was carefully used to perform a purse string around the wound just beneath the deep dermis, without injuring the prosthesis shell. The thread was tied, completely sealing the * Correspondence: tommaso.iannitti@gmail.com 2 Poliambulatorio del Secondo Parere, Modena, Italy 5 School of Biomedical Sciences, University of Leeds, Mount Preston Street, Garstang building, Leeds LS2 9JT, UK Full list of author information is available at the end of the article lumen of the pressure ulcer, thus preventing any leakage. Two horizontal lines, 3 cm long and 1 cm apart from the upper and lower pole of the sutured circumference, were then scraped with a blade No. 15 up to the deep dermis to expose the microvascular dermal network as newlyformed wound lips. A second layer of 5/0 nylon stitches, with single precision point cutting edge 3/8 circle needle (ASSUNYL®, Assut Europe, Italy), at 2.5 mm intervals, was delivered to join the two lips and bury the previously performed purse string ( Figure 1B). An adhesive skin closure (3M™ Steri-Strip™; 3M Italia Spa, Milan, Italy) reinforced the suture line, and polyurethane adhesive films covered the operated area. The patient received 1 g ampicillin three times a day for 3 days. No further medication was given to the patient until the moment of the final surgery.

Surgical procedure
The procedure was performed 12 days after the suturing of the pressure ulcer in order to verify the new suture healing outcome from the histological point of view and state the feasibility and effectiveness of our method (less invasive than removing and replacing the prosthesis and finally repairing the skin defects).
Under general anesthesia, the adhesive skin closure over the suture was removed and the sutured skin segment was resected with the knife on a 3 cm long and 1.2 cm wide segment which was processed for histology. Then the prosthesis was delivered through the previous incision, the cavity was irrigated with saline and povidone-iodine for three times and a new prosthesis was inserted. The deep subcutis was reinforced with strips of the prosthesis collagen capsule, and the skin wound was sutured intradermally.

Histological findings
The histological findings confirmed the complete functional success of the double suture. In fact, the buried wound was completely obliterated and replaced by young collagen spiraliform tissue with some chronic inflammatory cells in between. The purse-string stitch remnants were easily identified and fragmented ( Figure 2). In the cut specimen, the second linear suture, sealing the two horizontal artificially-induced (blade scarification on both sides) wound lips, was identified as well, and showed a further strong, young collagen layer, with transversal well-arranged bundles increasing the overall dermis thickness. In this second plane, the chronic inflammatory cells were scantier. This second layer was quite firm and resistant and still suture debris could be identified among the collagen fibres ( Figure 3A, B, C, D).

Second case presentation
Since 1940, skin tumours were often removed or debulked by excision or curettage. Nowadays, Mohs' surgery for basal cell carcinoma (BCC) is widely recommended by dermatologists as first line surgical therapy for skin tumours [6]. Here we show that the Palmieri's suture can also be applied to cases of lesions deriving from skin tumours. A 55-year-old woman came to the Policlinico  del Secondo Parere (Modena, Italy) for the sudden appearance of a skin lesion in the presternal region, which was diagnosed as melanoma ( Figure 4A). She had no family history of cancer, and was professionally exposed to the sun for 30 years.
We operated on her according to the following procedure: a 2/0 braided and coated synthetic absorbable pursestring suture (GLICOFIL® LAC, Assut Europe, Italy) was performed around the tumour area in the surrounding healthy skin. The second step was the excision of the skin lesion with a portion of the free surrounding margins. Immediately after, the purse-string suture was tensed and tied in order to reduce the scar area as much as possible. A second interrupted row of 3/0 Glicofil stitches (GLICOFIL® LAC, braided mid-term absorption, Assut Europe, Italy) covered the operated area according to our double suturing technique, as described above. The procedure was successfully performed with a reasonably good cosmetic outcome ( Figure 4B) decided by the surgeon and in accordance with the patient. The melanoma was not present at the 48-month follow-up.

Conclusion
There is a growing interest in developing new wound closure methods and materials [7]. The present case reports show the rationale and histological findings of a new small suture, named Palmieri's suture, aiming to increase the thickness of the dermis to manage and close any uncomplicated skin lesions or pressure ulcers. We support the clinical use of this procedure especially for not infected or contaminated breast prosthesis, small-sized pressure ulcers as it can improve the skin resistance and bury  the 'locus minoris resistentiae' of the ulcerated tegument under a thick collagen layer. In the dermatological/oncological surgery field, this technique is very useful because it reduces the size of the suture with a more appealing and less devastating cosmetic appearance. Our method differs from those previously described for two main reasons: (1) very thin aesthetic sutures are required either in the purse-string step to transfix an adequate portion of the dermis, without tearing the needle track or injuring the underlying prosthesis or in the superficial interrupted suture row where the densely applied nylon ophthalmic stitches produce a homogenous collagen layer with a strong but fine bundle network; (2) the second horizontal suture, covering the previous purse string, is performed by plication of the surrounding skin, following previous blade scraping of the microvascular dermal network of the skin margins. This procedure allows healing of the newlyformed opposite wound lips in a final resistant dermal scar. As a matter of fact, we did not find any buried remnants of the epidermal layers or adnexa at histological analysis where the dermal thickness was doubled by the skin suture overlying the ulcerated skin margins whose epidermal layer had previously been scraped out by the blade. This expedient differentiates Palmieri's suture from those previously described, such as the schematically drawn suture by Fife and Alam [8]. Our technique fulfils the criteria of an easy and quick learning curve and strong effective skin consolidation, which are specifically required in prosthetic breast surgery. The proper size of the needle and the thread chemical composition make the difference and must be carefully evaluated to avoid prosthesis perforation, skin tearing and suture failure.