TECHNICAL STRATEGY

Circular Excision and Purse-String Closure for

Pediatric Facial Skin Lesions
Aladdin H. Hassanein, MD, MMSc, Javier A. Couto, BS, and Arin K. Greene, MD, MMSc
compared with adults because children have minimal skin laxity
Abstract: Standard resection of pediatric facial skin lesions con- and rhytides. Circular excision with purse-string closure has been
sists of lenticular excision and linear closure. This one-stage described for infantile hemangiomas to limit the size of the scar;
procedure for circular lesions results in a linear scar 3 times longer these tumors often are round, large, and expand skin.1,2 We applied
than the diameter of the removed specimen. Circular excision and the principles of circular excision and purse-string closure to any
purse-string closure has been described for infantile hemangiomas
circular skin lesion on the face of children.
to reduce the length of scar. The purpose of this study was to analyze
the application of this technique for any type of circular facial skin
lesion in the pediatric population.
Records of consecutive pediatric patients with facial skin
METHODS
Following approval from the Committee on Clinical Investigation at
lesions treated with circular excision and purse-string closure from
Boston Children’s Hospital, we retrospectively reviewed consecu-
2007–2014 were reviewed. Patient age, sex, type of lesion,
tive children treated between 2007 and 2014 who underwent
location, and size were recorded. Number of stages necessary to
remove the area and complications were analyzed. circular excision and purse-string closure of a facial skin lesion
Seventy-seven children (74% female) underwent circular exci- by the senior author (AKG). Predictive variables were patient age,
sion and purse-string closure for an infantile hemangioma (46%), sex, and lesion characteristics (type, location, size). Outcome
pigmented nevus (27%), Spitz nevus (7%), pilomatrixoma (5%), variables included number of stages and complications. Data are
pyogenic granuloma (5%), vascular malformation (4%), or another presented as mean with standard deviation or range.
type of skin lesion (6%). Age at the time of resection was 6.0 years
(range 4 months–17 years) and mean lesion area was 3.9 cm2 (range
0.2–19.6); 30% of patients underwent a second procedure and no TECHNIQUE
infection or wound dehiscence occurred. A circle encompassing the round lesion, including any additional
Circular excision and purse-string closure is an effective tech- margin, is drawn and the lesion is excised (Fig. 1). Wide subcu-
nique to manage any type of circular skin lesion in the pediatric taneous undermining then is performed to facilitate tensionless
wound closure. An intradermal absorbable polydioxanone or poly-
population. It is particularly useful for lesions on the face because it
glactin purse-string suture is placed followed by superficial chromic
limits the length of a scar. A subset of patients may benefit from sutures to approximate the epidermis. The wound is reinforced with
second procedure to convert the circular scar from a circle into a cyanoacrylate and Steri-Strips (3 M; Maplewood, MN).3 The area is
line. taped for 6 weeks post-operatively to limit spreading of the scar.
The scar is evaluated 1 year post-operatively after it has fully
matured. No further operations are needed if the patient, family, and
Key Words: Circular, hemangioma, nevus, pediatric, purse string,
the surgeon are content with the appearance of the area. Otherwise,
scar additional stages can be performed to improve the scar with either
(J Craniofac Surg 2015;26: 1611–1612) another circular excision and purse-string closure to further reduce
the area of the scar or the round cicatrix can be excised and
converted to a linear scar.
T he standard technique for resection of a pediatric
lesion is lenticular excision and linear closure.
removal of circular lesions leaves a scar 3 times its
facial skin
Lenticular
diameter.1
Linear facial scars are more visible in the pediatric population

From the Department of Plastic and Oral Surgery, Boston Children’s

Hospital, Harvard Medical School, Boston, MA.
Received January 3, 2015.
Accepted for publication February 7, 2015.
Address correspondence and reprint requests to Arin K. Greene MD,
MMSc, Department of Plastic Surgery and Oral Surgery, Boston
Children’s Hospital, 300 Longwood Ave, Boston, MA 02115;
E-mail: arin.greene@childrens.harvard.edu
This article was presented at the Northeastern Society of Plastic Surgeons
31st Annual Meeting in Providence, RI September 13, 2014. FIGURE 1. Ten-year-old female with a pigmented nevus of the chin.
The authors report no conflicts of interest. A, Preoperative appearance. Simulation of markings for B, lenticular and
Copyright # 2015 by Mutaz B. Habal, MD C, circular resection with margins. D, After circular excision. E, Following
ISSN: 1049-2275 purse-string closure. F, One year post-operatively. Patient was satisfied with the
DOI: 10.1097/SCS.0000000000001779 scar and a second stage to convert to a linear scar was not performed.

The Journal of Craniofacial Surgery
Volume 26, Number 5, July 2015 1611
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Hassanein et al The Journal of Craniofacial Surgery
RESULTS
Seventy-seven children (74% female) underwent circular excision
and purse-string closure for hemangiomas (46%, n ¼ 35), pigmen-
ted nevi (27%, n ¼ 21), Spitz nevi (7%, n ¼ 5), pilomatrixomas (5%,
n ¼ 4), pyogenic granulomas (5%, n ¼ 4), vascular malformations
(4%, n ¼ 3), and other lesions (6%, n ¼ 5). Age during resection was
6.0 years (range 4 months–17 years). Lesions were removed from
the cheek (65%), forehead (10%), chin (9%), nose (9%), or lip (7%).
Lesion area was 3.9 cm2 (range 0.2–19.6) (hemangiomas 6.6 cm2,
range 0.8–19.6; non-hemangiomas 2.3 cm2, range 0.2–9.4;
P < 0.0001). Follow-up was 3.5  2.3 years. Lesions required
1.4  0.8 stages for removal; a second operation was performed
in 30% of the cohort (hemangiomas 49%, non-hemangiomas 14%).
No infection or wound dehiscence occurred.
DISCUSSION
Lenticular excision of a circular lesion leaves a scar 3 times its
diameter.1 Linear facial scars are more prominent in pediatric
patients than adults because children have less skin laxity and
rhytides. In an effort to minimize scar length, circular excision
and purse-string closure were used for removal of circular pediatric
facial lesions in this series.
The technique of circular excision and purse-string closure
previously has been described primarily for facial infantile heman-
gioma1,2 and adult skin lesions.4–8 Both these populations have
redundant skin (ie, expanded tissue from the hemangioma or adult
skin laxity), which facilitates purse-string closure. Our study shows
this technique is effective for any pediatric skin lesion using
subcutaneous undermining to recruit skin for purse-string closure.
Circular excision of pediatric facial lesions has several advan-
tages compared with lenticular resection. The lesion is traded for a
smaller round scar, which may be aesthetically more favorable than
a longer linear scar on a child’s face, which lacks rhytides.
Depending on the size of the resected lesion, the resultant cicatrix
can appear as an acne-like or ‘‘pockmark’’ scar. Seventy percent of
patients in this series underwent only 1 stage suggesting that the
facial circular scar was satisfactory. If the circular cicatrix is
considered unfavorable, it can be converted to a linear scar with
a diameter similar to that of the initial lesion.1 Lenticular excision of
the circular scar results in a shorter line because the scar has a
smaller diameter than the original lesion and a margin of normal
adjacent skin is not required. Another advantage of purse-string
closure is that it minimizes distortion of surrounding structures
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Volume 26, Number 5, July 2015
because tissue is pulled toward a central vector.1 If a circular
excision wound is complicated by infection or dehiscence, the
outcome of the scar is not adversely affected because the round
wound may contract with secondary healing to a similar appearance
as a noncomplicated circular closure.9
Circular excision and purse-string closure has an initial pleated
appearance, which resolves after a few weeks. More than 1 excision
may be necessary with this technique; however, only 14% of non-
hemangiomas underwent a second operation compared with 49% of
hemangiomas. This is likely because hemangiomas were bigger
than the other lesions, and thus excision resulted in a larger round
scar. Circular excision and purse-string closure should not be
performed in the scalp because a circular area of cicatrix is more
likely than a linear scar to cause visible alopecia.10 The scalp has
unfavorable skin laxity necessary for purse-string closure and thus
is more likely to result in a larger round scar. The length of a linear
scar in the scalp also is not critical because it is disguised by hair.
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# 2015 Mutaz B. Habal, MD