Cerclage Technique for Repairing Large Circular Defects of
the Trunk: Two-Staged Excision of a Plexiform Neurofibroma
TONY N. NAKHLA, DO,?FARAH AWADALLA, BS,yTEJAS D. DESAI, DO,?
DAVID C. HOROWITZ, DO, FAAD, FAOCD,?AND ROBERT M. SCHWARCZ, MD, FACSz
The authors have indicated no significant interest with commercial supporters.
classic clinical findings include neurofibromas, cafe ´
au lait spots, lisch nodules, axillary freckling, and
macroglossia. The predominant lesions in NF-1 are
cutaneous neurofibromas, which represent benign
proliferations of neuronal support structures. Plexi-
form neurofibromas (PNFs) are composed of nu-
merous encapsulated neurofibromas that develop as
deep nodules often involving the dermis and subcu-
taneous fat. The classic ‘‘bag of worms’’ description
gives these lesions a distinct, unmistakable appear-
ance (Figure 1). They occur in approximately 10%
of cases and are virtually pathognomonic of NF-1.1
Although uncommon (1%–5%), malignant periph-
eral nerve sheath tumors may arise from PNFs and
are often heralded by rapid growth or an acute onset
F-1 (von Recklinghausen’s disease) is an
autosomal dominantly inherited disorder. The
The majority of patients with PNFs need only ob-
servation. Patients may require treatment to avoid
significant functional and psychologic morbidity or
to rule out rare cases of malignant transformation.
Treatment options depend on location, size, patient
comorbidities, and other considerations.
Surgical excision remains the treatment of choice
and is curative with low rates of recurrence if the
lesion is completely resected.2A commonly em-
ployed technique for large PNFs is sequential exci-
sions.3Radiation therapy has been used successfully
in cases where surgery is contraindicated.4,5The use
of ablative lasers has also been reported on select
& 2008 by the American Society for Dermatologic Surgery, Inc. ? Published by Wiley Periodicals, Inc. ?
ISSN: 1076-0512 ? Dermatol Surg 2008;34:939–943 ? DOI: 10.1111/j.1524-4725.2008.34181.x
Figure1. Patient presenting with a large, 22?15-cm, sub-
scapular PNF, consistent with her diagnosis of NF-1.
?Department of Dermatology, Western University College of Osteopathic Medicine/Pacific Hospital, Long Beach,
California;yDrexel University College of Medicine, Philadelphia, Pennsylvania; andzDivision of Orbito-Facial Plastic
Surgery, Jules Stein Eye Institute, UCLA Medical Center, Los Angeles, California
mucosal and ophthalmic lesions.6–8Pharmacologic
therapy has not produced promising results, and the
use of chemotherapeutic agents is still investiga-
Figure2. Lesion is initially divided into two portions. The
larger portion is approximately two-thirds of the entire le-
sion and is excised during Stage 1.
Figure3. Excision of PNF along the deep subcutaneous
Figure4. Purse string suture. (A) The first purse string suture is placed. (B) Result after tightening of initial purse string
suture and placement of second purse string suture. The dotted line represents the original lesion size. (C) Result after
tightening of second purse string suture. At this point place horizontal mattress and simple interrupted sutures. (D) Re-
CERCLAGE TECHNIQUE FOR REPAIRING LARGE CIRCULAR DEFECTS OF THE TRUNK
Anesthesia of the lesion is achieved by infiltration
with approximately 200cm3of tumescent, anes-
thetic solution (0.1% lidocaine with 1:1,000,000
epinephrine). The solution is allowed approximately
15minutes to achieve adequate vasoconstriction and
anesthesia. The lesion is then divided into two un-
equal portions measuring approximately two-thirds
and one-third of the original lesion size (Figure 2).
The greater two-thirds portion of the tumor is ex-
cised during the first stage of the procedure to ensure
minimal wound tension during the second stage,
thereby minimizing the final scar. Using a No.10
blade, the margin of the larger portion of the lesion is
traced into the subcutis. Owing to its tremendous
vascular supply, excision along the deep subcutane-
ous plane is performed using a bovie electrosurgical
cutting unit (Figure 3). After adequate hemostasis
and closure of dead space, a running, subcuticular
stitch is placed around the circumference of the
wound using a 2.0 polydiaxonone (PDS II) suture on
an FS-1 needle in a purse string–type fashion (Figure
4).10This suture reduces the wound diameter to
approximately one-third of its original size (Figure
5B). A second cerclage suture placed in the same
manner yields a smaller defect (Figure 5C). This
defect is then repaired with 3-0 nylon horizontal
mattress and simple interrupted sutures with exci-
sion of resultant dog-ears as needed until the margins
are closely approximated (Figure 5D).
One month later, the second stage of the excision is
performed. The remaining smaller portion of the
lesion along with the resultant scar from the initial
stage is excised (Figure 6). We use the purse string
method in the same fashion until the defect is small
enough to close primarily (Figures 7A–7C). After
excision of resultant dog-ears, the second and final
stage yields a geometrically shaped closure (Figure
When excising a lesion of this magnitude, the po-
tential for postoperative complications is greatly in-
creased. The risks of seroma and hematoma as well
as the potential for toxicity due to the large volume
of anesthesia required are minimized by intraopera-
tive hemostasis, appropriate closure of dead space,
and the use of tumescent anesthesia, respectively.
Figure5. Stage 1. (A) Circular defect after excision to the premuscular tissue layer. (B) Purse string suture placed and
tightened to decrease the size of the defect. (C) A second purse string suture is placed and tightened leaving a smaller
defect. (D) Approximation and closure of remaining defect with horizontal mattress and simple interrupted sutures using 3-0
nylon while excising dog-ears. The result is a geometric approximation.
Figure6. One month after stage 1. The resultant scar abut-
ting the remaining one-third of the lesion. The dashed line
represents the margins of excision for stage 2.
NAKHLA ET AL
Surgical alternatives to this method are less favor-
able. An elliptical excision (either entirely in one
procedure or in staged excisions) results in a scar
three times the length of the lesion or two or more
separate lengthy scars. Another alternative, a split-
thickness skin graft, requires a donor site and, thus,
two separate areas of wound healing. It also
produces a poor cosmetic result, especially if the
donor tissue is obtained from a dissimilar cosmetic
unit. There is also the possibility of necrosis due to
graft failure. A large transposition flap would also
increase scar length and bears the potential for flap
Using the cerclage method, scar length is minimized
and the greatest amount of normal tissue is spared
(Figure 8). This method also inevitably produces an
irregular, geometric scar thereby improving overall
cosmesis as compared to linear wound closure.11
Furthermore, the dermatologic surgeon obviates the
use of general anesthesia, skin grafting, or large flap
repair, thereby reducing morbidity. This case dem-
onstrates an effective method for removing large
PNFs in staged excisions using local tumescent an-
esthesia. It also illustrates a valuable, seldom-used
technique in the armamentarium of dermatologic
surgery, the cerclage technique, for repairing large
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4. Robertson TC, Buck DA, Schmidt-Ullrich R, et al. Isolated
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type 1 neurofibromatosis. Fetal Pediatr Pathol 2006;25:87–93.
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Figure7. Stage 2. (A) Circular defect after excision to the premuscular tissue layer of the remainder of the PNF and previous
scar. (B) Purse-string suture is placed to decrease the size of the defect. (C) A second purse-string suture is placed and
tightened leaving a smaller defect. (D) Approximation and closure of remaining defect with simple interrupted and running
sutures using 3-0 nylon while excising dog ears. The result is a geometric approximation.
Figure8. The patient 3 months post-excision of PNF with a
CERCLAGE TECHNIQUE FOR REPAIRING LARGE CIRCULAR DEFECTS OF THE TRUNK
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report of a child. Int J Pediatr Otorhinolaryngol 2002;65:167–70.
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11. Robinson JK, Hanke CW, Sengelmann RD, et al. Surgery of the
Skin. 1st ed. Philadelphia: Elsevier Mosby, 2005, p. 404.
Address correspondence and reprint requests to: Tony N.
Nakhla, DO, Department of Dermatology, Western Uni-
versity College of Osteopathic Medicine/Pacific Hospital,
Long Beach, CA 90806, or e-mail: firstname.lastname@example.org
NAKHLA ET AL