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Presentation

Twizzler Technique for Low-Tension Closure of Lower Leg Wounds

Description

The transcript explains the Twizzler technique, a low-tension wound closure method for difficult lower leg wounds, where skin is dense, inelastic, and prone to tearing under conventional suturing. The speaker, a Mohs surgeon, describes how these wounds often fail direct closure and otherwise heal slowly by secondary intention, increasing infection risk, bleeding, and the burden of prolonged wound care. Twizzler uses a multi-pulley or percutaneous pulley suture system to redistribute force across multiple tissue vectors, reducing the tension on any single point and allowing gradual approximation of wound edges through repeated load cycling. The technique aims to minimize tissue trauma, ischemia, dehiscence, hypertrophic scarring, and suture breakage, while enabling the surgeon to place layered subcutaneous sutures under much less tension. The procedure can be left in place for up to two weeks and is described as fast, practical, and useful for wounds up to about three centimeters on the shin, with favorable patient experiences and healing outcomes.

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Conclusions

The Twizzler pulley suture technique appears to make difficult lower-leg wound closure easier by mechanically reducing tension across the incision.
By distributing force across multiple tissue vectors, the method may lower the risk of tissue tearing, suture breakage, dehiscence, and marginal necrosis.
Progressive load cycling seems to recruit additional skin laxity, allowing gradual approximation of wound edges with relatively few cycles.
The technique may reduce the need for skin grafts or prolonged secondary-intention healing in patients with tightly tethered lower-extremity skin.
Because it can be performed quickly and with less force, the method may improve postoperative comfort and simplify wound care for patients.
The approach appears especially useful for older, fragile, or high-risk patients whose lower-leg wounds are prone to poor healing, infection, or bleeding.
Leaving the pulley suture in place temporarily and adding layered subcutaneous sutures can support tension-minimized closure and good healing outcomes.
Overall, the presentation suggests the Twizzler technique is a practical and effective adjunct for challenging lower-leg reconstructions with favorable short-term results.