Foot &Ankle Specialist vol. 9 / no. 4 367 Abstract: Wound dehiscence and infection may arise when the skin around the foot or ankle is closed under tension after a surgical incision or trauma. Two cases where a piecrusting technique, using small transdermal incisions made in the surrounding skin similar to the holes in a pie crust, are presented and a literature review of the technique has been performed. The multiple small stab incisions perpendicular to the line of tension have enabled skin closure without tension and have healed with minimal scarring. Levels of Evidence: Level V: Expert opinion Keywords: wound closure; skin incisions; wound healing; wound dehiscence; bilateral forefoot reconstruction; multiple superficial short skin incisions; lace patterning; fishmouthing; meshing technique; multiple relaxing skin incisions; piecrusting T he skin after an incision or trauma may sometimes be difficult to approximate, and a suture under tension in the skin may lead to cutaneous ischemia, wound breakdown, infection, and sloughing. The surgical options are to leave the whole wound open to granulate by secondary intention (possibly with vacuum dressings), to perform delayed primary closure, to apply a split skin graft, to perform flap coverage, or to use a “piecrusting” technique. The piecrusting technique, using small transdermal incisions made in the surrounding skin similar to the holes in a pie crust, is not new and has also been termed multiple superficial short skin incisions (nicks), lace patterning, fishmouthing, meshing technique, multiple relaxing skin incisions, and tissue meshing advancement flap. 1-10 Table 1 lists the references in the English literature on the technique that, however, does not seem to be widely known. 11 The piecrusting technique is particularly useful in the dorsum of the foot after a forefoot reconstruction performed in both rheumatoid and nonrheumatoid patients, with a recent trend toward metatarsal head preservation. 12-17 The multiple small stab incisions perpendicular to the line of tension has been used to facilitate wound closure after a forefoot reconstruction in the 2 patients described here. Surgical Technique The tension in the skin becomes evident prior to closure of the incision(s) and pale/poorly vascularized and tight skin is seen after closure of the final wound and tourniquet release. Multiple full thickness 5 mm stab wounds through the dermis are performed using a No. 15 scalpel blade at 5 mm intervals perpendicular to the lines of tension. Each stab wound is noted to spread elliptically by 2 to 4 mm as it accepts a portion of the tensile load in the skin. The number of stab wounds should be as much as necessary such that the tension and paleness in the surrounding skin is abolished and bleeding can be seen from the edges of the stab incisions. 3 The wound is dressed with a nonadherent dressing such as mepitel and inspected at 5 to 7 days. Sutures are removed as usual at 14 days. 620635FAS XX X 10.1177/1938640015620635Foot <italic>&</italic> Ankle SpecialistFoot & Ankle Specialist research-article XXXX Piecrusting to Facilitate Skin Closure DOI: 10.1177/1938640015620635. From the Foot and Ankle Unit, Royal National Orthopaedic Hospital, Stanmore, UK. Address correspondence to Adam Lomax, MBBS, FRCS, Foot and Ankle Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK; e-mail: 1adamlomax@gmail.com. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2015 The Author(s) Dishan Singh, MBChB, FRCS, and Adam Lomax, MBBS, FRCS The piecrusting technique, using small transdermal incisions made in the surrounding skin similar to the holes in a pie crust, is not new . . .” “ 〈 〉 Case Report