Abstract:
A method and device comprising a plate with attached suture, the plate made at least partially of silicone, are provided for wound closure. The silicone in the plate inhibits scarring in the healing wound, and the device provides for improved wound closure.

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
       [0001]    This application is a continuation-in-part of U.S. patent application Ser. No. 12/313,599, filed Nov. 21, 2008, and claims the benefit of provisional patent Application Nos. 61/005,158, filed Dec. 3, 2007, 61/011,026, filed Jan. 14, 2008, and 61/070,646, filed Mar. 25, 2008. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    A cartilage repositioning device that can be utilized in nasal airway and aesthetic reconstructive procedures and surgeries of the nose and method for use are disclosed. The cartilage repositioning device disclosed may repair, partially restore, or restore the anatomic position of a collapsed or insufficient upper lateral cartilage, opening the internal nasal valve and causing a permanent repositioning of the upper lateral cartilage even after the device is removed. 
         [0003]    When the upper lateral cartilages (ULC) collapse or are insufficient, the associated internal nasal valve (INV) can be impinged, which impairs breathing and causes cosmetic problems. Internal nasal valve dysfunction is a common condition. A damaged upper lateral cartilage and its associated dysfunctional internal nasal valve may be due to prior nasal surgery, trauma, congenital deficits, or simply insufficiency due to an individual&#39;s genetic makeup. 
         [0004]    Various treatments of compromised upper lateral cartilage and its associated internal nasal valve dysfunction have been described and tested. However, these treatments either involve surgical cartilage grafting, which is invasive, requiring an extensive rhinoplasty, and may not be effective, or they involve removable devices which do not repair the collapsed cartilage. 
         [0005]    Endogenous cartilage grafts (commonly referred to as “spreader” or “onlay” grafts) are currently the gold standard in the repair of the insufficient upper lateral cartilage and internal nasal valve. While somewhat effective, these procedures require cartilage harvesting from elsewhere in the body and a major rhinoplasty procedure to undermine the skin or lining of the nose to adequately place these grafts. Even after extensive procedures, aesthetic and functional success is not achieved in many cases. 
         [0006]    The prior art has multiple surgical and nonsurgical devices which essentially deal with the nasal valve. These devices are commonly referred to as nasal dilators. The adhesively mounted external dilater disclosed in Johnson, U.S. Pat. No. 5,476,091, marketed as the BreatheRight™ Strip is an adhesive strip placed on the outer skin of the nose that, due to the recoil action of a support structure within the strip pulls open the nasal valve from an external position. The disadvantages of this device are that repeat placement is required for each use, and it is by definition noticeable on the external skin of the nose. 
         [0007]    The surgically implantable nasal dilator disclosed by Hurbis, U.S. Pat. No. 6,106,541, the surgically implanted external nasal valve batten disclosed by Romo, U.S. Pat. No. 6,454,803, and the nasal valve apparatus disclosed by Vassallo, U.S. patent application Ser. No. 11/144,354, sought to improve on the permanence and noticeability of the external nasal dilator. These implants require no cartilage harvesting as required for spreader or onlay grafts. However, permanent surgical implants placed in soft tissue, particularly the thin soft-tissue envelope of the nose, have long-term significant risks. Over the lifetime of a patient, all surgical implants have a potential to become infected or even to extrude through the skin of the nose or migrate and become misplaced. The hardware can eventually breakdown over time. In addition, as with grafting, a major surgical procedure (usually open rhinoplasty) is required for implantation. Furthermore, one of the implants, the external nasal valve batten implant, addresses only problems with the external nasal valve, and not the challenging internal valve as in the present device. 
         [0008]    Multiple internal nasal dilators including most recently the internal nasal dilator filter disclosed in Michaels, U.S. Pat. No. 6,971,388 have been described as well. These devices are largely dismissed by many clinicians due to their inconvenience. Like external dilators, they are not permanent, and must be applied before each use. Because they remain inside the nasal cavity, long-term usage can irritate and erode the internal nasal lining, creating chronic problems. In addition, most have some external component for security that is cosmetically noticeable and aesthetically unappealing. Finally, these devices also may interfere with the normal function of the nasal respiratory lining or mucosa. 
         [0009]    Surgical splints for use after straightening procedures of the nasal septum, another component of the internal nasal valve, such as Doyle, U.S. Pat. No. 3,935,859, are known. These splints are sutured on both sides of the nasal septum at the conclusion of the septoplasty procedure in order to stabilize the reduced septum and to prevent hematoma formation. Guastella, U.S. Pat. No. 5,931,799 introduced a wing of a septal splint which would additionally splint the outer portion of the nasal valve. The purpose of said wing is proposed to splint the nasal valve after nasal surgery and to prevent scarring or stenosis of this area. This wing is not intended to suture and subsequently buttress a collapsed upper lateral cartilage into a restored position. In addition, because of its cumbrous size and attached wings, this prior device may be uncomfortable for the patient at the time of removal and/or placement. 
         [0010]    Silicone had been disclosed as useful in wound healing because it inhibits scarring. Bandages and topical solutions containing silicone have been described. They can be applied to a closed and healing wound in order to inhibit scarring. However, no means of incorporating silicone into the wound closing process is known, and traditional wound closure devices such as stitches can exacerbate scarring. Additionally, silicone is typically applied to wounds after wound closure devices have been applied and removed and therefore after scarring has already commenced. What is needed is a device and method which incorporates a silicone component for scar reduction into an improved method and device for wound closure. 
       SUMMARY OF THE INVENTION 
       [0011]    A method and device for closing a wound in tissue having at least two edges comprising providing a device comprising a semi-rigid plate comprising silicone having a first surface and a second surface, said device including a suture, threading said needle and said suture through said plate, then through the tissue of a first edge of said wound, threading said needle and said suture through the tissue of an additional edge of said wound, threading the suture through the plate, tensioning said suture so as to simultaneously proximate said edges of said wound and proximate said first surface of said plate and said wound, compressing said wound with said first surface of said plate, and securing said suture. 
         [0012]    The foregoing and other objectives, features, and advantages of the invention will be more readily understood upon consideration of the following detailed description of the invention taken in conjunction with the accompanying drawings. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0013]      FIG. 1  is an enlarged perspective top-down view of the plate. 
           [0014]      FIG. 2  is an enlarged perspective bottom view of the plate with distal end of the suture fastened into position. 
           [0015]      FIG. 3  is an enlarged side view of the plate with distal end of the suture fastened into position. 
           [0016]      FIG. 4  is an enlarged end view of the plate with distal end of the suture fastened into position. 
           [0017]      FIG. 4   a  is an enlarged perspective bottom view of the plate with a suture-affixing portal. 
           [0018]      FIG. 4   b  is an enlarged perspective bottom view of the plate with an alternative suture-affixing portal. 
           [0019]      FIG. 5  is a cut-away perspective view of the nose, with only the structures below the skin visible, with parallel lines marking the ULC. 
           [0020]      FIG. 6  is a cut-away perspective view of the nose, with only the structures below the skin visible, with parallel lines marking the collapsed or insufficient ULC on the patient&#39;s left side. 
           [0021]      FIG. 7  is a cut-away perspective view of the nose, with only the structures below the skin visible, with parallel lines marking the ULC restored to its expanded position by the plate, revealed with a dotted line on the undersurface of the junction of the ULC and LLC. 
           [0022]      FIG. 8  is a base or bottom view of the nose, looking inside the nostrils, with the ULC and LLC visible through the skin and the patient&#39;s collapsed left ULC visible. 
           [0023]      FIG. 9  is a base or bottom view of the nose, looking inside the nostrils, with the ULC and LLC visible through the skin, showing the plate within the nasal passage, after the suture and needle have passed through the ULC and LLC. 
           [0024]      FIG. 10  is a base or bottom view of the nose, looking inside the nostrils, with the ULC and LLC visible, the ULC restored to its normal position by the plate and suture under proper tension, with suture fastened into position. 
           [0025]      FIG. 11  is a base or bottom view of the nose, looking inside the nostrils, with the septal cartilage visible through the skin and two needles which have traversed the septum, fed through the portal of the plate on the opposite side of the nose. 
           [0026]      FIG. 12  is a base or bottom view of the nose, looking inside the nostrils, with the septal cartilage visible through the skin and the plates in position buttressing the septum. 
           [0027]      FIG. 13  is a perspective view of the device disclosed herein being used to close a wound. 
           [0028]      FIG. 14  is a perspective view of the device disclosed herein closing a wound. 
           [0029]      FIG. 15  is a perspective view of a wound that has been closed with one embodiment of the device disclosed herein. 
           [0030]      FIG. 16  is a perspective view of a wound that has been closed with one embodiment of the device disclosed herein. 
       
    
    
     DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS 
       [0031]    It is conventionally believed that the shape or position of cartilage cannot be modified without the addition of more cartilage, such as through a grafting procedure using cartilage from elsewhere in the body. Consequently, conventional alteration of the shape or position of the upper lateral cartilage in order to repair a compromised internal nasal valve involves either a nasal dilator which temporarily moves cartilage into a different position, but which change is reversed upon removal of the device, or a more permanent repair through a cartilage graft. 
         [0032]    However, the inventor of the device and method disclosed herein was surprised to discover that the thin cartilage of the nasal envelope such as the upper lateral cartilage can heal into a different position without grafting if an opportunity for scar tissue development is provided and a dynamic device is used to reposition the cartilage and maintain the new position long enough for scar tissue to form. The inventor made this discovery when he was faced with a patient with insufficient upper lateral cartilage who had suffered four failed attempts by others to repair his nose through conventional grafting techniques. The inventor believed that another graft was likely to fail, and decided to try something new. He decided to attempt to dynamically reposition the cartilage and then allow scar tissue to affix it in its new location, even though it is conventionally believed that such a repair would not work. To his surprise, he discovered that a device which dynamically lifts upper lateral cartilage to at least the level of the lower cartilage while the position of the lower cartilage is maintained, then secures the cartilage while scar tissue forms, can repair an insufficient upper lateral cartilage. The device may be removable, because a device which is permanently implanted in the nose can cause irritation and erosion of the nasal lining. Moreover, it must fairly precisely position the cartilage. For example, if the device pulled the upper lateral cartilage and the lower lateral cartilage together so as to cause them to overlap one another, it would cause a cosmetic deformity called an alar retraction. For that reason, the inventor discovered that the upper lateral cartilage and lower lateral cartilage cannot simply be sutured together. Rather, a device which creates tension in an appropriate direction and location, and maintains an ideal spatial relationship between the cartilages during application of tension, is desirable. Because the device must maintain these spatial relationships during application of tension as well as maintain them during healing, the device must be capable of dynamically positioning as well as immobilizing tissue, and should be easily removable once healing is complete. 
         [0033]    The device and method disclosed herein improve the function and aesthetic appearance of a damaged or insufficient upper lateral cartilage and internal valve of the nose utilizing a simple, office-based procedure, and a device which does not require permanent implantation. The device dynamically repositions cartilage by supporting previously collapsed upper lateral cartilage in proximity to intact lower lateral cartilage so that it heals in its new position. 
         [0034]    Referring now to the drawings which form a part of this disclosure, in  FIGS. 1-4 , suture  10  is shown with a curved needle  14  on its free end  12  and opposite end  16  extending from plate  18 . In this embodiment, the plate should be small, flat, thin, and oblong or approximately rectangular. Ideally it will be less than 2 mm thick. It may be composed of a stiff but resilient material. The suture extends from the top surface of the plate, may be fastened to the top surface  20  of the plate  18 , or may be fastened to the bottom surface  22  of the plate  18  and extend through a hole in the plate in order to extend from the top surface  20  of the plate. The suture may extend from or be attached to the approximate center  24  of the plate. The suture  10  may be composed of permanent material like silk, nylon, or bioresorbable substances. The plate  18  may be made of various materials, from bio-inert synthetic materials commonly used in nasal surgery such as hard-grade reinforced silicone, polyvinyl chloride, or made of bioresorbable rigid materials including polyglycolic acid. The broad flexibility allowed with the material is permitted as the device need not be implanted into the nasal soft tissue, but only remains in the nasal cavity until removal or absorption. 
         [0035]    In the embodiment shown in  FIGS. 1-4 , the forward or anterior area of the plate  26  includes a portal  28  such as an eyehole  30  capable of receiving the needle  14  and suture  10  after they have been passed through cartilage layers. 
         [0036]    The plate  18  may also include a suture fastener  36 . In the embodiments shown in  FIGS. 1-4 , the fastener  36  is located on the bottom surface  22  of plate  18 . The fastener  36  may consist of a raised rigid flap comprised of a portion of plate  18  or a cleat on plate  18 , and may knotlessly fasten the suture to the plate. In  FIG. 2 , the fastener is shown as broad and rounded into a near semi-circle although it may be another shape and located elsewhere on the bottom surface  22  of the plate  18 . In the space between the fastener  36  and the plate  18  exists a narrow angle  40  that the suture  10  may be wedged into to lock it into a stable position. The bottom surface of the fastener  36  may have ridges or teeth that will assist in gripping and locking the passed suture  10 . The fastener  36  may be angled with its opening facing away from the nasal airflow, to allowed continued aerodynamic nasal airflow with the implant in place. Because the airflow is different on the right and left sides of the nose, right and left versions of the device with appropriate angulation may be produced. The fastener may be made of the same or a different material than the plate is. For example, the fastener may be made of metal even if the plate is not made of metal. 
         [0037]    A candidate for this procedure can be identified from a history and physical examination. Patients with collapse of the upper lateral cartilage  44 , as shown in  FIG. 6  manifesting as having depressions in the middle one-third of the nose  48  on one or both sides, as shown in  FIG. 6 , or evidence of narrowing  50  at the internal nasal valve  52  as shown in  FIG. 8 , are the ideal candidates for this procedure. A structurally intact lower lateral cartilage  46  is also required. The ability of the upper lateral cartilage  44  to re-expand in a particular patient can be tested by internally opening the internal nasal valve with a cotton-tipped applicator, or stretching the skin adjacent to the nose in a lateral direction, with resultant subjective improvement in breathing. 
         [0038]    The procedure itself begins with appropriate anesthesia for the patient. In an office setting, with an awake patient, topical and injected anesthesia should be all that is required. Referring to  FIG. 9 , a standard unilateral incision is made into the membrane  58  between the upper lateral cartilage and lower lateral cartilage through an intra-nasal approach, with endoscopic or head-light guidance. Limited undermining of the skin  60  over the lower portion of the upper lateral cartilage is performed to encourage the formation of scar tissue that will fasten the cartilage into its new position following healing. The area of maximal interior nasal valve narrowing or upper lateral cartilage collapse is identified. 
         [0039]    The needle  14  and suture  10  and plate  18  are introduced into the nasal cavity. As shown in  FIGS. 9-10 , after an intranasal or endoscopic approach and limited incision, the needle and free end  12  of the suture  10  are passed through the collapsed upper lateral cartilage  44  and sutured to the cephalic border of an intact lower lateral cartilage  46 . As shown in  FIG. 9 , the curved needle  14  is speared through the maximally collapsed lower border of the upper lateral cartilage  44 , from mucosal or lining side, to the undermined dorsal surface. The needle is regrasped, and then passed through the superior border of the lower lateral cartilage  46  at the incision site, with care taken to pass through a significant amount of the substance of the lower lateral cartilage  46 , while avoiding penetrating into the nasal external skin. The needle  14  and suture  10  then may be passed through the portal  28  in the plate  18 , which subsequently serves as a second point of fixation. 
         [0040]    As shown in  FIGS. 9 and 10 , downward tension upon the free end  12  of the suture  10  raises the plate  18  as a flag is raised on a flagpole by the halyard, using the lower lateral cartilage  46  as the pulley. Once pulled into the nasal cavity  54  the plate  18  is maneuvered into position at the junction of the upper lateral cartilage  44  and lower lateral cartilage  46 , and presses against the upper lateral cartilage  44  by virtue of the tension on the suture  10 . The plate  18  exerts pressure against the upper lateral cartilage  44 , repositioning it so as to open the internal nasal valve  52 . The suture  10  may then be fastened to the plate  18 , knotted, or in some other way prevented from being pulled back through the portal  28 . It may be attached to the bottom surface  22  of the plate  18  with a fastener  36  adapted to secure the suture, excess free end  12  of suture  10  may be removed.  FIGS. 7 and 10  show the plate in position. 
         [0041]    The desired level of tension is kept on the free end  12  of the suture  10 , as it is attached to the fastener  36  to secure the suture  10  and the position of plate  18 . For additional security, a second fastener, not shown, may be used as well. For example, the second fastener may be a v-shaped cut-out in the plate or may be a metal component fastened to the plate. Additionally or alternatively, an additional suture may extend from the bottom surface  22  of the plate  18 , and may be used to tie the suture  10  in order to affix it to the bottom surface  22  of the plate  18 . The portal  28  may be used to affix the suture to the plate  18 . This may be accomplished in a variety of ways. By way of example, as shown in  FIG. 4   a , the portal  28  may be teardrop or key hole shaped, composed of a wider area  28   a  and a narrower area  28   b . The free end of the suture  12  is passed through the wide area  28   a , then wedged into the narrower area  28   b , where it is trapped and thus affixed to the plate  18 . Alternatively, the portal can have inwardly directed elements  29   c  as shown in  FIG. 4   b  which permit the free end of the suture  12  to pass through the portal, but which then catch on the suture material and prevent the suture from being pulled back through the portal. The portal may affix the suture to the plate with the aid of a knot in the suture or without use of a knot. An eyehole may be sized to permit the passage of suture but may still be small enough to prevent the suture from being pulled back through it. 
         [0042]    The distance  34  between the portal  28  and the point of extension or attachment  32  of the attached end of the suture  16  should be approximately equal to the distance  72  between the needle&#39;s point of entry  74  in the upper lateral cartilage  44  and the point of entry  76  in the lower lateral cartilage  46 . This distance may vary, but may typically be approximately 6-8 mm. If the distance  34  is significantly smaller than the distance  72  then the upper lateral cartilage and the lower lateral cartilage will be pulled together so as to overlap one another after the repair, and a cosmetic deformity called alar retraction will occur. If the distance  34  between the point of attachment of the suture and the portal is substantially larger than the distance  72  between the cartilages the upper lateral cartilage may not be positioned correctly for the repair to occur. For the same reasons, the plate functions as a bridge between compromised tissue and structurally intact tissue, ensuring that the points of exertion of tension are appropriately placed. 
         [0043]    The plate  18  may be flat but resilient so that tension exerted by the suture  10  causes the plate to bow slightly  56  as shown in  FIG. 10  so that it is concave when viewed from inside the nostril. This slight bowing creates a slight angulation, which accommodates the separation of the upper lateral cartilage and lower lateral cartilage inside the nasal cavity that even when approximated would not be a straight plane. The bowing helps allow approximation without over-correction. 
         [0044]    Once healing occurs in several weeks, the device and its suture can be completely removed or bio-resorbed. This avoids both the implantation risks of a permanent implant (infection and extrusion), and the chronic irritation and maintenance required of a typical internal or external dilator. In addition, its placement requires only a minor procedure done either endoscopically or under operator headlight guidance. 
         [0045]    An immediate benefit to the nasal airway should be seen and felt. Aesthetic improvement may be difficult to assess initially due to temporary edema of the skin. 
         [0046]    In addition to the upper lateral cartilage, the other key anatomic components of the internal nasal valve include the nasal septum  62 . Septal deviation is thus an additional cause of narrowing of the internal nasal valve. Using a modification of the present invention, the septum  62  may be stabilized and splinted after septoplasty. This procedure does not replace the septoplasty procedure, but just enhances the results in a simple fashion. 
         [0047]    A similar plate  68  may be used for this procedure. As shown in  FIGS. 11-12 , the plate may be larger, and a straight instead of a curved needle  64  may be used. As shown in  FIG. 11 , in addition, two of the devices, including 2 sutures and needles may be used. 
         [0048]    At the conclusion of a standard septoplasty procedure, the lining flaps of the nasal skin remains loose and unapproximated. To reapproximate the flaps together in the midline, the device disclosed herein may be used. A straight needle  64  with suture  66 , harnessed to a plate  68  is passed completely through the septum  62  to the opposite nasal cavity. An identical device is used from the opposite side as well. Once passed through the septum  62 , the two needles are passed through their respective portals  70 , and tension is subsequently applied to these needles  64 . The plates sandwich the septum  62  between them as shown in  FIG. 12 , and each suture is then affixed to the opposing plate  68  by a fastener  36 . 
         [0049]    An additional use for the device disclosed herein and variations thereof is scar prevention during wound closure and healing. Silicone has been demonstrated to reduce hypertrophic, keloid, and other scars when applied to a wound. Silicone bandages, creams, and pads can be placed over a healing wound in order to reduce scarring. However, bandages, creams, or pads cannot eliminate the need for suturing in order to close the wound, and therefore they must be used after the wound has been sutured. For that reason, silicone is conventionally used only after sutures have been removed, which is after the wound has already been sealed and after scars have already begun to develop. Thus, the use of silicone earlier in the healing process may enhance its scar prevention properties. 
         [0050]    Moreover, the use of conventional sutures may contribute to scarring. They tension the sutured tissues primarily where the suture contacts the tissue, which causes the suture to compress the skin in narrow stripes across the wound. This can create a “train track” scar. Conventional suturing can lead to a complication known as “pin-cushioning” when wound edges are uneven, or when uneven tensioning of tissues by sutures pushes tissue edges up. Additionally, because sutures are conventionally knotted tightly, they cannot be repositioned and their tension cannot be adjusted without disturbing the healing tissue. Thus, a wound closure system which avoids these drawbacks may also reduce scarring. 
         [0051]    The device herein has scar prevention properties and may be used as an alternative to conventional suturing, thus accomplishing wound closure with the benefit of silicone for scar reduction and while avoiding the drawbacks of conventional suturing. The present device may be used to both close wounds and to aid in scar prevention in delicate scar revision or flap surgery, high tension wounds, and other wound treatment situations. 
         [0052]    Referring now to  FIGS. 13-16 , in one embodiment, the present device comprises a suture  80  with a surgical needle  78  on its free end, harnessed to a plate  82 . The plate  82  may be composed of a silicone sheet or molded plate. Its size and shape may vary depending on the shape and size of the wound and its anatomic site. The plate should have sufficient rigidity to exert pressure on the healing wound, thus limiting scar progression through compression. 
         [0053]    The plate may include one or more portals  90  such as eyeholes or notches which direct the suture from a first or wound-facing side of the plate  94  to the second or top side of the plate  96 . It may also include a mechanism for fastening the suture to the plate, such as a cleat  92  or other fastener for suture securing. In an alternate embodiment, shown in  FIG. 15 , the plate may have two or more portals  90 , and no attached suture. In this embodiment, the suture can be knotted on top of the device. 
         [0054]    The device is used to proximate the edges of a wound to close the wound, and can then compress the surface of the closed wound, with tension distributed along the full area of the plate instead of the very narrow width of the suture thread as with conventional suturing. Because of the dynamic attachment of the suture to the plate via the eyehole or notch, pulling from the tissue will result in additional compression from the plate. 
         [0055]    In addition, because of the portal fastener components, the suture may be secured without tying a knot, and can have its tension adjusted during the healing process in order to accommodate changes in the tissue caused by edema or healing. Because no suture tying is required, the device can be used for both external and endoscopic procedures where there is limited access to the surgeon for tying knots. Because there is less risk of train-track scarring, the suture plate may be left in place longer, allowing more silicone exposure to the wound, more immobilization, and more support during healing, as well as the prevention of moisture loss from the environment. 
         [0056]    The procedure itself begins with appropriate anesthesia for the patient. Once adequate subcutaneous or submucosal stitches are placed if necessary, the device may be used. The device should be used instead of mucosal or cutaneous sutures, in areas where there may be a high risk for scarring or increased risk of vascular compromise to tissue, such as the corner of a rotational flap where maximal tension occur, or where previous scars have already been excised. 
         [0057]    The needle  78  and suture  80  harnessed to the plate  80  is introduced into the tissue of one edge  84  of the wound, and subsequently passed through an additional edge  86  of the wound  88  as in normal mucosal or dermal skin. Care must be taken to pass through a significant amount of the substance of the subdermal or submucosal tissue to permit adequate eversion and closure. 
         [0058]    Once passed through, the needle  78  and suture  80  are pulled in a direction away from the tissue. Due to a “pulley” effect, the plate is subsequently urged toward the tissue and into position proximal to the wound  88  at the same time that the edges of the wound  84 ,  86  are proximated. Before the plate contacts the tissue, the needle and suture are fed through the portal  90 , the needle and suture are pulled again, until the plate is maneuvered into position flush with the tissue plane, as shown in  FIG. 14 , the closed wound  88  at its midpoint (as a flag would be raised on a flagpole). 
         [0059]    The wound closes just as the plate becomes flush with the tissue. The desired level of tension is kept on the needle end of the suture, and it is fed into the fastener  92  or tied to secure its position and tension. For additional security, a second fastener, perhaps a v-shaped cut-out in the plate, may be used as well. 
         [0060]    The plate can be removed at any point after healing, from days to weeks simply by unfastening the suture, and removing the plate from the tissue. 
         [0061]    Optional features are also possible on the plate. A single plate may have multiple sutures and their respective portals or cleats in parallel, as shown in  FIG. 16 . This would allow one plate to cover a longer incision. The plate may be flat, curved, or oblong shape, depending on the tissue needing repair. 
       Example 
       [0062]    Eight patients underwent rhytidectomies which left typical S-shaped incisions on both sides of their heads. The posterior-most hairline limb incisions were used to test the wound closure device disclosed herein. One side was randomly considered to be the treatment side, and was closed with three semi-rigid silicone plates and attached suture. The other side was closed with conventional surgical staples. 
         [0063]    The devices were fashioned using sterile 1 mm thick silicone sheets (Micromedics, Minneapolis). The 4-0 prolene suture was fastened to the device by passing the needle through the device twice and then tying it to itself on the distal end of the suture, thus securing the plate to the tail of the suture. The curved P-3 needle remained attached to the suture. The needle was then passed again through the plate in order to keep the knot on the opposite surface to skin contact. 
         [0064]    To close the wound using the disclosed device, its curved P-3 needle was carefully passed through both skin edges, in a fashion similar to simple closure, with care taken to avert wound edges. The suture thread was then passed through both skin edges in unison, thus drawing the plate closer to the skin edge. The needle was then passed through the opposite end of the device as the knot side, and the needle was pulled further away from the wound, until the skin edges approximated and the device was cinched down, and was flush with the closed incision. 
         [0065]    Then, on the exposed, superficial side of the plate, the needle side of the suture was tied at the desired tension to the tail of the knot on the device. This process was repeated until the incisional limb is closed with devices. 
         [0066]    At six week and 16 week intervals postoperative, postauricular wounds were assessed, and in all cases the wounds on the treatment side had significantly less scarring then the control wounds. 
         [0067]    The terms and expressions which have been used in this specification are intended to describe the invention, not limit it. The scope of the invention is defined and limited only by the following claims.