ORLANDO Partial closure after Mohs surgery offers many benefits for some candidates, J. Robert Hamill Jr., M.D., said at the annual meeting of the Florida Society of Dermatologic Surgeons.
He suggested that dermatologic surgeons consider partial closure for:
▸ Surgical sites under high tension, including legs, scalp, and fingers. "Scalps can be tight and can be very painful," Dr. Hamill said. "When I first started I closed everything completely."
▸ Surgery confined to one anatomic unit, which facilitates a favorable cosmetic outcome. This applies in particular to the eyelids, nose, lips, and ears. "Keep this in mind because your surgical result will be better," Dr. Hamill said. "Anytime I can stay within an anatomical unit, I will do it."
▸ Sites where surgery might compromise function, especially the eyelids, lip, nose, and fingers.
▸ Surgical sites where complete closure might cause ischemia or necrosis.
"Another benefit is monitoring for recurrence of tumor by not covering the defect," said Dr. Hamill, who is in private practice in Hudson, Fla. A partial closure decreases surgery time, he added.
"Many areas granulate well with no closure," Dr. Hamill said. For example, he partially closed a Mohs defect on a patient's chest and allowed the rest to granulate. Although the outcome was good, "patients like these have to be followed closely," he advised.
In addition, Dr. Hamill chose a partial closure for a patient who had squamous cell carcinoma on his ear.
"I could have done an extensive, two-stage procedure, but the patient wanted something simple," Dr. Hamill said.
"I let it granulate in. It was very functional, and the patient was very happy."
A patient with a small basal cell lesion on his scalp ended up with a large defect after Mohs surgery. "The patient was already thinning on top. You will have traction alopecia" if you do a complete closure, Dr. Hamill said at the meeting.
A partial closure yielded a good result at 2 weeks post operatively; 3 years post operatively there was no additional hair loss.
Lines of relaxed tension are the best place to hide surgical scars, Dr. Hamill said. Pull normal skin as tight as possible and anchor it onto subcutaneous tissue or cartilage with a partial closure, Dr. Hamill suggested. "It's a great trick to increase the chance of flap survival."
A simple advancement flap with partial closure works well for surgery on a digit, Dr. Hamill said. Maintain a digit in a hyperextended position during surgery so the tightness is easily gauged, he suggested.
Partial closure can be handy for surgery close to the eyes to avoid ectropia. "Ectropia can be a problem, especially in the elderly," Dr. Hamill said. With a partial closure, the area with the highest tension can be removed and left to granulate in. "I have patients sit up so I can see if there is ectropia, he said. "There is no sense in doing the surgery and then having the patient sit up."