LUCAYA, BAHAMAS Partial closure is an underutilized technique that can improve the outcome of surgical reconstruction after Mohs surgery for many patients, Dr. J. Robert Hamill Jr. said at a meeting of the American Society for Mohs Surgery.
Indeed, closing only part of the wound and leaving the rest to granulate on its own is advantageous in a wide variety of situations. Surgical sites to consider for partial closure include:
▸ Tumor sites that need to be monitored for recurrence.
▸ Surgical sites under high tension, including the leg, scalp, and fingers.
▸ Sites where function may become compromised, especially the eyelid, lip, nose, and finger.
▸ Sites where complete closure may cause ischemia or necrosis.
"You don't have to close every defect," said Dr. Hamill of the department of dermatology at the University of South Florida, Tampa, who also has a private dermatology practice in Hudson, Fla.
Many areas granulate well without any closure, especially in the concave areas on the nose, eyelid, ear, and templethe so-called NEET areas (J. Am. Acad. Dermatol. 1983;9:40715).
Surgical scars will have the best results when they are kept within anatomical units (especially the eyelids, nose, lips, and ears), and are best hidden within the lines of relaxed tension. Indeed, an overriding principle is that "the best surgical scar is the one you don't need to extend," he said.
Partial closures allow you to shorten a scar and to decrease overall surgery time, a particularly important consideration in elderly patients.
Some preliminary data even suggest that partial closuresby not creating a dead spacemay be associated with a reduced risk of postsurgical infection. Avoiding infection is becoming especially critical in this era of methicillin-resistant Staphylococcus aureus, Dr. Hamill said.
It's important to warn patients that there will be a small hole or wound in the area you've partially closed, which may take up to 23 weeks to completely heal. During this time, there may be crusting or oozing that may require cleaning. Depending on their comfort level, patients can either clean the wound themselves or come back to your office.
"Patients are very receptive to partial closures as long as you tell them up front what to expect," said Dr. Hamill.
Partial closure is also the best option any time there is a risk for ectropion. "If a closure results in pulling, I always adjust the flap by placing the patient in a seated position and removing sutures, [thereby] creating a partial closure so there is no ectropion immediately after suturing," he noted.
In some cases, it may even make sense to consider a partial closure after a complete one in areas of high tension, such as the leg or scalp. If you've done a complete closure in such an area, try waiting 5 minutes, he advised.
If the area looks white and ischemic, you may want to take out a few sutures to create a partial closure. This will allow the flap to completely take and is always better than partial necrosis. A clinical pearl is to debride the new partial defect every 2 weeks so that the defect heals from within, thus preventing a depressed scar, he said.
And another clinical pearl: When using a simple transposition flap, it may be possible to subdivide the defect to create two separate but smaller areas of granulation, rather than one larger area. Doing so may reduce the healing time and produce a smaller scar. This technique is especially useful on the nose if a complete closure pulls the tip and results in congested breathing.
"You can make a very complex closure simple and prevent functional deficit," Dr. Hamill said.
Overall, the aim is to "keep it simple and work with nature," he said.
This patient had ectropion that resulted from the closure of a lateral advancement flap used to repair a defect on her lower eyelid.
The partial closure was created by removing the medial superior sutures until the ectropion was no longer present.
One month after surgery, there is no ectropion with only minimal swelling, which eventually resolved over the next few months. Photos courtesy Dr. J. Robert Hamill Jr.