Practice Gap
Nonmelanoma skin cancers most commonly are found on the head and neck. In these locations, many of these malignancies will meet criteria to undergo treatment with Mohs micrographic surgery. It is becoming increasingly common for patients to have multiple lesions treated at the same time, and sometimes these lesions can be in close proximity to one another. The final size of the adjacent defects, along with the amount of normal tissue remaining between them, will determine how to best repair both defects.1 Many times, repair options are limited to the use of a larger and more extensive repair such as a flap or graft. We present a novel option to increase the options for surgical repair.
The Technique
We present a case of 2 large adjacent postsurgical defects where intraoperative tissue relaxation allowed for successful primary linear closure of both defects under notably decreased tension from baseline. A 70-year-old man presented for treatment of 2 adjacent invasive squamous cell carcinomas on the left temple and left frontal scalp. The initial lesion sizes were 2.0×1.0 and 2.0×2.0 cm, respectively. Mohs micrographic surgery was performed on both lesions, and the final defect sizes measured 2.0×1.4 and 3.0×1.6 cm, respectively. The island of normal tissue between the defects measured 2.3-cm wide. Different repair options were discussed with the patient, including allowing 1 or both lesions to heal via secondary intention, creating 1 large wound to repair with a full-thickness skin graft, using a large skin flap to cover both wounds, or utilizing a 2-to-Z flap.2 We also discussed using an intraoperative skin relaxation device to stretch the skin around 1 or both defects and close both defects in a linear fashion; the patient opted for the latter treatment option.
The left temple had adequate mobility to perform a primary closure oriented horizontally along the long axis of the defect. Although it would have been a simple repair for this lesion, the superior defect on the frontal scalp would have been subjected to increased downward tension. The scalp defect was already under considerable tension with limited tissue mobility, so closing the temple defect horizontally would have required repair of the scalp defect using a skin graft or leaving it open to heal on its own. Similarly, the force necessary to close the frontal scalp wound first would have prevented primary closure of the temple defect.
A SUTUREGARD ISR device (Sutureguard Medical Inc) was secured centrally over both defects at a 90° angle to one another to provide intraoperative tissue relaxation without undermining. The devices were held in place by a US Pharmacopeia 2-0 nylon suture and allowed to sit for 60 minutes (Figure 1).3
Figure 1. Adjacent postsurgical defects after removal of 2 separate squamous cell carcinomas. The SUTUREGARD ISR devices are oriented perpendicularly to one another prior to tightening.
After 60 minutes, the temple defect had adequate relaxion to allow a standard layered intermediate closure in a vertical orientation along the hairline using 3-0 polyglactin 910 and 3-0 nylon. Although the scalp defect was not completely approximated, it was more than 60% smaller and able to be closed at both wound edges using the same layered approach. There was a central defect area approximately 4-mm wide that was left to heal by secondary intention (Figure 2). Undermining was not used to close either defect.
Figure 2. Primary linear closure of both defects was possible after 60 minutes of intraoperative tissue expansion, with the exception of a small central area within the superior defect that was left to heal by secondary intention.
The patient tolerated the procedure well with minimal pain or discomfort. He followed standard postoperative care instructions and returned for suture removal after 14 days of healing. At the time of suture removal there were no complications. At 1-month follow-up the patient presented with excellent cosmetic results (Figure 3).
Figure 3. Excellent healing of both surgical defects 1 month after surgery.