SANTA ANA PUEBLO, N.M. The reducing opposed multilobed flap repair offers significant advantages over traditional closure methods for medium-size skin cancer defects below the knee, especially with respect to flap necrosis and overall complications, Dr. Anthony J. Dixon said at a meeting of the American Society for Mohs Surgery.
The reducing opposed multilobed (ROM) technique, which Dr. Dixon developed and first described a few years ago, uses a random-pattern skin flap for defects below the knee that are 1045 mm in diameter (Dermatol. Surg. 2004;30:140611). The pattern consists of semicircular lobes that extend both cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.
"The next semicircle is two-thirds the diameter of the first semicircle and so on," said Dr. Dixon, a dermatologic surgeon who practices in Belmont, Australia. "You keep making semicircles until you have semicircles 58 mm in diameter; then you stop."
The number of semicircles depends on the depth of the primary lesion. "It's quite common to have three semicircles on each side [of the defect]," he said.
The technique involves transposing each semicircular lobe with standard sutures, starting from the lobes most distant from the defect and working inward.
"Throughout the technique you know that tension is being accumulated along the way," said Dr. Dixon, who also is director of research for Skin Alert Skin Cancer Clinics, a network of 13 clinics in Australia. "Rather than tension being in the central defect, tension is being accumulated at the periphery. Therefore, it should result in less wound tension and breakdown centrally."
Postoperatively, Dr. Dixon advises his patients to minimize walking for 24 hours and then slowly increase the amount of walking. "We ask them when they are seated to elevate their leg when they can for the first 4 days," he added.
He takes every alternate suture out in 2 weeks and the rest at 3 weeks. At 6 months, scarring from the procedure "is invariably difficult to find," he said.
In an unpublished analysis, Dr. Dixon and his associates compared 212 patients who underwent ROM flap repairs with 83 patients who underwent repair with ellipse or with other random flap patterns. The diameter of the defect size in all patients ranged from 11 to 45 mm.
The rate of partial flap necrosis was 0.9% in the ROM flap group, compared with 7.2% in the non-ROM flap group, a difference that was statistically significant. The overall rate of complications was 12.7% in the ROM flap group, compared with 28.9% in the non-ROM flap group, a difference that also was statistically significant, he reported.
There were no statistically significant differences between the two groups in terms of the rates of postoperative infections and wound dehiscence, although the rates were smaller in the ROM flap group than in the non-ROM flap group.
The patients "generally liked" the ROM flap procedure. "They liked being able to get up and walk around," Dr. Dixon said.
The study had several limitations: It was not randomized, it was a consecutive series of patients, and all the procedures were performed by Dr. Dixon. "A prospective, randomized controlled trial would be valuable to confirm the findings of this retrospective study," he said.
The reducing opposed multilobed (ROM) flap repair is used for defects below the knee.
Semicircular lobes extend cephalically and caudally from the defect. The largest semicircle is two-thirds of the diameter of the primary defect.
Each of the lobes is transposed with standard sutures, starting from the lobes most distant from the defect and from working inward.
Suturing is finished. Every alternate suture will be taken out in 2 weeks, and the rest at 3 weeks. Photos courtesy Dr. Anthony J. Dixon