Antihelical Defect Closure By Secondary Intention: Revisiting an Old Paradigm

© 2024 HMP Global. All Rights Reserved.

Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

An 82-year-old patient with multiple comorbid conditions, including hypertension and chronic alcohol and tobacco use, presented with a recurrent squamous cell carcinoma to the right ear. Previous treatment included excisional biopsy 2 months prior. On examination, he had a 1.5-cm fungating and friable mass at the junction of the right ear antihelix and scapha (Figure 1). The patient declined skin graft or local flap closure in preoperative discussion. The mass and underlying cartilage was excised to clear margins resulting in a 3-cm full-thickness defect including cartilage at the antihelix-scapha junction. The wound base was treated with hydrolyzed collagen powder (Figure 2). At 1 week postoperative, daily wound care was begun with hydrolyzed collagen gel. The wound was monitored weekly and closed by secondary intention (Figure 3). At 4 weeks postoperatively the wound was closed, with only a small amount of central flattening (Figure 4). The patient was satisfied with the cosmesis of the final result.

Figure 1: Preoperative. Fungating recurrent squamous cell carcinoma of the right ear antihelix and scapha.

Figure 2: Left: Defect following excision to clear margins with central cartilaginous defect of the antihelix. Right: Hydrolyzed collagen powder applied to the wound base, covered with a nonadherent wound contact layer and bolster dressing for 7 days.

Figure 3: Left: 1 week postoperatively. Daily wound care with CellerateRx wound gel begun. Right: 2 weeks postoperatively.

Figure 4: Final result 4 weeks postoperatively. Note the small amount of central flattening.

Healing by secondary intention is the natural healing response that occurs when a wound is left open and consists of epithelial and fibroblast migration and scar formation. It is the oldest method of wound closure and predates the practice of medicine.¹ Healing by secondary intention is often used in dermatologic surgery for the closure of superficial wounds following shave biopsy, cryotherapy, chemical cautery, and electrical desiccation.² In full-thickness surgical wounds, however, healing by secondary intention is more often a strategy for wound salvage in situations such as marginal necrosis, infection, and wound dehiscence. Advantages include decreased need for additional procedures, decreased cost, avoidance of additional donor sites, and easy monitoring for tumor recurrence in oncologic defects.³

Disadvantages of healing by secondary intention include pain or dysesthesia, infection, hypopigmentation, wound contraction, and hypertrophic scarring.² Pain is minimized by maintaining a moist environment, increasing dermal elasticity, and reducing tension. Once the wound is closed, dysesthesias may occur over the scar and can be treated with vibration desensitization. Infection is a concern with any open wound but is minimized with proper wound care and may be treated with antibiotics if needed. Hypopigmentation is expected in the process of wound healing with repigmentation occurring slowly over a period of years. Wound contraction occurs during the natural course of the wound healing response and can favorably result in a smaller wound size and scar. On the face, however, wound contraction can result in distortion of adjacent anatomical landmarks, such as the eyebrow, eyelid, or nasal ala. To minimize these contractures, guiding sutures may be used to decrease tension in the wound adjacent to these landmarks.² Finally, hypertrophic scarring is common in full-thickness wounds and over convex surfaces. It improves with time but may be treated with intralesional steroids or 5-fluorouracil to soften and flatten the scar.

Wound healing by secondary intention may be accelerated by maintaining a clean, moist environment to promote epithelial and fibroblast migration.² Wound care consists of a daily dressing change with an occlusive or semi-occlusive dressing. Rate of closure is a logarithmic function of wound diameter.⁴ Various dressings and topical agents have been investigated with no statistically significant differences found in rate of wound healing.⁵ A gauze dressing is the cheapest dressing but is associated with more frequent dressing changes, more time spent managing dressings, and more pain. Other dressings such as foams, alginates, and hydrocolloids require less frequent dressing changes and are associated with decreased pain and increased patient satisfaction but are much more expensive. While animal studies, case reports, and literature reviews have expounded upon the benefits of biologic dressings such as collagen in open wounds,^6,7 larger clinical studies have not shown any significant difference in time to closure or cosmesis.⁸ With the advent of newer, more refined biomaterials, further research is warranted to reinvestigate the routine use of collagen in healing by secondary intention.

The cosmetic outcome of healing by secondary intention can be predicted with excellent, satisfactory, and variable outcomes according to facial subunits as described by Zitelli in 1984.² Areas healing with excellent cosmesis include the concave surfaces of the nose, eye, ear, and temple (NEET). Areas with satisfactory outcomes include the forehead, antihelix, eyelids, and remainder of the nose/lips and cheek (FAIR). Areas healing with variable cosmesis include the convex surfaces of the nose, oral lip (vermillion) area, cheeks, and chin (NOCH,) with superficial wounds resulting in a better cosmetic result than deeper wounds.

In regards to the ear, cosmetic outcomes of healing by secondary intention have been further subdivided into 8 subunits by Levin in 1996, including the helix; antihelix; concha; tragus; lobule; posterior auricle; and combined defects of the posterior auricle and helix, and helix and antihelix.³ Areas healing with the most favorable cosmesis were the posterior auricle, tragus, antihelix, concha, and combined helix and antihelix. Areas healing with the worst cosmesis were the lobule, helix, and combined posterior auricle and helix. Defects of the helix including cartilage and those of the lobule are associated with distinct notching due to the lack of cartilaginous support, known as a “cookie bite” deformity. Cartilaginous defects of the central ear including the antihelix or concha are associated with an area of central flattening that does not compromise the final result. Should a poor cosmetic result occur, scar revision may be performed following wound closure.⁹

Healing by secondary intention has been found to be non-inferior and in some cases superior to other reconstructive methods, including primary closure, skin grafting, and local flaps,^9,10 and should not be overlooked as a viable strategy in wound closure.