T he treatment of skin cancer has reached an elevated importance in dermatology because of the epidemic rise in numbers of skin cancer patients. In fact, the incidence of non-melanoma skin cancer has been rising since the 1960s at a rate of 4% to 8% per year.1 As dermatologists, we’re challenged to diagnose and treat patients’ skin cancers in a timely and effective fashion, while still maintaining an emphasis on a good cosmetic outcome. As we’re well aware, maintaining a good cosmetic outcome can be difficult. Some wounds left by the extirpation of skin cancers require the surgeon’s appreciation of the geometric dynamics of wound closure and the incorporation of flaps and grafts (and sometimes the combination of the two) to effectively tailor the closure to the individual patient’s defect. Here is a “roadmap” for the dermatosurgeon so that even the most difficult wounds can be handled in an effective and cosmetically elegant fashion. These are several simplifications that range from the fundamental to the more advanced. In this article we’ll review primary closure/flaps, incomplete closure (second intention healing), inclusion of Burrow’s triangles in the defect, partial closure and flaps A.R.T. In part two, we’ll review contiguous island grafting, distant grafting, and multiple cancers in the same surgical field. Primary Closure/Flaps The elliptical (fusiform) excision is a basic tool of cutaneous surgery.2 The design of the wound lends itself to the closure design (side-to-side). Wound edges often come together with undermining and layered closure. The subcutaneous sutures should be made of a strong absorbable suture material such as Vicryl, Maxon, or Monocryl, which will take the tension off the wound edges. This technique prevents excessive scarring of the wound from the superficial stitching and allows a more cosmetically pleasing result. A horizontal elliptical excision can be used to improve a drooping nose.3 Incomplete Closure Second Intention healing (leaving the wound open) is always a consideration but it must be remembered that this always takes much longer to heal than an effective closure. A thorough understanding of the physiology of wound healing provides the dermatologist with fundamental knowledge that allows a rational management of surgical wounds.4 Many times a wound can be partially closed, and second intention can be relied on to heal the remaining smaller defect. Allowing the wound to begin to heal by second intention does not preclude subsequent closure before healing is complete.5 Partial Closure/Flap The simple act of partially closing a defect will make the wound smaller so that the flap needed to close the wound will be smaller. Smaller flaps have better viability and will heal more quickly. Burrow’s Triangle in the Defect In developing a flap, it’s important to remember that the Burrow’s triangle can be placed anywhere along the extension incision of the flap. By imagining the triangle as part of the primary defect, you can make a unique design that often leaves a more natural-appearing scar. Flaps — A • R • T It is important for the surgeon to run through the menu of flaps available when addressing a wound. The A.R.T. of flaps is an acronym for “Advancement, Rotation and Transposition” — building from the more basic to the more complex. The transposition flap has the advantage over other flaps that it can redirect the forces of the closure and therefore the scar. Variations on the transposition flap can be tailored to the individual patient’s defect.
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Unusual Wound Closures after Skin Cancer Surgery
T he treatment of skin cancer has reached an elevated importance in dermatology because of the epidemic rise in numbers of skin cancer patients. In fact, the incidence of non-melanoma skin cancer has been rising since the 1960s at a rate of 4% to 8% per year.1 As dermatologists, we’re challenged to diagnose and treat patients’ skin cancers in a timely and effective fashion, while still maintaining an emphasis on a good cosmetic outcome. As we’re well aware, maintaining a good cosmetic outcome can be difficult. Some wounds left by the extirpation of skin cancers require the surgeon’s appreciation of the geometric dynamics of wound closure and the incorporation of flaps and grafts (and sometimes the combination of the two) to effectively tailor the closure to the individual patient’s defect. Here is a “roadmap” for the dermatosurgeon so that even the most difficult wounds can be handled in an effective and cosmetically elegant fashion. These are several simplifications that range from the fundamental to the more advanced. In this article we’ll review primary closure/flaps, incomplete closure (second intention healing), inclusion of Burrow’s triangles in the defect, partial closure and flaps A.R.T. In part two, we’ll review contiguous island grafting, distant grafting, and multiple cancers in the same surgical field. Primary Closure/Flaps The elliptical (fusiform) excision is a basic tool of cutaneous surgery.2 The design of the wound lends itself to the closure design (side-to-side). Wound edges often come together with undermining and layered closure. The subcutaneous sutures should be made of a strong absorbable suture material such as Vicryl, Maxon, or Monocryl, which will take the tension off the wound edges. This technique prevents excessive scarring of the wound from the superficial stitching and allows a more cosmetically pleasing result. A horizontal elliptical excision can be used to improve a drooping nose.3 Incomplete Closure Second Intention healing (leaving the wound open) is always a consideration but it must be remembered that this always takes much longer to heal than an effective closure. A thorough understanding of the physiology of wound healing provides the dermatologist with fundamental knowledge that allows a rational management of surgical wounds.4 Many times a wound can be partially closed, and second intention can be relied on to heal the remaining smaller defect. Allowing the wound to begin to heal by second intention does not preclude subsequent closure before healing is complete.5 Partial Closure/Flap The simple act of partially closing a defect will make the wound smaller so that the flap needed to close the wound will be smaller. Smaller flaps have better viability and will heal more quickly. Burrow’s Triangle in the Defect In developing a flap, it’s important to remember that the Burrow’s triangle can be placed anywhere along the extension incision of the flap. By imagining the triangle as part of the primary defect, you can make a unique design that often leaves a more natural-appearing scar. Flaps — A • R • T It is important for the surgeon to run through the menu of flaps available when addressing a wound. The A.R.T. of flaps is an acronym for “Advancement, Rotation and Transposition” — building from the more basic to the more complex. The transposition flap has the advantage over other flaps that it can redirect the forces of the closure and therefore the scar. Variations on the transposition flap can be tailored to the individual patient’s defect.
T he treatment of skin cancer has reached an elevated importance in dermatology because of the epidemic rise in numbers of skin cancer patients. In fact, the incidence of non-melanoma skin cancer has been rising since the 1960s at a rate of 4% to 8% per year.1 As dermatologists, we’re challenged to diagnose and treat patients’ skin cancers in a timely and effective fashion, while still maintaining an emphasis on a good cosmetic outcome. As we’re well aware, maintaining a good cosmetic outcome can be difficult. Some wounds left by the extirpation of skin cancers require the surgeon’s appreciation of the geometric dynamics of wound closure and the incorporation of flaps and grafts (and sometimes the combination of the two) to effectively tailor the closure to the individual patient’s defect. Here is a “roadmap” for the dermatosurgeon so that even the most difficult wounds can be handled in an effective and cosmetically elegant fashion. These are several simplifications that range from the fundamental to the more advanced. In this article we’ll review primary closure/flaps, incomplete closure (second intention healing), inclusion of Burrow’s triangles in the defect, partial closure and flaps A.R.T. In part two, we’ll review contiguous island grafting, distant grafting, and multiple cancers in the same surgical field. Primary Closure/Flaps The elliptical (fusiform) excision is a basic tool of cutaneous surgery.2 The design of the wound lends itself to the closure design (side-to-side). Wound edges often come together with undermining and layered closure. The subcutaneous sutures should be made of a strong absorbable suture material such as Vicryl, Maxon, or Monocryl, which will take the tension off the wound edges. This technique prevents excessive scarring of the wound from the superficial stitching and allows a more cosmetically pleasing result. A horizontal elliptical excision can be used to improve a drooping nose.3 Incomplete Closure Second Intention healing (leaving the wound open) is always a consideration but it must be remembered that this always takes much longer to heal than an effective closure. A thorough understanding of the physiology of wound healing provides the dermatologist with fundamental knowledge that allows a rational management of surgical wounds.4 Many times a wound can be partially closed, and second intention can be relied on to heal the remaining smaller defect. Allowing the wound to begin to heal by second intention does not preclude subsequent closure before healing is complete.5 Partial Closure/Flap The simple act of partially closing a defect will make the wound smaller so that the flap needed to close the wound will be smaller. Smaller flaps have better viability and will heal more quickly. Burrow’s Triangle in the Defect In developing a flap, it’s important to remember that the Burrow’s triangle can be placed anywhere along the extension incision of the flap. By imagining the triangle as part of the primary defect, you can make a unique design that often leaves a more natural-appearing scar. Flaps — A • R • T It is important for the surgeon to run through the menu of flaps available when addressing a wound. The A.R.T. of flaps is an acronym for “Advancement, Rotation and Transposition” — building from the more basic to the more complex. The transposition flap has the advantage over other flaps that it can redirect the forces of the closure and therefore the scar. Variations on the transposition flap can be tailored to the individual patient’s defect.
