Use of Dynamic Tissue System Adhesive Skin Closure Device and Multi-Tissue Platform Porcine Xenograft to Achieve Primary Closure After Wide Local Excision of a Melanoma

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The effectiveness and efficiency of the DTS adhesive skin closure device (ABRA Surgical & Adhesive systems; Access Pro Medical) has been shown in the management of crush injuries and other large extremity wounds.¹ Superficial spreading melanomas account for 70% of all diagnosed melanomas.² Malignant melanoma accounts for only 10% of all skin cancers, but it is the leading cause of skin cancer deaths.³ Breslow depth is used to determine the excision margins of malignant melanoma as defined by the National Comprehensive Cancer Network.⁴ Usually, 1-cm margins are used for melanomas with a depth of less than 1 mm, 1- to 2-cm margins are used for melanomas with a depth between 1 and 2 mm, and a melanoma with a Breslow depth greater than 2 mm should be excised with 2-cm margins.⁴ These excisions result in a large wound that usually cannot be closed by conventional primary techniques. The MelmarT trial is currently underway to assess noninferiority between 1-cm and 2-cm margins.⁵ Until those results are available (and if they indeed show noninferiority of 1-cm margins), 2-cm margins will continue to be the standard of care based on Breslow depth.

Typically, the resulting defect from a 2-cm–wide local excision in an extremity is not amenable to conventional primary closure. The current case report highlights the use of a DTS adhesive skin closure device and porcine xenograft to quickly achieve primary closure of such a defect.

The DTS adhesive skin closure device is designed to achieve primary closure of large wounds using dynamic tension; furthermore, the device reapproximates large wounds over a prolonged course of a few days to 2 weeks (depending on the size of the wound) using dynamic tension from elastic bands.⁶ These bands are made from a silicone elastomer.⁷ Reapproximation of large defects through dynamic tension is achieved via progressive adjustments of the elastic bands as the tissue allows, until primary closure occurs.

MTP xenograft (XCelliStem Wound Powder; Stemsys), which is derived from the extracellular matrices of porcine lung and spleen, encourages wound healing by facilitating constructive remodeling; it also appears to have antimicrobial properties.^8,9 The decellularization and preparation of this material results in viable cell-signaling proteins and growth factors that contribute to site-specific tissue deposition (constructive remodeling) including collagen, elastin, fibronectin, fibroblast growth factor, and vascular endothelial growth factor. Furthermore, MTP xenograft has been shown to aid in establishing an environment conducive to wound healing while improving outcomes.⁹

The MTP xenograft is a powder that can be applied to a surgical wound prior to closure. The current study describes the case of a 61-year-old male with a superficial spreading malignant melanoma (1.1-mm Breslow depth) on the right posterior calf that was managed with wide local excision with a 1-cm margin and sentinel lymph node biopsy. Successful primary closure of the resulting soft tissue defect was achieved with the DTS adhesive skin closure device in conjunction with MTP.

A 61-year-old male presented to a plastic surgeon (P.A.) with a pigmented lesion measuring 1.3 cm in maximum dimension located in his right mid posterior calf. The patient had noticed the mass 4 to 6 months prior and pointed it out during the clinic visit. Previous medical history included hypertension, hypercholesterolemia, and benign prostatic hypertrophy. The patient had undergone several excisions of nonmelanoma skin cancers over the past 15 years. A narrow excisional biopsy of the indeterminant dermal mass revealed a Clark level IV superficial spreading malignant melanoma with Breslow depth of 1.1 mm and mitotic rate of 1 mm². There was no evidence of ulceration, lymphovascular invasion, or satellite nodules.

A 2-cm–wide local excision of the melanoma biopsy site was performed (Figure 1A). Lymphatic mapping and an inguinal sentinel lymphadenectomy were also performed. The resulting soft tissue defect measured 11.0 cm long × 9.0 cm wide ×1.0 cm deep (Figure 1B). The soft tissue defect could not be closed primarily.

The DTS adhesive skin closure device was applied, and MTP porcine xenograft was applied at the time of initial excision (Figure 2A). Approximately 2 g of MTP porcine xenograft powder was applied thoroughly and evenly across the wound defect. Following application of the MTP xenograft, the DTS device was applied. The MTP xenograft was applied only once prior to the placement of the DTS device. Four pairs of individual adhesive devices were applied to the skin, with an elastic band then applied to each pair. Dynamic tension was utilized via progressive readjustments of the bands. The defect maximum width decreased from 9.0 cm initially to 1.5 cm after application of the DTS closure device (Figure 2B). After the DTS device was applied, a portion of the cephalad and caudad wound was primarily closed. Wound margins were then 5.0 cm long × 1.5 cm wide × 1.0 cm deep.

This procedure was performed in an outpatient surgery center, and the patient was discharged the same day with the device in place. The device allowed for immediate mobility postoperatively. Primary skin closure was achieved quickly (especially considering the size of the defect), by postoperative day 7 (Figure 1C). Readjustments were made on postoperative days 3 and 7 by the surgeon who performed the initial excision. Delayed primary closure with bidirectional interrupted vertical mattress sutures was performed on postoperative day 7. The DTS adhesive skin closure device remained in place for 10 days after primary closure to offload tension on the primary skin closure. Prior to removal of the device, the patient had already resumed daily activities, including golfing. The patient was ambulatory and active with the DTS adhesive skin closure device in place. As of this writing, the patient had retained full functionality, was pleased with the cosmetic result (Figure 1D), and had no issues with chronic pain.

Institutional review board approval was not required for this case report. Written informed consent was obtained from the patient on admission, and all material presented in this study was deidentified.

Wide local excision is the standard of care for melanomas, and the surgical margin depends on Breslow depth of the melanoma.⁷ As noted previously, wide local excision of melanomas with a Breslow depth of 1 mm to 2 mm requires a surgical margin of 2 cm.⁴ Quite often, wide local excision to 2-cm margins leads to a large wound that is not amenable to primary closure. In these situations, several closure techniques are available to manage these soft tissue defects. These techniques include skin grafts and local regional flaps; however, these can be time- and resource-consuming, and they are associated with additional risks to the patient, such as poor skin graft take requiring additional surgeries and necrosis of locoregional flaps.¹⁰

The DTS adhesive skin closure device is designed to achieve primary closure of large wounds using dynamic tension.³ The DTS adhesive skin closure device decreases the wound dimensions such that primary closure of the cephalad and caudad portions of a wound are accomplished intraoperatively.⁶ Closure is achieved through regular reapproximation of the wound via dynamic tension. This is accomplished through progressive readjustments of the elastic bands of the device. Although the current case report discusses the use of MTP powder with the DTS device, the DTS device can be used with other cellular and tissue-based products, such as porcine urinary bladder matrix.¹

The DTS adhesive skin closure device has many applications. It has been used to successfully close sizable open myelomeningoceles.¹¹ Additionally, the device can be coupled with porcine xenograft products. As noted previously, MTP powder facilitates constructive remodeling and has antimicrobial properties. This powder, which is derived from the extracellular matrices of porcine lung and spleen, contains several components, including collagen, elastin, and fibroblast growth factor, as well as cell-signaling proteins that may help facilitate healing through site-specific tissue deposition (constructive remodeling). The combination of the DTS adhesive skin closure device and the constructive remodeling properties of the MTP porcine xenograft may have contributed to wound closure and healing in the current case.

The approximate cost of the DTS adhesive device used in this case was $500. The approximate cost of MTP used was $520 (for 250 mg; 500 mg costs $1009.50). In contrast, the estimated cost of a skin graft operation is $1419, and the approximate cost of regional flap closure is $2165.¹² Use of the DTS skin adhesive and porcine xenograft in the current case resulted in primary closure in a wound that would otherwise have required skin grafting or regional flaps. This multimodality approach to wound closure has applications for other cutaneous malignancies for which a wide local excision is necessary. Further, the approach can be used by both general and plastic surgeons. It is another option for dermatologists, general surgeons, surgical oncologists, and plastic surgeons to consider when managing cutaneous malignancies that require more extensive soft tissue excision where primary closure cannot be achieved.

This case report has limitations. While no definitive conclusions can be drawn due to the singular nature of the case report, it does highlight the necessity for further research into the applicability of the DTS skin adhesive device and porcine xenograft for closure of large skin defects. Although the MTP xenograft has components associated with site-specific tissue deposition (constructive remodeling), its effect is difficult to quantify because this is a single case report. However, its benefits have been documented in other wound-related case series in the literature.^1,9

This report and its results show that the DTS adhesive skin closure device is an additional option for the closure of large defects following a wide local excision in the management of a melanoma on the extremities.

Authors: Jad F. Zeitouni, BBA¹; Reagan Collins, BA¹; Patricia Arledge, MD¹; Yana Puckett, MD, MBA, MPH, MSc2; and Catherine A. Ronaghan, MD³

Affiliations: ¹Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; ²West Virginia University School of Medicine, Department of Surgery, Charleston, WV; ³Texas Tech University Health Sciences Center, Department of Surgery, Lubbock, TX

ORCID: Arledge, 0009-0005-6543-9457; Ronaghan, 0000-0003-4940-2695; Zeitouni, 0000-0003-3723-9018

Disclosure: The authors disclose no financial or other conflicts of interest.

Correspondence: Jad F. Zeitouni; Medical Student, Texas Tech University Health Sciences Center School of Medicine, Department of Surgery, 3601 4th Street, Lubbock, TX 79410; jad.zeitouni@ttuhsc.edu

Manuscript Accepted: January 22, 2024