Chapter 161: Skin Closure After Resection Of Skin Malignancies, Including Melanoma

INTRODUCTION

Several studies have demonstrated a dramatic increase in the number of skin cancer diagnoses in recent years.^1,2 These increasing numbers amount to a growing patient population in need of skin malignancy management and subsequent reconstruction. Oncological surgeons should be equipped to manage these malignancies in all regions of the body. Following resection, patients are left with defects of variable sizes that involve a variety of cosmetically and functionally sensitive areas. This chapter gives oncological surgeons an outline of reconstructive principles when addressing such defects. For defects requiring more advanced reconstruction, such as the use of complex flaps, management generally would require the scope of practice of a reconstructive plastic surgeon.

GENERAL PRINCIPLES

Wound Healing

There are three basic ways in which wounds heal. Primary healing occurs when wound edges are directly reapproximated, as in suturing two wound edges together. The healing process begins within hours after closure. Secondary wound healing, or “healing by secondary intention,” occurs when wounds are allowed to heal by contraction and epithelialization. Delayed primary healing occurs when a subacute or chronic wound is converted to an acute wound by sharp debridement and is then closed primarily.³

Barriers to Healing

There are many factors that can complicate wound healing and these can create difficulties in reconstruction after resection of skin malignancies. Complications are more likely to occur when reconstructing tissue with a history of radiation therapy or infection, as well as in patients who have systemic illnesses, such as diabetes. Immunocompromised patients also exhibit delayed wound healing. Smoking and nutritional deficiencies can also negatively impact wound healing. When dealing with lesions in patients who have several factors decreasing their ability to heal wounds, it is important to first maximize their wound healing ability prior to reconstruction and to inform them that they are at a higher risk for postoperative complications.^3,4

Reconstructive Options

When attempting to close soft tissue defects, it is generally best to begin with the most straightforward reconstructive option. Healing by secondary intention or direct closure with primary healing is considered the most basic form of healing wounds. However, when this is not possible, other forms of reconstruction must be considered. Skin grafts can be appropriate coverage for some defects, but others will require more advanced soft tissue coverage with regional or distant flaps.^4,5

Temporary Wound Coverage

When managing skin malignancies, reconstruction is often delayed while pathological results can be obtained. Temporizing dressings that can keep the wound clean and protected during the interim are useful. There are several dressings that can serve this purpose. In general, dressings that prevent skin retraction and prevent widening of the defect are most useful. Wound vacuum-assisted therapy can be useful in ...