Mohs wounds of the forehead: healing by secondary intention

Accurate prediction of the course of wound healing allows patients with Mohs surgical wounds on the face to be objectively selected either for surgical repair or for spontaneous healing. Parameters affecting wound healing--location, depth and size of wound--were documented at intervals for 135 patients who had full-thickness defects in the forehead after Mohs surgery, which were left to heal by secondary intention. Quality of cosmesis was determined at least four months after surgery. Final cosmetic result was predictable on the basis of wound location, size and depth. Allowing selected Mohs surgical wounds to heal spontaneously offers optimal cancer surveillance, simplified wound care and elimination of reconstructive procedures along with their associated costs and potential complications.     

Granulation Tissue Flap Technique in Extensive Wounds for Covering Exposed Bone After Tumor Excision

BACKGROUND: Second intention partial wound healing followed by skin grafting is a well-established method in dermatosurgery. In wide tumor excision, where periosteum is removed, growth of granulation tissue in the central areas of bare bone can be prolonged. OBJECTIVE: We describe a new technique for a faster, reliable closure of large defects utilizing granulation tissue flaps. METHODS: Postoperative wounds were treated with wet dressings until granulation tissue had developed on the wound edges. The central defects were then covered with lateral granulation tissue flaps. Subsequently split skin grafting was performed. RESULTS: Thirty-eight patients (37-99 years old) were treated between 1991 and 1999. Skin defects were located primarily on the scalp and forehead, and ranged from 3 to 13 cm in diameter. Wound bed preparation for skin grafting was achieved in all patients. Only minor complications, such as partial granulation flap necrosis in 5 of 38 patients or delayed skin graft healing in 4 of 38 patients, were seen. CONCLUSIONS: This technique for the closure of extensive skin defects is safe and effective.     

Effective Management of Difficult Surgical Defects Using Tissue-Engineered Skin

BACKGROUND: Graftskin, a bilayered living skin construct, is an effective therapeutic option in the management of chronic venous ulcerations and simple acute surgical excisions. However, it is not routinely used in the management of complicated surgical wound defects. OBJECTIVE: To determine the effectiveness of graftskin as a therapeutic modality in difficult surgical defects. METHODS: Two patients with complex surgical wound defects after Mohs micrographic surgery underwent a single application of graftskin. The engineered skin was fenestrated and sutured in place. The wounds were examined on a weekly basis. One hundred percent healing was defined as complete reepithelialization (wound coverage). RESULTS: Graftskin was well tolerated by these patients and resulted in complete wound healing within 9 weeks of application. CONCLUSION: Graftskin is an excellent alternative for difficult surgical wounds not amenable to other therapies. Graftskin results in a shortened healing time and decreased morbidity. It should be considered for wounds in which healing by secondary intention is preferably avoided.     

Effect of Acitretin on Wound Healing in Organ Transplant Recipients

Background. Systemic retinoids possess significant benefits in cutaneous malignancy chemoprevention; however, retinoids have been associated with excessive granulation tissue and hypertrophic scarring.
Objective. The objective of this study was to assess wound healing outcomes in organ transplant recipients, both with and without the concomitant use of systemic acitretin chemoprophylaxis.
Methods. Twenty-nine immunosuppressed organ transplant recipients underwent treatment of basal cell or squamous cell carcinoma by Mohs or excisional surgery, with a total of 85 wounds. Wounds were evaluated postoperatively at early (average 12.9 days) and late (average 75.8 days) time points. Endpoints for all wounds included infection, hypertrophic granulation tissue, and hypertrophic scarring. Reconstructed wounds were also evaluated for dehiscence.
Results. Eleven patients taking oral acitretin had 41 wounds, of which 33 were reconstructed and 8 healed by second intention. The 18 patients not taking acitretin (control group) had a total of 44 wounds, of which 33 were reconstructed and 11 healed by second intention. There were no statistically significant differences between the acitretin group and the control group in the incidences of infection, dehiscence, hypertrophic granulation tissue, or hypertrophic scarring at early or late evaluation points.
Conclusions. Systemic acitretin chemoprophylaxis does not appear to increase the risk of wound healing complications in organ transplant recipients.     

The use of a bovine collagen construct for reconstruction of full-thickness scalp defects in the elderly patient with cutaneous malignancy

Full-thickness defects of the scalp following cancer resection are reconstructive challenges when bone is exposed. Local, regional, and/or free tissue transfer have all been described for reconstruction when the pericranium is exposed. We examined the surgical outcomes from 23 patients who underwent placement of bovine collagen constructs. Thereafter, delayed skin grafting was performed. The average age of the patients was 70 years. All patients had one of the following: melanoma (n = 13) squamous cell carcinoma (n = 5), angiosarcoma (n = 2), basal cell carcinoma (n = 1), spindle cell carcinoma (n = 1), or malignant pilar tumor (n = 1). The average defect size was 51 cm, with a range of 9 cm to 169 cm. Average time between bovine construct placement and skin grafting was 30 days. Histologic studies demonstrated persistence of the construct and infiltration of nascent fibroblasts. Six patients had delayed healing due to microabscesses in the constructs. All wounds eventually healed. In the elderly, this is a simple method to treat full-thickness scalp defects.     

The effect of pentoxifylline on the healing of full-thickness skin defects of diabetic and normal rats

In this paper, the effects of systemic pentoxifylline administration on normal and diabetic wound healing are studied. Twenty-four normoglycemic and 24 diabetic rats were compared, exploring the healing of standardized (15᎗ mm) full-thickness wounds by secondary intention. Twelve rats of both groups received intraperitoneal pentoxifylline 10 mg/kg per day. The strength of the healed tissues was evaluated by straining tests, the healing time of each wound was recorded, and the healed tissues were examined histologically. In the diabetic group, the only significant difference between the rats receiving pentoxifylline and the others was the shortened healing time. Pentoxifylline significantly reduced the time needed for complete epithelization and also increased the tensile strength significantly in normoglycemic rats. As expected, significant differences were recorded between the normoglycemic and diabetic rats regarding healing time and scar tissue strength. In conclusion, systemic pentoxifylline administration may be helpful in shortening the healing time of full-thickness wounds both in diabetic and normoglycemic patients, and it can increase the tensile strength of the healed wound in normoglycemic organisms.     

The cone flap: a fasciocutaneous flap option for plantar heel ulcers

Plantar heel wounds are often difficult to epithelialize in a timely manner. When healing is achieved through secondary intention, the results are often fragile and prone to reulceration. The cone flap provides a surgical option to allow plantar skin coverage for these difficult-to-heal wounds. The fasciocutaneous nature of the flap provides a well-vascularized pedicle for wound coverage. Following this simple method, a durable primary closure is available to all surgeons who work with chronic foot wounds.     

Regional Variation in Wound Contraction of Mohs Surgery Defects Allowed to Heal by Second Intention

BACKGROUND: The phenomenon of wound contraction results in a decrease in wound size and a healed scar significantly smaller than the original defect. OBJECTIVE: This study was undertaken (1) to determine the amount of wound contraction in Mohs surgery defects allowed to heal by second intention, (2) to evaluate for regional differences in wound contraction based on the facial anatomic zones for second intention healing described by Zitelli, and (3) to determine whether regional differences in wound contraction account for observed differences in cosmetic outcome. METHODS: One hundred sixty secondarily healed Mohs surgery defects limited to the head and neck having a wound age of greater than 12 weeks in 102 consecutively examined patients were carefully measured with a tissue caliper. The percent wound contraction was calculated and compared for each Zitelli anatomic subunit. The final shape of the wound (quantitatively described) and the cosmetic acceptability (subjectively rated by the patient and examiner) were also compared with the percent wound contraction for each anatomic area. RESULTS: Both NEET (concave surface of the nose, eye, ear, and temple) and FAIR (forehead, antihelix, eyelids, and the remainder of the nose, lips, and cheeks) areas were identical in terms of mean wound contraction (74%), cosmetic acceptability (97%), and conversion to a wound shape with a ratio of maximal length to width of greater than 3.0 (fusiform and linear shapes) (52%). NOCH areas (convex surface of the nose, oral lips, cheeks and chin, and the helix of the ear) demonstrated less wound contraction (66%), cosmetic acceptability (78%), and fusiform-linear conversion (29%). Subset differences and variables that appear to influence wound contraction are discussed. Secondarily healed wounds in areas with one or more positive contraction variables contract 75%, whereas defects in areas with negative contraction variables contract 55%. CONCLUSIONS: Regional differences in wound contraction of secondarily healed head and neck wounds exist and account for some differences in cosmetic acceptability. Scar location, regardless of the degree of wound contraction, is the most important factor for the final cosmetic outcome.     

Staged method using antibiotic beads and subsequent autografting for large traumatic tibial bone loss: 22 of 23 fractures healed after 5-20 months

Introduction The vascularity of surrounding soft tissues, which is related to muscle cover, is important for the healing of traumatic bone loss. Muscle cover on the distal tibia is limited compared to the diaphyseal and proximal tibia, and delayed healing of fractures in this area is common. We evaluated the healing of traumatic bone loss in the proximal, diaphyseal, and distal tibia.

Patients and methods 23 open tibial fractures with substantial bone loss (mean 52 (34-104) mm) were treated using a staged method with antibiotic-impregnated beads and later autologous bone grafting at second-stage surgery on average 8 weeks after the injury.

Results 22 fractures healed after mean 40 (20-79) weeks. The average healing time in the distal tibia (mean 30 weeks) was 7 weeks shorter (95% CI: 12-26 weeks) than in the proximal tibia (37 weeks), and 16 weeks shorter (95% CI: 3-29 weeks) than in the tibial shaft (47 weeks). The length of the bone and the type of soft tissue cover (free muscle or secondary suture) had no effect on healing time.

Interpretation Our study suggests that the method we used is applicable in all parts of the tibia, although the healing of bone loss is slower in the diaphyseal tibia than in the proximal and distal tibia.     

Staged method using antibiotic beads and subsequent autografting for large traumatic tibial bone loss

Introduction The vascularity of surrounding soft tissues, which is related to muscle cover, is important for the healing of traumatic bone loss. Muscle cover on the distal tibia is limited compared to the diaphyseal and proximal tibia, and delayed healing of fractures in this area is common. We evaluated the healing of traumatic bone loss in the proximal, diaphyseal, and distal tibia.

Patients and methods 23 open tibial fractures with substantial bone loss (mean 52 (34–104) mm) were treated using a staged method with antibiotic-impregnated beads and later autologous bone grafting at second-stage surgery on average 8 weeks after the injury.

Results 22 fractures healed after mean 40 (20–79) weeks. The average healing time in the distal tibia (mean 30 weeks) was 7 weeks shorter (95% CI: 12–26 weeks) than in the proximal tibia (37 weeks), and 16 weeks shorter (95% CI: 3–29 weeks) than in the tibial shaft (47 weeks). The length of the bone and the type of soft tissue cover (free muscle or secondary suture) had no effect on healing time.

Interpretation Our study suggests that the method we used is applicable in all parts of the tibia, although the healing of bone loss is slower in the diaphyseal tibia than in the proximal and distal tibia.     

Management of Large Surgical Defects of the Forehead and Scalp by Imbrication of Deep Tissues

BACKGROUND: When facing surgical defects, the dermatologic surgeon follows certain basic principles that help reduce the inherent tension to allow for a better cosmetic outcome. These commonly include the use of undermining, releasing technique such as galeotomy if applicable, selection of suture material of appropriate tensile strength, and closure along relaxed skin tension lines. OBJECTIVE: To review the imbrication of deep tissues, another surgical principle aimed at wound tension reduction and widely utilized by cosmetic surgeons in forehead lifts and scalp reductions, as it applies to dermatologic surgeons in the repair of large surgical defects of the upper face and scalp. The latter may be utilized both with primary closure and with local flaps. METHODS: We describe in detail the technique of imbrication of deep tissues and provide illustrations for a better understanding of how to correctly use this surgical principle. RESULTS: The dermatologic surgeon has an additional tool, termed imbrication of deep tissues, available to aid in the closure of sizable wounds of the forehead and scalp as seen following Mohs surgery for cutaneous malignancies by providing deep tissue support. CONCLUSION: Imbrication of deep tissue is an effective tool that may be used by dermatologic surgeons in conjunction with the more commonly utilized basic surgical principles to enhance the cosmetic outcome in the closure of large, high-tension defects of the forehead and scalp.     

Amniotic membrane is a potential regenerative option for chronic non‐healing wounds: a report of five cases receiving dehydrated human amnion/chorion membrane allograft

A case series of five patients with a total of six chronic non‐healing wounds (>30 day duration) were non‐randomly selected to evaluate the performance, safety and handling properties of dehydrated human amnion/chorion membrane allograft, an amniotic membrane scaffolding product. The patients had lower extremity wounds that had previously failed standard of care within a university outpatient/inpatient wound healing programme. Five wounds treated with dehydrated amnion/chorion membrane allograft showed a mean 43% area reduction from baseline (51% median) at 3 weeks into treatment and completely healed with a 64‐day median time to closure (SD ±27·6 days). One wound worsened at 3 weeks and was found to have a complete central vein obstruction that was treated with long‐term mild compression but still eventually healed at 6 months. Removing this outlier, the four responding wounds had a 72% mean and 69% median change in area from baseline, at the 3 week point. All five patients received only one application of dehydrated human amnion/chorion membrane allograft, and there were no adverse events. The product was easy to use, administer and handle. In summary, dehydrated human amnion/chorion membrane allograft appears to be a safe, effective and easy to use therapy for chronic non‐healing wounds. This study describes the details of these clinical cases and provides an overview of the current evidence on the use of amniotic tissue in clinical practice.     

Use of a lyophilized bovine collagen matrix in postoperative wound healing.

BACKGROUND: Immediate reconstruction is the preferred approach to the management of defects following Mohs micrographic surgery. In a minority of patients, however, reconstruction is contraindicated, and a long-term biological dressing that stimulates wound healing and minimizes wound care is desirable. OBJECTIVE: We wanted to assess the utility of a lyophilized, type I bovine collagen matrix (SkinTemp) in wound care and wound healing following Mohs micrographic surgery. METHODS: Fifteen patients were treated with a bovine collagen matrix following Mohs micrographic surgery. Study wounds were evaluated for time to complete granulation, time to complete epithelialization, and adverse reactions including infection and allergy. The time to complete healing (granulation and epithelialization) for this group was compared to 15 size- and site-matched surgical defects. RESULTS: The use of bovine collagen matrix provided more rapid wound healing than traditional second intention healing at all anatomic sites studied. The time to complete healing averaged 6.1 weeks with bovine collagen matrix versus 9.4 weeks for the control group. Use of bovine collagen matrix required an average of 3.0 dressing changes weekly compared to 7.0 changes weekly in the control group. There were no wound infections or allergic reactions to it. CONCLUSIONS: A Type I bovine collagen matrix provided a safe, readily available alternative to traditional methods of second intention healing. It minimized wound care while reducing the time for complete healing. A larger study should be performed to confirm the results of this pilot study.     

Secondary‐intention healing following Mohs micrographic surgery for squamous cell carcinoma of a finger

Mohs micrographic surgery is the best therapeutical option for hand squamous cell carcinoma without bone involvement; however, the reconstruction of the surgical defect could be very difficult if the tumour is located in the distal phalanx of a finger. We present the case of a patient with a squamous cell carcinoma of the distal phalanx of a finger, which was treated with Mohs micrographic surgery, and its surgical defect was successfully resolved by secondary‐intention healing using hydrocolloid dressings.     

应用人工真皮和自体皮移植修复难愈性创面

目的 了解人工真皮联合自体皮移植修复难愈性创面的可行性并评价其治疗效果.方法 选择20例住院患者共25处持续8周以上的难愈性创面,分为慢性溃疡组9例11处创面,为创伤、烧伤后瘢痕溃疡创面;骨外露组11例14处创面,骨外露面积为0.8～77.0 cm~2(最大面积为22.0 cm×3.5 cm).手术方法 为I期扩创移植人工真皮,2～6周后局部血管化良好,外露肌腱和骨质被类真皮组织覆盖,Ⅱ期移植自体薄断层皮片. 结果 慢性溃疡组9例患者的11处创面中,9处愈合优良,2处经换药后愈合.骨外露组11例患者的14处创面中,12处愈合优,外露骨质得到有效覆盖;2处创面因感染人工真皮未成活,随后行皮瓣修复手术.随访5-24个月,未见创面复发,外观满意,无明显增生性瘢痕,供皮区亦无明显瘢痕形成. 结论 人工真皮联合自体皮移植修复难愈性创面,方法 简便、创面愈合质量高、供皮区损失轻微,为难愈性创面的修复提供了新的选择.     

Recovery course of full-thickness skin defects with exposed bone: an evaluation by a quantitative examination of new blood vessels

BACKGROUND: Full-thickness skin defects with exposed bone are often hard to heal. The lack or delayed re-vascularization is considered one of the major causes, and the periosteum is also suggested to have an important role in tissue regeneration. MATERIALS AND METHODS: Full-thickness skin defect wounds with exposed bone were made in the parietal region of Wister rats. The periosteum of the exposed parietal bone was removed in the periosteum-lacking group, but maintained in the control group (periosteum-intact group). The wound was covered by an artificial dermis made of collagen. The wound healing process was histologically compared. Double immunostaining of alpha-smooth muscle actin (SMA) and von Willebrand factor (vWF) was used for re-vascularization examination, and the blood vessel density in the artificial dermis was quantified. RESULTS: The density of the blood vessels in the uninjured parietal tissue was approximately 80 vessels/mm(2). To reach this density, 7 and 21 days were required for the control (periosteum-intact) and the periosteum-lacking groups, respectively. This coincided with complete revascularization, fibroblast migration and the reentry of blood vessels to the upper layer of the wound were observed. CONCLUSION: The described results support the importance of the periosteum in the full-thickness skin defect healing process.     

Healing of partial thickness porcine skin wounds in a liquid environment.

This study employs a liquid-tight vinyl chamber for the topical fluid-phase treatment of experimental wounds in pigs. Continuous treatment with normal saline significantly reduced the early progression of tissue destruction in partial thickness burns. Uncovered burns formed a deep layer of necrosis (0.49 +/- 0.004 mm, mean +/- SD) although burn wounds covered with empty chambers demonstrated less necrosis (0.14 +/- 0.01 mm), fluid-treated wounds formed no eschar, and little tissue necrosis could be detected (less than 0.005 mm). Topical treatment with hypertonic dextran increased water flux across burn wounds by 0.24 ml/cm2/24 hr (mean, n = 95) over saline-treated wounds during the first 5 days after wounding. When partial thickness burn and excisional wounds were immersed in isotonic saline until healed, the daily efflux of water, protein, electrolytes, and glucose across the wound surface declined during healing to baseline values found in controls (saline-covered unwounded skin). The declining protein permeability was used as a reproducible, noninvasive, endogenous marker for the return of epithelial barrier function. Saline-treated excisional wounds healed within 8.6 +/- 0.6 days (mean +/- SD, n = 27) and burn wounds within 12.1 +/- 1.4 days (mean +/- SD, n = 15). Healing of fluid-treated wounds occurred without tissue maceration and showed less inflammation and less scar formation than healing of air exposed wounds (no attempt was made to compare rates of healing between air- and fluid-exposed wounds). We consider the fluid-filled chamber a potentially very useful diagnostic, monitoring, and delivery system for wound-healing research and for human wound therapy.     

Prevention of atrophic nonunion development by recombinant human bone morphogenetic protein-7.

Severe periosteal and soft tissue disruption at the time of fracture may result in the formation of an atrophic nonunion. We have developed a reproducible atrophic nonunion in an animal model. The purpose of this study was to evaluate whether the immediate application of recombinant human BMP-7 to the fracture site could rescue the healing process in this nonunion model. A total of 56 three month old Fisher 344 rats were utilized. A 1.25 mm diameter K-wire was inserted into the femur in a retrograde fashion, and a mid-diaphyseal closed transverse fracture was created using a standard three point bending device. To create a nonunion, the fracture site was exposed and 2 mm of the periosteum was cauterized on each side of the fracture. The fracture site was immediately treated with either the application of rhBMP-7 50 microg in 25 microl of rat tail tendon collagen buffer (BMP-7 group), or with 25 microl of rat tail tendon collagen buffer only (Control group). Fracture healing was evaluated with serial radiographs every two weeks for an eight weeks period. Specimens at four and eight weeks were subjected to biomechanical and histological evaluation. None of the Control group healed throughout the eight weeks experimental duration. At four weeks 63% of the BMP-7 group had healed, and all had healed by six weeks. This investigation showed pronounced differences between the BMP-7 group and the Control group both histologically and biomechanically. In conclusion, we have demonstrated that the immediate application of BMP-7 may rescue the fracture healing process and prevent the development of nonunion following severe periosteal disruption.     

Noncontact low‐frequency ultrasound therapy in the treatment of chronic wounds: A meta‐analysis

Our objective was to summarize and quantify the effects of a noncontact low‐frequency ultrasound (NLFU) therapy on healing of chronic wounds. We performed a meta‐analysis of eight published studies reporting effects of NLFU on wound size and healing rate of chronic wounds in 444 NLFU‐treated patients. A search of the PubMed database was conducted in January 2010 and updated in October 2010. We used random‐effects linear regression models to estimate the proportional reductions in wound area and volume and the proportion of wounds healed from baseline to last follow‐up. In four studies (N=188) reporting change in wound area from baseline, NLFU was associated with 85.2% area reduction (95% CI 64.7%–97.6%) over a mean 7 weeks. In four studies (N=278) reporting reduction in wound volume, NLFU was associated with 79.7% volume reduction (95% CI 46.1%–98.8%) over a mean 12 weeks. In seven studies (N=429) reporting proportion of wounds healing by study end (mean time to healing 8.2 weeks; median 6.8 weeks), meta‐analyzed healing rates over time suggest 32.7% of wounds healed on average by 6 weeks (95% CI 23.3%–42.1%) and 41.7% by 12 weeks. NLFU for treatment of chronic wounds was associated with consistent and substantial wound size reductions, as well as favorable rates of healing.     

Treatment of soft tissue defects in pediatric patients using the V.A.C. system

Twenty-seven consecutive pediatric patients presenting to the orthopaedic surgery or plastic surgery services were reviewed after completion of wound care with the Vacuum Assisted Closure (V.A.C.) system. Each patient presented with complex soft tissue wounds requiring coverage procedures. Patients with acute wounds and wounds present after nonsuccessful attempts at surgical closure (dehisced incisions and failed flaps) were treated. All soft tissue defects healed without extensive coverage procedures using the V.A.C. system. In the majority of patients, use of the V.A.C. system produced a profuse bed of granulation tissue over all exposed bone, tendon, joint, and/or hardware, which could be covered with split thickness skin graft. Other patients were treated successfully with delayed primary closure, local flap advancement (one patient underwent a pedicled cross-leg flap), or by secondary intention. Use of the V.A.C. device is valuable in increasing the rate of granulation tissue formation and healing of extensive soft tissue injuries in pediatric patients. This vacuum system aids in the debridement of necrotic tissue and local soluble inflammatory mediators that may inhibit the proliferation of granulation tissue. These improvements in the local wound environment seem to accelerate wound healing compared with traditional methods. Before the development of the V.A.C. system, a minimum of nine patients within this group would have required free tissue transfer to obtain adequate coverage. The V.A.C. device seems to permit earlier coverage with local tissue or split-thickness skin grafting techniques, thereby decreasing the need for extensive microvascular tissue transfers in pediatric patients.