- Wound Closure:
- If there is concern regarding the ability to achieve suitable wound closure:
- A plastic or reconstructive surgeon may be consulted:
- Ideally in the preoperative setting
- A plastic or reconstructive surgeon may be consulted:
- If there is concern regarding the ability to achieve suitable wound closure:
- Options for closure include:
- Primary closure
- Skin grafting
- Local and distant flaps
- Primary closure:
- Is the method of choice for most lesions:
- But it should be avoided when it will distort the appearance of a mobile facial feature or interfere with function
- Many defects can be closed using an advancement flap, undermining the skin and subcutaneous tissues to permit primary closure
- Primary closure may be facilitated with the longitudinal axis of an elliptical incision to be approximately three times the length of the short axis:
- Lesser extension of the longitudinal axis can also sometimes be employed
- The skin and subcutaneous tissue are removed down to, but generally not including the underlying muscular fascia
- Closure of the wound edges is usually performed in two layers:
- A dermal layer of 3-0 undyed absorbable sutures and either interrupted skin closure using 2-0, 3-0, or 4-0 nonabsorbable sutures and / or a running subcuticular skin closure using 4-0 monofilament absorbable sutures
- Three layers are sometimes used:
- Particularly for primary melanomas of the back:
- With approximation of Scarpa’s fascia
- Particularly for primary melanomas of the back:
- After excision:
- The specimen should be oriented for permanent assessment of histologic margins
- Is the method of choice for most lesions:
- Application of a skin graft is one of the simplest reconstructive methods used for wound closure:
- Split-thickness skin grafts are most commonly used:
- For lower extremity primary lesions:
- Split-thickness grafts can be harvested from the contralateral extremity
- For lower extremity primary lesions:
- In general, skin grafts should be harvested from an area remote from the primary melanoma and outside the zone of potential in-transit metastasis
- A full-thickness skin graft:
- Can provide a result that is both more durable and of higher aesthetic quality than a split-thickness graft
- Full-thickness grafts have most commonly been used on the face:
- Where aesthetic considerations are most significant, but can also be used elsewhere
- Donor sites for full-thickness skin graft to the face:
- Should be chosen from locations that are likely to match the color of the face:
- Such as the postauricular or preauricular skin or the supraclavicular portion of the neck
- Should be chosen from locations that are likely to match the color of the face:
- Local flaps:
- Offer numerous advantages for repair of defects that cannot be closed primarily:
- Especially on the distal extremities and on the head and neck
- Color match is excellent, durability of the skin is essentially normal, and normal sensation is usually preserved
- Offer numerous advantages for repair of defects that cannot be closed primarily:
- Transposition flaps and rotation flaps of many varieties have been used:
- Although for patients with high risk of in-transit metastasis, extensive flap reconstruction may significantly alter regional lymphatics
- Distant flaps may be considered when sufficient tissue for a local flap is not available and when a skin graft would not provide adequate wound coverage
- Use of a wound VAC to facilitate granulation tissue:
- That serves as a healthy tissue bed for subsequent skin graft can often obviate the need for complex reconstructive options (e.g., melanoma arising on the heel of the foot)
- Split-thickness skin grafts are most commonly used:
Rodrigo Arrangoiz MS, MD, FACS, FSSO 