Current Issue
Spring/Summer 2025, Vol. 32 No. 1
Hong Kong J. Dermatol. Venereol. (2025) 32, 52-60
Views and Practice
Reconstructive surgery after skin cancer resection
HF Cheng 鄭學輝
Correspondence to: Dr. HF Cheng
Skin Right Skin Surgery and Laser Centre, Room 1005, 1006 and 1008, 10/F, South China Building, 1 Wyndham Street, Central, Hong Kong
Introduction
Closure of skin cancer surgery defect is both an art and a science. The choice of closure method is determined by characteristics of the surgical defect, operator's expertise and preference, and patients' acceptance. The author would like to present some skin cancer surgery cases where simple reconstructive procedures were employed. The rationales behind the choice of repair method and their executions will be discussed.
Background
Early skin cancer can be effectively cured surgically provided that it is completely removed. As with a lack of Mohs micrographic surgery in our locality, complete margin clearance must be achieved during primary surgery. In general, small cancer defects are easy to repair and outcome usually favourable. Large skin cancers may require either staged excisions or immediate reconstruction after the tumour removal. Staged excisions mean serial debulking and linear closures, which may be unsuitable for certain facial or scalp defects. In such cases, reconstructive surgery may become a viable alternative option. It is essential to clarify patients' beliefs and expectations prior to reconstructive endeavours, as these surgical procedures alter anatomy and resulted in permanent changes.
Methodology
This review consists of selected skin cancer surgeries performed at Fanling social hygiene clinic between year 2023 to 2024. All were carried out under local anaesthesia, with primary cancer resection and reconstructive procedures completed in one sitting. Verbal consent was obtained for the publication of clinical images. Six patients and five surgical techniques were reviewed. Total margin clearance was achieved in all the recruited cases. There was no reported local recurrence, post-operative complication or functional impairment. All patients expressed satisfaction with the final surgical outcome.
Illustrative cases
Case 1A
Clinical summary:
An 86-year-old healthy woman presented with a 1 cm cutaneous horn on her left mandibular cheek (Figure 1a). Diagnostic shave biopsy showed a squamous cell carcinoma with close deep margin. The patient opted for conservative management at the plastic surgery clinic. The resultant 2.5 cm circular defect healed gradually over five months (Figure 1b).
Case 1B
Clinical summary:
A 70-year-old man undergoing peritoneal dialysis for renal failure presented with a 7 mm pigmented basal cell carcinoma nodule on his right nasal sidewall (Figure 1c). Initial diagnostic punch biopsy reduced the tumour to a 2 mm nodule (Figure 1d). He opted conservative care in the subsequent definitive surgery. The 1 cm circular defect gradually healed over eight weeks (Figure 1e).
Discussion:
Second intention healing works well on small, superficial defects at concavity like upper nasal bridge, medial canthus of eyes, depressed areas of ear auricle, supra-basal hollow of nose, and central philtrum of upper cutaneous lip.1 Study had shown that wounds allowed to heal by second intention can lead to a high level of patient satisfaction on par with those managed by primary surgical closure.2 Patients should be informed about prolonged healing time and potential complications, namely suboptimal cosmetic outcomes, chance of wound infection and possibility of revision surgery.
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| Figure 1 (a) The lesion of primary cutaneous squamous cell carcinoma over left mandibular cheek immediately before the diagnostic shave excisional skin biopsy. (b) The wound healed well with second intention healing. This photo was taken five months after the shave excision. (c) A 7 mm nodular basal cell carcinoma over the right nasal sidewall. (d) The appearance of the tumour and the pre-operative markings prior to the definitive surgery. (e) Complete wound healing was observed 8 weeks after the definitive surgery. |
Case 2
Clinical summary:
A 97-year-old healthy woman presented with a 2-year history of progressively enlarging patch of pigmented basal cell carcinoma on her right lateral forehead (Figure 2a). An AT plasty was decided, taking advantage of an abundant right temple skin laxity (Figure 2b). After tumour extirpation the ovoid defect was fashioned into a pyramidal-shaped defect. Two lateral advancement flaps were raised; medially from the side of the right eyebrow and infero-laterally from the right temple. Dissection was kept superficial and use of electrocautery limited to a necessary minimum. The inferior dog ear was displaced sideway and hidden within the lateral canthal rhytids (Figure 2c). The patient tolerated the procedure well. There was no brow ptosis or loss of ipsilateral forehead frown lines after the operation (Figure 2d).
Discussion:
The fronto-temporal branch of facial nerve courses superficially over temple region. Hence, it is mandatory to limit the surgery at sub-dermal fat when operating around this region.3 Preservation of brow integrity carries cosmetic and functional significance. Repairing medium sized temple or lateral forehead defect calls for meticulous surgical planning. Healing by second intention may distort eyebrow contour or eyelid free margins. Skin graft may fall short of colour or textural match. A horizontally oriented defect would make a banner transposition flap a viable option, but the scar will be geometric and difficult to hide. AT plasty advances the skin flaps linearly into the defect.4 It respects loco-regional anatomy and patterns of relaxed skin tension lines. Placement of incisions along the border of forehead and eyelid aesthetic regions also help make the horizontal limb of the scar invisible (Figure 2d).
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| Figure 2 (a) Appearance of pigmented basal cell carcinoma over the right lateral forehead. (b) The markings of the AT plasty. The entire horizontal limb abutted the superior border of right eyebrow and curved infero-laterally along the orbital rim. The design incorporated the concept of the forehead and eyelid aesthetic regions. (c) The operative site immediately after percutaneous suturing. The inferiorly displaced dog ear was buried within the lateral canthal rhytids. (d) The appearance of the surgical scar 16 weeks after the operation. The vertically oriented scar was thin and relatively more obvious, but the appearance was highly acceptable when viewed from the front. The preservation of frown lines testifies to the integrity of motor functioning of upper facial nerve. The horizontal limb of the scar including the dog ear repair was imperceptible. |
Case 3
Clinical summary:
A 72-year-old healthy man presented with Bowen's disease arising from a seborrhoeic keratosis on his right parietal scalp. The initial shave biopsy failed to remove the lesion completely (Figure 3a). At definitive surgery, a 3 cm tumour defect was created. Rotation flap reconstruction was then performed. A curvilinear incision was made along the frontal scalp hairline. Wound tension reduction was achieved by generous undermining and galeal relaxing incisions (Figure 3b). The flap was raised and rotated into the scalp defect. Dog ear was repaired outside the flap pedicle (Figure 3c). Percutaneous sutures were removed on day 15. The scar was concealed along the hairline and the final appearance is appealing to the patient (Figure 3d).
Discussion:
Scalp skin is notoriously thick, inelastic and difficult to mobilise. Elliptical repair will result in a lengthy scar. Baldness and contour difference renders skin graft surgery suboptimal. Second intention healing is reserved for cases where reconstructive surgery is impractical. Rotation flap completely transfers the tremendous wound tension to the secondary defect.5 The design would highly depend on the defect location, availability of nearby skin laxity and patient's acceptance. Surgical undermining should be kept below the galea aponeurotica in order to avoid unnecessary surgical trauma and blood loss.6 The wide flap base at the pedicle ensures a stable vascular perfusion, making the flap robust and reliable.
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| Figure 3 (a) The appearance of tumour before the diagnostic shave biopsy. (b) A single rotation flap, mobilised after circumferential surgical undermining and serial galeal relaxing incisions underneath the flap. Temporalis muscle belly was visualised within the curvilinear arc of secondary defect. (c) Appearance immediately before the trimming of flap tip. The secondary defect had been secured by buried dermal sutures. The tricone excision outside the pedicle alleviated tissue redundancy from flap movement and assisted the flap advancement into the primary defect. (d) Appearance of the surgical scar 17 weeks after the operation. The scar was nicely concealed by the scalp hairs. |
Case 4
Clinical summary:
A 78-year-old man was referred by his general practitioner for an incompletely excised Bowen's disease on his left forearm (Figure 4a). Due to a lack of surrounding skin laxity, full-thickness skin graft repair was decided. At surgery, the 3.5 cm defect was first reduced using buried purse-string suture. Donor skin harvested from the left inner arm was de-fatted and trimmed to fit the left forearm defect (Figure 4b). The skin graft was fenestrated and secured with a bolster dressing (Figure 4c). The wound healing took three weeks. There was no graft failure or donor site morbidity (Figure 4d).
Discussion:
A tight but well-vascularised forearm defect calls for skin graft surgery.7 Full-thickness grafts offer superior textural and colour match, contract less in the long run, resist trauma better and are less prone to pigmentary changes, justifying its application in this case. Graft survival also depends on wound bed vascularity. Patients with microangiopathy (e.g. from hyperglycaemia, vasculitis, use of cigarette and systemic immunosuppressants) may be unsuitable candidates. Contracture occurs in all skin grafts over time regardless of their thickness. Prior placement of purse-string suture helps mitigate the wound tension, improving graft survival.8 The downside of skin graft surgery includes graft failure, infection, delayed return of graft sensation, multiple incisions. Patients' compliance with graft site immobilisation is crucial to prevent graft failure.7
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| Figure 4 (a) The appearance of the left forearm wound from a partially shaved Bowen disease. The clinical photo was taken at the time of first dermatologic consultation. (b) Defatting of ipsilateral left inner arm skin graft during tissue harvesting. (c) Appearance of the skin graft on the left forearm before the application of bolster dressing. The graft had been fenestrated and fully anchored by sutures. Haemostasis had been achieved. (d) Appearance of the skin graft 3 months after surgery. The colour and texture match nicely with the surrounding skin. |
Case 5
Clinical summary:
A 92-year-old man presented with a 2-year history of a progressively enlarging fleshy skin nodule on his left shoulder (Figure 5a). Wide local excision and Mercedes flap reconstruction were performed (Figure 5b). Three Burow's triangles were created around a 2.8 cm primary defect as per the relaxed skin tension lines (Figure 5b). Wound edges were approximated by buried dermal sutures and then percutaneous horizontal mattress suture (Figure 5c). Pathology report showed porocarcinoma in-situ with clear resection margins. There was no adverse functional consequence from the surgery. The scar is aesthetically pleasing to the patient and his family (Figure 5d).
Discussion:
Defect repair near a joint requires considerations on mobility and function. Complex skin lines pattern and requirements of daily activities preclude elliptical repair, second intention healing or skin graft surgery. The Mercedes flap satisfies all the anatomic and functional requirements.9 Small Burow's triangles means minimal tissue wastage. The wound tension is evenly dispersed by three pairs of advancement flaps, allowing tension-free closure (Figure 5c).
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| Figure 5 (a) The anatomical location of the left shoulder tumour nodule. (b) The design of the flap reconstruction was based on skin tension lines, which were abundant and multi-directional over this anatomical region. (c) Wound edge approximation using buried vertical mattress techniques. The wound tension was markedly reduced, making the placement of percutaneous sutures effortless. (d) Appearance of the scar 10 weeks after the Mercedes flap reconstruction. Percutaneous horizontal mattress was employed to create wound edge eversion. The contour difference from eversion had been completely settled, and there was no scar depression. |
Conclusion
Wound closure after skin cancer surgery presents various challenges. Optimal outcomes rely on a thorough understanding of local anatomy, attention to wound tension factors, and clear surgical margins. Reconstructive surgery restores forms and function, enhances quality of care and improves patient's satisfaction. It is prudent to consider patients' perspectives when selecting repair methods. Dermatologists proficient in simple reconstructive surgery could greatly facilitate daily clinical management and enjoy a greater professional fulfilment.
References
1. Rohrer TE, Cook JL, Kaufman AJ. Second intention healing and primary closure. In: Flaps and grafts in dermatologic surgery. 2nd ed. Philadelphia: Elsevier 2018, p34-49.
2. Stebbins WG, Gusev J, Higgins HW 2nd, Nelson A, Govindarajulu U, Neel V. Evaluation of patient satisfaction with second intention healing versus primary surgical closure. J Am Acad Dermatol 2015;73:865-7.e1.
3. Dahlke E, Murray CA. Facial nerve danger zone in dermatologic surgery: temporal branch. J Cutan Med Surg 2011;15:84-6.
4. Shew M, Kriet JD, Humphrey CD. Flap Basics II: Advancement Flaps. Facial Plast Surg Clin North Am 2017;25:323-35.
5. Starkman SJ, Williams CT, Sherris DA. Flap Basics I: Rotation and Transposition Flaps. Facial Plast Surg Clin North Am 2017;25:313-21.
6. Boyer JD, Zitelli JA, Brodland DG. Undermining in cutaneous surgery. Dermatol Surg 2001;27:75-8.
7. Rohrer TE, Cook JL, Kaufman AJ. Skin grafts. In: Flaps and grafts in dermatologic surgery. 2nd ed. Philadelphia: Elsevie 2018. p132-44.
8. Simman R, Bach K, Achauer SM. Purse-String Suture Technique in Reducing Surgical Defect Size. Eplasty 2022;22:ic14. Published 2022 Aug 18.
9. Valesky EM, Kaufmann R, Meissner M. The Mercedes flap and its new variants: a 'workhorse' flap for the dermatological surgeon? J Eur Acad Dermatol Venereol 2016;30:1332-5.
