Chapter 42: Reconstructive Surgery of Skin Cancer Defects

SUMMARY

• Surgical removal of skin cancer leads to an operative wound. The aesthetic and functional closure of this defect is a skill learned with study and experience. Many wounds are best repaired conservatively, and a linear closure frequently results in an ideal repair. Advanced wound closures, including flap and graft reconstructions, require a broad knowledge of anatomy and tissue mechanics along with an appreciation of geometry, a steady hand, and attention to detail. Entire texts are devoted to the broad field of surgical reconstruction. This chapter aims to hit the high points and provide logical direction in the choice and execution of repairs.

DON’T FORGET

• Always consider patient factors. Patients vary widely in their expectations and desires. Some patients are extremely concerned with any potential disfigurement, while others prefer rapid and easy healing.

• Discuss medications and smoking history before repairing a wound. Patients who are heavy smokers and those on multiple anticoagulants are less likely candidates for elaborate reconstructions.

• Closure tension is the number one cause of necrosis and dehiscence. Design repairs should be under a minimum of tension.

• Always operate precisely and in a planar manner. Know at which depth your repair should be accomplished. Know your anatomy, and avoid trauma to major neurovascular structures.

• Hemostasis is imperative. No wound should be closed with active bleeding.

• Repairs under low tension and with little undermining tend to be relatively painless. Large flap reconstructions and taut linear repairs can be quite uncomfortable. Prepare your patients.

• Reconstructions may cause discomfort, swelling, erythema, numbness, and transient distortion. Prepare your patient before reconstruction, and provide clear instructions in postoperative wound management.

CLINICAL PEARLS

• Assess each patient for tissue mobility. There is no guide to the direction of closure that will fit each patient. An orientation that works on one patient may require modification for a different patient.

• Each patient has a different skin type and quality. There is an enormous difference between thick, sebaceous tissue and atrophic, sun-damaged skin devoid of adnexal structures. Design repairs that are based not only on location but also on patient expectations and patient-specific factors.

• Always use the appropriate instruments and operate in a professional, clean environment that is conducive to excellent patient care.

• The more you read about reconstruction of the skin, the better you will be as a surgeon. This is a lifelong learning experience. Develop and reread a curriculum often. Go back to the literature to improve your techniques. Learn from your mistakes, and improve upon your outcomes. Do not accept second-rate results.

• Plan repairs meticulously, and execute them with skill and attention to detail. The easiest time to effect a successful closure is the first time. Plan for success, and avoid failed reconstructions. Thorough knowledge of the literature and experience in training will guide you toward this goal.

• Flaps are “sexy” reconstructions, but they should not be the go-to repair for most operative wounds. Always consider patient comfort, desires, and ...