Extended Dermal Apposition: A Simple Technique for the Closure of Irradiated Perineal and Sacral Wounds

Abstract

Sir: The irradiated perineal or sacral wound is frequently encountered by reconstructive surgeons. Unfortunately, these are difficult wounds because of location and radiation-induced damage to the vasculature, fibroblasts, and the regulatory growth factors of wound healing.1 The damage to fibroblasts may be particularly important in wounds subjected to high tensile forces. Irradiated fibroblasts exhibit reduced proliferation, abnormal migration, decreased quality of synthesized collagen, impaired proline hydroxylation, and decreased collagen gene expression.1 As a result, the tensile strength of the surgical wound is decreased.2 We present our experience with these traditionally challenging wounds using an extended dermal apposition technique for closure. The technique is simple, requires no distant donor site, fills dead space, and is universally applicable. Nine patients (six men and three women) underwent this procedure from 2004 to 2009 (Table 1). Five patients had a sacral chordoma and required sacrectomy. The remaining four patients suffered from rectal cancer and had undergone abdominoperineal resection. All patients had preoperative radiation therapy (average, 44.2 Gy; range, 19.8 to 54 Gy). Five patients also had postoperative radiation therapy (average, 27.4 Gy; range, 19.8 to 57.6 Gy).Table 1: Patient CharacteristicsIf needed to fill dead space, the gluteus musculature is mobilized and its fascial layer sutured together. The tissue edges are pushed together manually and the lateralmost area of contact is marked. An ellipse is then defined and drawn around these markings. The ellipse is then deepithelialized with scissors or a knife. Typically, we deepithelialize a distance of 1.5 to 4 cm on each side of the wound. We extend the deepithelialization the length of the irradiated field and where tension is maximal. Often, this is not the entire length of the wound (Fig. 1).Fig. 1.: Posterior view of a typical patient in the series demonstrating original wound extending into the peritoneal cavity (left). The deepithelialized dermis is advanced into the wound and closed in layers (right). The superior portion of the wound was closed without deepithelialization.The leading dermal edges are then brought together in the midline and sutured with interrupted absorbable sutures. Once this is done, the ellipse is advanced toward the midline with subsequent layers of absorbable suture (usually three additional layers) driving the leading edges into the depth of the wound (Fig. 1). Ultimately, the epidermal edges are brought together in the midline with cutaneous nylon sutures and a liquid skin adhesive. The patient is instructed to avoid pressure to the wound for 4 weeks and an air-fluidized bed is often used. The nine patients in this series all had completely healed wounds (Fig. 2).Fig. 2.: Preoperative (left) and 6-week postoperative (right) photographs after wound closure using the extended dermal apposition technique. This patient received 50.4 Gy of preoperative and 19.8 Gy of postoperative irradiation. He also received 79.2 Gy directed to his prostate for concomitant prostate cancer before the dermal invagination closure.Preoperative radiotherapy is important in the treatment of rectal cancer and sacral chordomas, promoting successful resection and allowing bladder, anal sphincter, and nerve preservation.3,4 Unfortunately, it results in a higher rate of wound complications.3,4 Not only do these nonhealing wounds use time and resources, they can also delay the onset of life-saving adjuvant chemotherapy or postoperative irradiation.3,4 Muscle flaps are frequently used in these situations.5 The benefit of the extended dermal apposition technique is that it is simple and quick, allows for some dead-space filling, and is performed with a minimal donor defect. It leaves other reconstructive options available. It can be performed at the time of cancer resection or after wound breakdown. Most importantly, we have found it to be durable. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Tristan L. Hartzell, M.D. Miguel Medina, M.D. Division of Plastic and Reconstructive Surgery Francis J. Hornicek, M.D. Department of Orthopedic Surgery William G. Austen, Jr., M.D. Division of Plastic and Reconstructive Surgery Massachusetts General Hospital Harvard Medical School Boston, Mass.