Integra as a temporary method of wound cover post Mohs surgery

Abstract

Skin substitutes are a novel addition to the plastic surgeon's armamentarium in the management of difficult wounds. They are commonly used in burn injuries or difficult to heal ulcers. Skin cancer resection often may involve large areas of skin that are difficult to close and may require skin grafts. In centres where a Mohs micrographic surgery service is available, reconstruction may be done almost immediately after resection as tumour clearance is provided instantly with on-the-table analysis during Mohs surgery. However, problems arise when such a service is not available at the hospital and a predefined clearance margin is excised with the lesion by the plastic surgeon, but histological clearance cannot be guaranteed until histological results are back several weeks later. Current practices involve either performing a skin graft immediately post resection or leaving the wound open and treating it with dressings until the histological results are available before moving onto a more definitive skin closure such as a skin graft. The disadvantages of performing a skin graft immediately post resection are that it runs the risk of incomplete clearance either at the borders or even at the depth of the resection, which may lead to further procedures either to resect more of the skin graft where tumour clearance was not achieved or to subject the patient to another skin graft procedure to cover the defect. The disadvantages of leaving the wound open and treating it with dressings whilst waiting for histological results are that first an open wound has an increased chance of becoming infected, which may require further procedures or antibiotics to clear the wound bed from infection prior to grafting. Also, the patient is inconvenienced from having to come back to a dressing clinic or seeing the practice nurse on a regular basis for dressing changes, not to mention the stigma or psychological impact an open wound on a visible area of the body might cause the patient. We propose that the use of a skin substitute such as Integra may be useful in this domain in terms of providing a temporary dressing whilst awaiting histological clearance 1. This is especially useful for large skin cancer resections with indeterminate clearance margins. The use of Integra provides a temporary wound cover over the resected area and prepares the wound bed for grafting 3 weeks later when histological results are available. When vascularised, armed with the histological results, one could either proceed to resect more tissue easily to achieve the clearance required and proceed straight on to grafting as a one-stage procedure, or if histological results are clear, a skin graft could be placed on the vascularised skin substitute directly on return. This not only allows definitive closure of the wound but also confirms histological clearance, which is advantageous both to the surgeon and the patient. Charles Yuen Yung LOH, MBBS, MSc, MRCS1 Meiling Loh, Medical Student2 & Syed A Mashhadi, MBBS, FRCS-ed, FRCS-Plast3 1Department of Plastic Surgery Ninewells Hospital Dundee, UK 2Department of Plastic Surgery National University of Singapore Singapore, Singapore 3Department of Plastic Surgery St Thomas' Hospital London, UK [email protected]