Publications

A Novel Method of Mohs Defect Closure Using Posterior Deltoid Skin

Practice Points

  • The use of a full thickness posterior deltoid ‘scoop’ graft can be used for large Mohs defects in delicate areas which can be difficult to close.
  • Once the graft is taken, the donor site will heal nicely by secondary intention because of its location on the superior-lateral deltoid inevitably resembling a vaccination site.
  • This graft technique is technically easy to perform and has been shown to heal with minimal scarring.

A novel method of skin closure using a full thickness posterior deltoid scoop graft is described for larger difficult to close Mohs defects. The ease of use and success of healing with this type of graft is particularly of note. A case is presented with clinical photographs to demonstrate the benefits and results when performing this technique.

Case Report

A 79 year old female presented with a large biopsy proven nodular basal cell carcinoma of the dorsum of the right foot. Three stages of Mohs surgery cleared the tumor margins and options for repair were considered. Based on the lower extremity location, fragility of skin and size of defect a graft was determined to be the best closure option. We describe a novel method of closure for defects using a graft from the posterior deltoid.

Patients who have had Mohs surgery may be left with sizeable defects that cannot be closed primarily. These defects may prove especially challenging when a surgeon is faced with a large defect in a patient who is elderly with fragile skin. Surgeons may find defects on the lower leg defects or dorsal foot to be exceptionally difficult to close and may also take a lengthy amount of time to heal. The surgeon will most likely consider various surgical options.

Surgeons may consider this novel method of using posterior deltoid skin grafts as an effective surgical closure in such instances of sizeable Mohs defects. This article will describe a novel and simple graft technique that will be demonstrated by a case. The area where the graft is excised will not need sutures and will heal by secondary intention resulting in a scar that resembles the lateral deltoid scar found after vaccinations. This procedure can be performed using a DermaBlade, Xeroform Occlusive Gauze Patch, Nylon black monofilament nonabsorbable 4-0, Surgical Suture Absorbable Plain gut 5-0, 2 small bolsters, and Lidocaine HCl 1% and Epinephrine 1:100,000 Injection (Figure 1).

Graft and Closure Technique

An appropriately measured area on the upper, postero-lateral deltoid is mapped out with a surgical marker after the skin is cleansed with a topical antiseptic. The area is injected with Lidocaine HCl 1% and Epinephrine 1:100,000. The excision can be performed in one large scoop movement using a DermaBlade. We prefer to coat the cutting side of the blade with mupirocin ointment improving the ease of excision. Attention is given to ensure an exact thickness and diameter of the donor graft for the recipient site. The graft donor site from the posterior deltoid area of the arm will then heal by secondary intention without the need for suturing (Figure 2). The donor site heals quickly with basic aftercare and often resembles a healed vaccination site. Four 2mm slits in the graft are cut to allow for exudative drainage. The graft will then be placed over the Mohs defect and secured with interrupted 6.0 nylon sutures. An occlusive gauze patch is applied and 2 small bolsters are sutured to the sides of the graft. The advantage of using this procedure is that the surgeon can control the diameter and thickness of the graft more precisely using the DermaBlade and precludes the need for ‘debeveling’. This procedure requires a basic amount of preparation, provides an excellent source for donor tissue, and heals with an excellent aesthetic result.

 

Comment

Patients present with different and sometimes challenging types of skin integrity. Operating on atrophied, friable, lower extremity skin can be challenging and necessitates various methods to accomplish closure. Lipnik1 has described such instances of surgical closures with fragile skin using a polyethylene adhesive film. A variety of non-invasive and complimentary techniques are being developed for these skin types2, 3 . This novel method described above is time efficient, easily implemented, and heals well. Surgeons should consider this method using a posterior deltoid skin graft when dealing with such challenging cases.
References

1. Lipnik MJ. A Novel Method of Skin Closure for Aging or Fragile Skin. Cutis. 2015 Oct;96(4):260-262. Retrieved from https://www.mdedge.com/cutis/article/103504/aesthetic-dermatology/novel-method-skin-closure-aging-or-fragile-skin?page=0%2C1

2. Freed JS, Ko J. An Innovative Advance in Non-invasive Wound Closure: A New Paradigm. Military Medicine. 2018;183:472-480. Retrieved from https://doi.org/10.1093/milmed/usx165

3. Pacifico MD, Teixeira RP, Ritz M. Suturing of fragile skin. J Plast Reconstr Aesthet Surg. 2009;62:e637–38. Retrieved from https://doi.org/10.1016/j.bjps.2008.11.091

Acknowledgements: We would also like to show our gratitude to the Dr. S. Mark Burnett for sharing this interesting surgical technique.

Figure Captions:

Figure 1. From top to bottom the supplies include 2 small bolsters, Surgical Suture Absorbable Plain Gut 5-0, Nylon black monofilament nonabsorbable 4-0, DermaBlade, and a Xeroform Occlusive Gauze Patch.
Figure 2. Graft excision site of posterior deltoid area of the patient’s arm healing by secondary intention (A). Example of secondary intention healing of upper deltoid small pox vaccine which our patients’ site eventually resembled (B).
Figure 3. BCC outlined prior to Mohs (A). Graft sutured in place (B).

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O'Donogue Dermatology
1952 Field Road
Sarasota FL 34231

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