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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 difficult to close Mohs defects.
  • The site of excision of the graft does not need to be sutured; this will heal by
    secondary intention.
  • The graft technique is simple and easy to perform and has shown effective
    healing with minimal scarring.

A novel method of skin closure using a full thickness posterior deltoid scoop graft is described for large difficult to close Mohs defects. The ease of use and success of healing of 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.

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 minimal scar. 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

The skin is first cleansed with a topical antiseptic, such as Hibiclens, where the graft will be taken from on the posterior deltoid area of the arm. The excision area is measured by outlining the area of the mohs defect with a sterile pen. 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. 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 graft excision site will then resemble somewhat of a small vaccination scar. The surgeon will then cut four 2mm slits in the graft to allow exudate to come through. The graft will then be placed on the area of the Mohs defect with the occlusive gauze patch. The 2 small bolsters will then be sutured to the sides of the graft. An advantage of using this procedure is that the surgeon can control the depth and thickness of the graft easily using the DermaBlade. This procedure requires a minimal amount of time and the use of a few large movements make it quite simple to perform.

Figure 1. From left to right 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 without the bandage (A) and with the bandage (B).

Figure 3. Patient’s dorsal right foot where the skin was to be removed (A). The patient’s right dorsal foot is shown partially healed (B) and fully healed (C).

Case Report

The procedure described was performed on a patient’s dorsal right foot (Figure 3) where the Mohs defect was located. This defect following Moh’s surgery was so
large that it could not be sutured primarily, which is why this novel procedure was considered. The graft was taken from the posterior deltoid area of her right arm,
which was not sutured. Both the posterior deltoid area of the arm and the dorsal right foot displayed efficient healing throughout the entire process.

Comment

Patients present with many different types of skin and operating on fragile elderly skin proves especially difficult which is why different methods should be taken into consideration. Lipnik1 has described such instances of surgical closures with fragile skin using a polyethylene adhesive film. When dealing with these sizeable defects in fragile skin, the defect cannot be closed primarily and a graft may be considered. This novel method described above is time efficient, simple, and heals successfully. Surgeons may consider this method using a posterior deltoid skin graft when dealing with such challenging instances.

REFERENCES

1. Lipnik MJ. A Novel Method of Skin Closure for Aging or Fragile Skin. Cutis.
2015 Oct;96:260-262

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