This article describes a surgical vignette on how to use wound closure strips to reconstruct wound defects with atrophic skin.
Figure 1. After the lesion was excised with adequate margins, multiple attempts were made to close the dermal layers with absorbable sutures. However, the skin was so atrophic that it fell apart with the needle entering the skin.
Surgical wounds created by skin lacerations or cutaneous surgery can result in wounds that often are under significant tension for wound approximation. In addition to wound closure tension, intrinsic properties of the skin can make skin closure challenging.
Also, a patient’s environmental and medical history can affect the nature of the skin and subsequent wound closure. For instance, in an immunocompromised patient or a patient on chronic oral or topical steroid use, the epidermis and dermis are physiologically altered. Long-term use of topical or oral glucocorticoids can lead to the development of skin atrophy which is characterized by reduced skin thickness and elasticity, telangiectasia, and purpura.1
Glucocorticoids have been shown to reduce the proliferation and size of keratinocytes and to impair the skin barrier through inhibition of lipid synthesis in addition to decreasing the proliferation of fibroblasts and the production of extracellular matrix (ECM) proteins.1 Also, glucocorticoids inhibit collagen synthesis in fibroblasts and reduce the expression and activity of collagenases and other matrix metalloproteinases in keratinocytes and fibroblasts.
Furthermore, through regulation of hyaluronan synthase-2 in fibroblasts and keratinocytes, glucocorticoids decrease the level of hyaluronic acid, a glycosaminoglycan which plays an important role in maintaining dermal and epidermal structure, flexibility, and water binding capacity.1 By affecting important ECM components, glucocorticoids restrict the dynamic remodeling of the skin, thus contributing to skin atrophy that can significantly affect surgical wound closure.1
Adhesive strips (also known as coaptive films or adhesive tape) are a well-established method of wound closure. Benefits of epidermal approximation with adhesive strips include faster closure time, ease of use, lack of visible puncture marks, less tissue reactivity, decreased risk of tissue strangulation, and minimizes needle-stick injuries.2 In addition, patients avoid a return visit to the office for suture removal.
Initial studies by emergency medicine, cardiothoracic surgery, plastic surgery, and orthopedic surgery have failed to show a significant difference in wound dehiscence, infection, patient satisfaction, or long-term cosmesis between these devices and conventional sutures.2-7 However, the direct applicability of these findings to dermatologic surgery is less clear because of the use of bilayered repairs and the deliberate creation of excisional cutaneous defects as opposed to simple incisions. The combination of buried sutures for approximation of the dermis and superficial sutures for precise alignment of the epidermis remains the preferred closure technique among most dermatologists.2
Many studies have compared the overall cosmetic outcome of traditional epidermal sutures with adhesive strips in layered dermatologic repairs on the back and have shown that adhesive strips result in equivalent long-term scar outcome when compared with traditional epidermal sutures.2,3,6-8 However, in instances where the skin is so atrophic that buried absorbable sutures cannot be placed, other methods of wound closure should be explored, especially in sites of slow healing potential such as the lower extremities.
A 78-year-old, immunosuppressed patient presented for surgical excision of a squamous cell carcinoma on the right pretibial leg. The patient was on chronic oral prednisone for a history of polymyalgia rheumatica for more than 10 years. On physical exam, the skin was friable and atrophic on palpation surrounding the tumor. After the lesion was excised with adequate margins, multiple attempts were made to close the dermal layers with absorbable sutures. However, the skin was so atrophic that it fell apart with the needle entering the skin (Figure 1). A purse-string closure was attempted as well, however, the dermal suture was unstable and tore through the skin.
Figure 2. The wound was closed with a technique of using adhesive wound closure strips on the epidermis adjacent to the wound.
At this point, the wound was closed with a technique of using adhesive wound closure strips on the epidermis adjacent to the wound. This served as a synthetic skin anchor of which the needle and suture could pass through without tearing the skin. Care was taken to place liquid adhesive around the surgical site and the adhesive strips were placed parallel to the wound edges. Multiple 4.0 polyprolene sutures were tied in simple interrupted fashion to approximate the wound edges and sutures were left in for 3 weeks to allow for adequate healing due to the patient’s immunosuppression (Figure 2). A pressure dressing was applied and the patient was instructed to leave the bandage on for 24 hours, after which he could shower and perform daily dressing changes with mupiricin ointment and nonstick gauze.
Studies have shown that when adhesive strips are used as the sole method for wound closure, they do not provide comparable strength to wound closure with sutures alone.8 The wound could have also been allowed to heal by secondary intention; however, that would have lengthened the healing time considerably, especially in this anatomical location. In contrast, our combination of suturing through the adhesive strips allows for a tightly bound adhesive shield that should maintain integrity of the closure as others have reported.8 This is a very reproducible technique that can be used in other areas of the body with atrophic skin such as the dorsal hand, foot, and fingers and toes.
Dr Dane is a board-certified dermatologist and Mohs/Procedural Dermatology fellow at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Dr. Lee is the medical/surgical director of Affiliated Ambulatory Surgery P.C. and the director of Procedural Dermatology of the ACGME-accredited Affiliated Dermatologists and Dermatologic Surgeons, P.A. Fellowship in Micrographic Surgery and Surgical Oncology.
Dr. Rogachefsky is the program director of the ACGME-approved Micrographic Surgery and Procedural Dermatology Fellowship and a practicing dermatologist at Affiliated Dermatologists and Dermatologic Surgeons in Morristown, NJ.
Disclosure: The authors report no relevant financial relationships.
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