Pearls for Practice: Closing Wounds Resulting From Cancer Removal Under Local Anesthesia Using Micro-autografts in the Wound Clinic

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Daphne Denham, MD, Comprehensive Wound Care, Northbrook, IL

  Many skin cancers, including basal cell carcinomas, squamous cell carcinomas, and superficial malignant melanomas, are removed using Mohs’ micrographic surgery techniques.1,2

  This method removes the suspicious tissue, which is immediately examined under the microscope. This microscopically controlled tumor excision is a method of obtaining complete margin control during removal of the skin cancer. It also preserves the greatest amount of noncancerous tissue.

  Wounds resulting from cancer removal have been closed by wound approximation, skin grafts, and pedicled flaps or spontaneously by secondary intention. The reconstruction may be delayed and may require a larger operative procedure than the tumor extirpation. Often patients are on anticoagulants or steroids, further complicating wound closure.

  A new method of microautografting (Xpansion Micro-autografting Kit, SteadMed Medical LLC, Fort Worth, TX) using a very small graft of autologous dermis and epidermis obtained under local anesthesia and minced to allow expansion of up to 1:100 was used in a series of postcancer wound closures in patients on anticoagulants.3,4 Because of the excessive bleeding after the cancer removal, wound bed preparation was performed before the wound closure procedure. In our series of 8 patients, the Mohs’ surgical excisions totally removed the cancers. Following wound bed preparation, the microautografting procedure was successful, with graft adherence occurring at the first dressing change and complete wound closure usually occurring within 4 to 6 weeks. Three illustrative cases from our series are presented.

Four days; five weeks postgrafting.

  Case 1. An 84-year-old female patient on anticoagulant therapy for atrial fibrillation and with a long history of venous insufficiency with ulceration had a biopsy for a suspicious area in a venous ulcer. The biopsy revealed squamous cell carcinoma, which was treated by Mohs’ surgery. The excisional site measured 7.5 cm x 5.0 cm x 0.5 cm and had significant bleeding. After wound bed preparation with collagen, hypochlorous acid, and Drawtex hydroconductive dressings (SteadMed Medical LLC, Fort Worth, TX), micrografting was performed under local anesthesia. At the first dressing change 4 days later, the minced grafts could be visualized in place (see Figure 1). All of the micrografts were essentially healed at 5 weeks (see Figure 2).

  Case 2. An 89-year-old woman with significant venous stasis disease being treated with anticoagulation presented with a squamous cell carcinoma on the right anterior shin. Mohs’ surgery was used to remove the cancer, leaving a defect measuring 4.0 cm x 3.5 cm x 0.3 cm. After wound bed preparation, minced microautografts were applied to the wound in the wound clinic (see Figure 3). Immediately postapplication, the micrografts were noted to be adherent in place in the cancer removal defect (see Figure 4). EdemaWear compression dressings (Compression Dynamics, LLC, Omaha, NE) were used to maintain graft immobilization and control edema postoperatively. The wound was totally healed 8 weeks post grafting.

  Case 3. A 76-year-old woman with chronic venous insufficiency presented with squamous cell cancer on her left lower leg. Following Mohs’ cancer excision, the defect measured 5.0 cm x 4.2 cm x 0.1 cm; it was hemorrhagic because of systemic anticoagulation. Electrocoagulation of the bleeding left an unacceptable bed for microautografting (see Figure 5). Wound bed preparation required 18 days until micrografting could be performed. Three weeks later, the graft was healing satisfactorily, with only 3 small areas left to epithelialize. The defect was essentially healed 10 weeks after grafting (see Figure 6).

  In summary, this new technique of combining Mohs’ micrographic surgery and microautografting proved to be successful and well accepted by the patients. No hospitalization was required, and all procedures were performed under local anesthesia.

Pearls for Practice is made possible through the support of SteadMed Medical, LLC, Fort Worth, TX (www.steadmed.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of SteadMed Medical, LLC; OWM; or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.

References: 

1. Shriner DL, McCoy DK, Goldberg DJ, Wagner RK. Mohs micrographic surgery. J Am Acad Dermatol. 1998;39(1):79–97.

2. Hanke CW. Frederic Mohs tribute: history of Mohs micrographic surgery. J Drugs Dermatol. 2002;1(2):169–174.

3. Smith DJ. Achieving efficient wound closure with autologous skin. Today’s Wound Clinic. 2014;Jan/Feb:23–24.

4. Hackl F, Bergmann J, Granter SR, Koyama T, Kiwanuka E, Zuhaili B, et al. Epidermal regeneration by micrograft transplantation with immediate 100-fold expansion. Plast Reconstr Surg. 2012;129(3):443e–452e.