Once a tumor or growth has been treated or removed by any method, both the surgeon (who should fully inform patient) and the patient must decide what to do with the hole or defect that remains. For example, if the wound is left to "heal by itself", the wound will ooze and may need cleaning for months, depending on the size. Letting a wound heal by itself usually results a large volume of scar. The author rarely uses this method because of these pitfalls.

Next, we will discuss side-to-side closure, flaps and grafts. These closure methods usually require no care after one to two weeks. The Web site author prefers to sew the vast majority of all defects for faster healing and best cosmetic appearance.

One method of closure includes the ELLIPSE, otherwise known as side-to-side closure. Take, for example, tumor A of hole B (if the tumor was not removed by Mohs microsurgery) below:

Note that the arrows represent the 3mm margins around the tumor. See Tumor in the glossary.

If we put stitches in positions C, D, E, F to try to close the defect, standing cones (dog or pig ears) G and H result and will stick out for many years, as shown in I. But cutting out wings I or K, as shown in L, which are each roughly as long as defect B is wide, as shown in M, produces a long line N. Note that N is at least five times as long as the tumor and at least three times as long as the defect was wide; this is the biggest disadvantage of this technique. One advantage is cost. This method is usually relatively inexpensive when compared to other tumor removal techniques. These facts can be independently confirmed by examining a page of text from a plastic-surgery textbook.

FLAPS take advantage of the nearby loose skin. Flaps can be very compact. The website author has had extensive training in flap reconstruction and usually performs three or four of these procedures per day. The website author trained under the world-famous Dr. Leonard Dzubow who has authored many textbooks and scientific papers on flaps. The simplest, and one of the most straightforward flaps is shown below:

Typical tumor A, results in defect B. Cut O is followed by deeper tissue lifting (cross hatched), creating loose flap P. Flap P is easily sewn by stitches Q to make the final scar R. The advantage of a flap is that the scar is much shorter than the side-to-side method. In addition, the scar is broken or bent, which is less noticeable to the human eye.

GRAFTS may require the most time and patience. Grafts are used when there is no adjacent skin to flap next to the defect, or when the flap would distort body parts or be to large for practicality. With a graft, tissue is removed completely from a preferably hidden donor site, usually behind or in front of the ear or neck or from the groin, and transplanted onto the hole defect, frequently on the lip or tip of the nose. The author has had much success with grafts. However, graft disadvantages include a second donor wound and the time needed for the graft's color and texture to match the surrounding skin.

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A skin graft is a piece of skin that has been completely removed from one area on the body, the DONOR site, and moved to another entirely separate area, the RECIPIENT site. The graft is usually needed and placed in an area that has just had a deep growth or cancer removed, a place where adjacent (touching) skin is not sufficient or stretchable enough to cover or pull over the area in question. A graft may be likened to a piece of sod (square of grass). Once the graft is removed for transplantation, it is very fragile and may easily be killed. Just like a new piece of sod, the skin graft will try to send down new "roots" (tiny microscopic blood vessels) during the first week. A graft has just enough stored energy to send roots down only once. One instance of shearing, rubbing or bumping to a new skin graft is just like having a child run over a piece of sod. The tiny roots may be torn, and the skin graft or piece of sod, as the case may be, will DIE because it does not have enough stored energy to send roots down again.

The author has a success rate approaching 100% with his grafting techniques and prefers to place a mineral-oil-greased cotton ball (the BOLUS), tied down by stitches, for seven days over the skin-recipient site. To most doctors, success in grafting occurs when most of the graft "takes" or lives. The author believes that graft success should be measured by complete survival of 100% of the graft and patient satisfaction with the blending of the new and nearby tissues. Patients are advised not to disturb, cut, manipulate, pull or touch the bolus for one week, but just to drip mineral oil on the bolus with an eyedropper.

The disadvantage of a skin graft is that the moved tissue may not appear exactly the same as the tissue that surrounds the defect. There is usually a slight mismatch, but this may be made less obvious with the use of dermabrasion (sanding) or laser abrasion. Often the skin grafted from a site such as the fold of a collarbone or behind the ear may have LESS sun damage than the sun-damaged tissue near the area that has just borne a skin cancer. In a typical case, the more pristine (sun-protected) tissue that has been grafted may be noticeable against a backdrop of the remaining elastic-sun-damaged tissue on the nose (sun damaged skin being a prime location for the formation of skin cancers). The author has developed a method called "graft-electrodotting" that uses an electric instrument to make artificial pores in newly grafted tissue. Graft-electrodotting often improves a tissue match on highly porous recipient sites such as the nose. The procedures just mentioned help to blend the skin zones between damaged and undamaged, thick and thin, with and without glands, etc.

1. Aspirin, aspirin-like products and alcohol may cause you to BLEED. Just one baby aspirin can cause bleeding for one week! For pain relief from headaches the week prior to surgery TYLENOL® brand or other acetaminophen is recommended. However, the most current medical literature now appreciates that medicines like aspirin and coumadin for prevention of heart attack or stroke need not be stopped for mere skin cancer surgery.
2. It is best if you do not have much pain. Pain may increase your blood pressure, causing bleeding. Bleeding into a wound may then cause more pain, further increasing the blood pressure, which may lead into a vicious cycle.
3. A wound kept below heart level has a higher blood pressure and is more likely to bleed or throb than is a wound which is elevated above heart level.
4. Bleeding after surgery is BAD if blood builds up inside the wound causing a ball or pain. Some bleeding MAY be okay and expected if the blood leaks slowly out of the wound.
5. The purposes of Telfa® or gauze dressings are to keep dirt, etc., off the stitch line, to prevent blood from seeping onto clothes or bed sheets and to prevent the moistening antibiotic grease from staining clothes or bed sheets.
6. Gentle swimming in a clean pool, showering, bathing and sweating are all right if the stitches are coated with antibiotic ointment. Swimming in the ocean may be DANGEROUS because of sewage and other contaminants.
7. The best ice-water pack is a BAGGIE® or ZIPLOC® bag containing small ice cubes or crushed ice and liquid water. When ice and water are present, the temperature will remain around 32F (0C) and not get too cold. Also, the ice/water mix fits (conforms to) most wound sites well.
8. It is usually best not to use Neosporin® since about 1 in 5 people are or will become allergic to Neosporin. Such a local allergy may alter the local skin immunity thus may allow the wound to become infected and take longer to heal. Unfortunately since the early 1990's, even Polysporin® has been showing a 1 in 20 allergic rate, which is disappointing and concerns the author regarding the manufacturing process.
   
   

Paul J. Weber, M.D., P.A. 5353 North Federal Highway, Suite 400 Fort Lauderdale, FL 33308 Tel: 954-489-9800 | Fax: 954-489-0401