Reconstructive Surgery on Cutaneous Malignancies

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As plastic surgeons, dermatologists typically refer us cases involving skin cancers dealing with the head/neck which require advanced closure techniques to minimize scar burden and resulting deformities. ⁣⁣

We are trained in “cutaneous oncology” in terms of evaluation and treatment of skin cancers, as well as coverage of resulting defects. ⁣⁣
Micrographic surgery (Mohs surgery) is performed by our dermatology colleagues and is a technique based on complete tumor excision with maximal normal tissue preservation. ⁣⁣
We often work with Mohs trained dermatologists who remove skin cancers that meet requirements. ⁣⁣
We assist them in covering the resulting defect after tumor excision with margin clearance. Mohs surgery ensures margin and tumor clearance in areas requiring maximal tissue preservation (nose, lips, eyelids). ⁣⁣
In some cases, Mohs is not indicated and we are able to perform the oncologic portion as well as the reconstructive portion. ⁣⁣
In this patient, I was able to visualize tumor margins and perform a margin analysis (to ensure negative margins) prior to central tumor removal. ⁣⁣
Once the margins were deemed negative via a pathologist on site who performs frozen sections, the remaining tumor is removed and the defect can be closed in the same setting. ⁣⁣
Please note this patient did not receive Mohs surgery. ⁣⁣
I performed the excision, achieved margin control, and then also performed
the reconstruction with local tissue rearrangement.

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Previously, we presented an example of reconstructive surgery I perform for cutaneous malignancies (skin cancers) involving face, scalp, and neck. ⁣

Removal of cancer in an aesthetic unit (with margins) and closure of the defect with scars in an inconspicuous location. ⁣

Principal in replacing like tissue with like tissue (color match and tissue thickness are taken into consideration) and tissue is moved or rotated or advanced with its corresponding blood supply. ⁣

This is where the art of plastic surgery comes into play. We are trained to respect aesthetic subunits and cover like tissue with like tissue to ensure minimal distortion, and best color match and thickness. ⁣

When considering coverage options, we need to be aware of how to best rotate or re-arrange adjacent tissue to cover the defect with a design that respects blood flow or tissue perfusion to ensure healing. ⁣

Sometimes adjunct procedures are needed to get the best results (eg. revisions including debulking, dermabrasion, etc). ⁣

This lady underwent partial chin defect coverage with bilateral V-Y advancement flaps and a single revision. ⁣

Healing time is 4-6 weeks. ⁣

Revisions are small office procedures with minimal downtime and healing in 1-3 weeks. ⁣

Additionally, I advise my patients on sun avoidance and scar maturation postoperatively. ⁣

It can take 6-8 weeks for scars to regain most (but never all) of their tensile strength. Scars often look worse before they look better. ⁣

We recommend sun avoidance or covering the scar for 1 year (physical block or sunblock and physical block).⁣

No scar revisions prior to one year. It usually takes one year for scars to really settle and look as close to normal as possible. ⁣

I also remind patients there is no “scarless” surgery but we try to optimize the size and placement of scars according to local and aesthetic units.

GalaFLEX Surgical Scaffold for Plastic or Reconstructive Surgery

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Another important technique to point out from the case that we’ve recently posted about(please see our grid @dreffiepolitis ), is the use of Galaflex Ravioli construct⁣⁣⁣⁣⁣.⁣⁣

The GalaFLEX Scaffold (Galatea Surgical, Inc., Lexington, MA) for plastic and reconstructive surgery belongs to a new generation of products for soft tissue reinforcement made from poly-4-hydroxybutyrate (P4HB)⁣. ⁣

It is comprised of high-strength, resorbable P4HB monofilament fibers. It is a knitted macroporous scaffold intended to elevate, reinforce, and repair soft tissue. The scaffold acts as a lattice for new tissue growth, which is rapidly vascularized and becomes fully integrated with adjacent tissue as the fibers resorb.⁣

The “ravioli” technique involves using 2 pieces of extra thick ADM to completely wrap the TE/implant. The 2 pieces of ADM are cut to the size of the TE/implant with 1 piece covering the anterior and the other covering the posterior surface of the TE/implant.⁣⁣

Acellular dermal matrix (ADM) is a soft connective tissue graft generated by a decellularization process that preserves the intact extracellular skin matrix. Upon implantation, this structure serves as a scaffold for donor-side cells to facilitate subsequent incorporation and revascularization. In breast reconstruction, ADM is used mainly for lower pole coverage and the shaping of a new breast. It helps control the positioning of the implant in the inframammary fold, and prevents the formation of contractile pseudocapsule around the breast implant.⁣⁣

The “ravioli” construct is something Dr. Stephen Sigalov came up with which involves performing a 360 degree wrap of the implant with Galaflex to stabilize the implant in the breast pocket given the normal landmarks are obliterated with the mastectomy. The Galaflex or P4HB totally resorbs (turns in CO2 and H20) in 18-24 months and is replaced by the patients own Type 1 collagen to provide long lasting implant support. Type 1 collagen is the strongest collagen in the body. This prevents issues such as stretch, bottoming out, malposition, implant flipping etc. ⁣⁣