A Pearl for Pretibial and Forearm Repair Following Mohs Micrographic Surgery

Wound repair in particular areas of the body presents treatment challenges. Epidermal fragility, inflamed margins, and heightened skin tension secondary to suturing, increase the risk of wound dehiscence and delay healing. Friable tissue is also more likely to be torn by the sutures themselves. No gold standard currently exists for the treatment of pretibial or forearm wound defects. Several techniques have been proposed within the literature including the use of Steri-Strips^TM and sutures on linear lacerations,¹ in addition to suturing (with Adhesive Retention Suture device) followed by fixative application.² There are no previously reported management regimens, however, that involve the use of bilayered closure and liquid adhesive.

 

 

A bilayered suture technique was devised for pretibial and forearm wound closure following Mohs micrographic surgery. The patient's wounds are cleaned after the procedure using chlorhexidine. The wound is approximated using a 3.0 nylon pulley suture. To decrease wound tension, it can be left in place or removed when the closure, using 3-0 interrupted polyglactin 910 sutures for the subcutaneous layer and interrupted 3-0 nylon sutures for the epidermal layers, is completed. Dermabond (Ethicon) or Mastisol (Ferndale) are subsequently applied to the linear closure and surrounding skin (Figure 1A). Once the adhesive dries, a pressure bandage is applied. Lastly, sutures are removed and the surgical site is assessed at 3 weeks follow-up (Figure 1B). Bilayered closure, then tissue adhesive application, an innovative method for pretibial and forearm wound closure after Mohs surgery, decreases superficial dehiscence and allows for adequate wound healing and approximation. The use of adhesive with this technique helps to prevent the skin 

 

from being torn apart with suture tensions, and the sutures from ripping through the friable skin with tension, or inflammation/edema in the early stages of wound healing. In our experience, this is an easy, safe, accessible method to close pretibial and forearm wounds, under tension, and provides a valuable teaching lesson for dermatology residents and fellows.³ 

 

 

1. Silk J. A new approach to the management of pretibial lacerations. Injury. 2001;32(5):373-376. 
2. Roybal LL, Howerter S, Markus B, et al. Use of a novel adhesive suture retention wound closure device to prevent patient follow-up visits during the COVID-19 pandemic. JAAD Case Reports. 2020;6(7):593-597. 
3. Farshchian M, Sklar LR. The pinch stitch: a pearl for suturing wounds under tension. J Drugs Dermatol. 2020;19(12):1262.