INTRODUCTION
Dermatologic surgeons often encounter defects with exposed periosteum, especially when treating skin cancers on the scalp, temples, and shins. These sites are traditionally considered challenging due to limited vascularity, which can delay granulation and slow re-epithelialization. Consequently, the prevailing dogma "you cannot heal over bone"2 often leads surgeons to favor primary closure, local flaps, or full- or split-thickness skin grafts to expedite wound closure and minimize prolonged wound care. These approaches, however, may not be suitable for all patients, particularly those with advanced age, comorbidities, or limited caregiving support, and may necessitate the use of secondary intent healing (SIH).1,2 Still, there remains a critical gap in recent literature characterizing healing outcomes and timelines for supraperiosteal wounds managed with SIH. Here, we describe the successful management of a 98-year-old patient with a post-Mohs surgery defect of exposed periosteum that was successfully managed with SIH. We discuss wound management strategies and clinical decision-making to guide the use of SIH based on our experience and the available literature.
Clinical Observation A 98-year-old male with atrial fibrillation on rivaroxaban presented with a large 3.4 × 2.2-cm exophytic mass with poorly defined surrounding erythema, ultimately found to be a cutaneous squamous cell carcinoma (cSCC) of the left frontal scalp (Figure 1). The patient, otherwise active and independent for his age, elected with his family to undergo Mohs surgery, resulting in a final defect measuring 5.5 x 2.7 cm with depth down to cortical bone. Repair options were discussed, outlining risks and benefits of healing via primary versus secondary intent. Given the patient's age, independence, the size and location of the lesion, risks associated with more complex reconstruction, and the patient and family's preference, the final decision was made to heal via secondary intent.
A simple repair was performed with purse string closure to decrease the size of the resultant surgical defect and allow the center of the wound to heal via granulation. A dehydrated human amniotic membrane fenestrated graft was placed over the base of the wound bed over cortical bone, and the wound was dressed with gentian violet, white petrolatum, and non-stick gauze. One week later, the site was debrided, cortical bone scraped with a 3 mm disposable curette to elicit pinpoint bleeding, the desired endpoint, and the fenestrated graft was replaced. The wound was then dressed with silver-impregnated hydrofiber dressing, non-adherent dressing, transparent film dressing, and pressure dressing. The following week, the patient underwent bone debridement of necrotic tissue with a 3 mm curette, and the site was dressed with medical-grade honey, hydrocolloid dressing, and transparent film dressing. For the following 2.5 months, the patient presented for weekly in-office nurse-performed wound care consisting of gentian violet, medical-grade honey, and calcium alginate dressing. Then, for the next 3 months, the patient came in every 2 weeks for continued wound checks and simple petroleum jelly wound care (Figure 1). Of note, at 6 months post Mohs, his clinical course was complicated by a small foci of hypergranulation tissue, which is currently undergoing treatment with topical corticosteroids.
Clinical Observation A 98-year-old male with atrial fibrillation on rivaroxaban presented with a large 3.4 × 2.2-cm exophytic mass with poorly defined surrounding erythema, ultimately found to be a cutaneous squamous cell carcinoma (cSCC) of the left frontal scalp (Figure 1). The patient, otherwise active and independent for his age, elected with his family to undergo Mohs surgery, resulting in a final defect measuring 5.5 x 2.7 cm with depth down to cortical bone. Repair options were discussed, outlining risks and benefits of healing via primary versus secondary intent. Given the patient's age, independence, the size and location of the lesion, risks associated with more complex reconstruction, and the patient and family's preference, the final decision was made to heal via secondary intent.
A simple repair was performed with purse string closure to decrease the size of the resultant surgical defect and allow the center of the wound to heal via granulation. A dehydrated human amniotic membrane fenestrated graft was placed over the base of the wound bed over cortical bone, and the wound was dressed with gentian violet, white petrolatum, and non-stick gauze. One week later, the site was debrided, cortical bone scraped with a 3 mm disposable curette to elicit pinpoint bleeding, the desired endpoint, and the fenestrated graft was replaced. The wound was then dressed with silver-impregnated hydrofiber dressing, non-adherent dressing, transparent film dressing, and pressure dressing. The following week, the patient underwent bone debridement of necrotic tissue with a 3 mm curette, and the site was dressed with medical-grade honey, hydrocolloid dressing, and transparent film dressing. For the following 2.5 months, the patient presented for weekly in-office nurse-performed wound care consisting of gentian violet, medical-grade honey, and calcium alginate dressing. Then, for the next 3 months, the patient came in every 2 weeks for continued wound checks and simple petroleum jelly wound care (Figure 1). Of note, at 6 months post Mohs, his clinical course was complicated by a small foci of hypergranulation tissue, which is currently undergoing treatment with topical corticosteroids.
DISCUSSION
SIH predates modern medicine, having been the default method of healing since humans first existed.3 Reluctance to use SIH for supraperiosteal wounds persists due to concerns about limited vascular support, delayed granulation, and risks of desiccation or osteonecrosis,2,4 compounded by limited literature and the emergence of newer reconstructive techniques.5 Early case series from the 1980s and 1990s reported successful SIH over periosteum in dozens of patients, particularly on the scalp, with acceptable cosmetic and functional outcomes. Two
