While most skin cancer patients would like nothing more than to put their experience behind them, the majority carry constant reminders of their battle with cancer in the form of surgical scars. In some cases, skin cancer surgical scars can cause serious disfigurement, particularly on facial areas that are hard to hide or camouflage. Now, thanks to pioneering research, dermatologists can offer patients more effective facial reconstruction options to reduce the appearance of scars following skin cancer surgery.
Speaking at the 66th Annual Meeting of the American Academy of Dermatology, dermatologist Tri H. Nguyen, MD, FAAD, associate professor of dermatology, director of Mohs micrographic and dermatologic surgery, and program director of procedural dermatology at the University of Texas M.D. Anderson Cancer Center in Houston, discussed how dermatologists are improving patient satisfaction by using the newest innovations and techniques to minimize surgical scars from facial skin cancers.
"For years, dermatologists have used a number of tried-and-true healing options for wounds resulting from skin cancer surgery from effectively allowing Mother Nature to heal wounds without medical or surgical intervention to various closure techniques, surgical flaps and skin grafts," said Dr. Nguyen. "While these methods have proven quite effective in minimizing surgical scars, dermatologists are drawing on their expertise in how the skin heals to expand the current treatment options and further enhance results."
Barbed Stitch Technique
One relatively new development is the barbed suture (or stitch) technique, reported Dr. Nguyen, which has simplified how dermatologists close difficult wounds. Instead of tying multiple stitch knots in the wound as is common with traditional closure techniques, Dr. Nguyen explained that a dermatologic surgeon threads a running "baseball stitch" through the wound or a continuous stitch that weaves in and out similar to the stitching on a baseball causing the barbs to catch onto the connective tissue of the wound. In essence, the barbs on the stitches anchor themselves to the deep tissue of the wound and gradually close the wound together without tying knots.
"The barbed stitch technique was recently introduced and, in my experience, the technique has proven successful in closing complicated wounds very quickly and efficiently," said Dr. Nguyen. "Since the patient’s operation time is greatly reduced because multiple stitch knots are avoided, their risk of surgical complications is theoretically less as longer surgeries are associated with greater risk of infection and other complications."
In addition, Dr. Nguyen explained that since the barbed stitch is thick, it works best for large wounds in areas of thicker skin and with high resistance that are hard to stretch such as the rigid scalp area. This procedure is not recommended in areas where the skin is thin, for instance on the nose or eyelids. He added that patients with thick skin on their cheeks may also be good candidates for the technique.
Dermabrasion and Lasers
All surgeries will leave scars and a "scar less" surgery is unrealistic. One approach that comes close is immediate sanding (dermabrasion) of the incision line. In this method, which was developed by dermatologists, a wound is closed with deep stitches first to bring the skin edges together. Sanding is then performed with either a mechanical abrasive device or a laser (intense beam of light energy) to remove the epidermis (the skin’s outer layer) all along the entire incision line. This sanding is done at the time of surgery rather than several months afterwards, which is when traditional dermabrasion is completed. Once the epidermis is sanded down, the dermatologist places the top stitches and seals the wound.
Over the course of about seven to 10 days, the cells in the area where the skin was sanded down or stripped migrate over the upper stitch line and effectively hide that line. "The migrating cells effectively seal the scar and blend it in with the surrounding skin," said Dr. Nguyen.
Dr. Nguyen noted that both dermabrasion and lasers can be used immediately after surgery on almost any area of the face except the eyelids or lips. The best candidates for these procedures are fair-skinned patients and those without an abundance of oil glands along the stitch line itself.
"In general, the smoother the skin and the fairer the patient, the better dermabrasion or lasers work together with traditional closure techniques to minimize a scar’s visibility," explained Dr. Nguyen. "In many cases, adding these methods into the mix can result in an almost scar-less outcome. In fact, these technologies can hide the stitches so well that even under magnification you cannot detect them."
Skin Substitutes as Skin Grafts
While traditional skin grafts in which a person’s own skin is removed from another part of the body and is then stitched over the wound are commonly used in skin cancer reconstruction surgery, a newer application of this technique involves using a skin substitute instead of a person’s own skin to close the wound. The skin substitutes currently being used contain an animal protein matrix that the body integrates into the scar.
"Skin substitutes are a good option for patients who don’t have a lot of healthy skin to use for a graft, such as those with widespread sun damage," said Dr. Nguyen. "Another benefit is that skin substitutes eliminate the need for a second surgery site, and for very deep wounds skin substitutes can be used underneath the skin to plump and shape depressed areas."
Dr. Nguyen believes that the future of facial reconstruction looks bright, with more promising research on the horizon to minimize scarring following skin cancer surgery. "Two frontiers in wound reconstruction will involve determining how to modify bad or abnormal scars that sometimes heal poorly and developing products such as creams or injectables that promote wound healing based on a greater understanding of how healing occurs at a cellular or biological level," added Dr. Nguyen.
In 2007, it was estimated that more than 1 million new cases of skin cancer will be diagnosed in the United States. Research has shown that in 2004, the total direct cost associated with the treatment for non-melanoma skin cancer was $1.5 billion and $291 million for melanoma.
(Source: 66th Annual Meeting of the American Academy of Dermatology: American Academy of Dermatology: February 2008)