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Facial Plast Surg 2012; 28(05): 497-503
DOI: 10.1055/s-0032-1325643
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Scars after Second Intention Healing

Matthew R. Donaldson
1   Department of Mohs Micrographic Surgery and Cutaneous Oncology, Mountain West Dermatology, Grand Junction, Colorado
,
Brett M. Coldiron
2   Department of Dermatology, University of Cincinnati, Cincinnati, Ohio
› Author Affiliations
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Publication History

Publication Date:
01 October 2012 (online)

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Abstract

Second intention healing (SIH) is useful for many defects after skin cancer removal. SIH decreases intraoperative morbidity and reduces procedure costs. Granulating wounds are rarely infected, have minimal pain or bleeding, and care is simple. Location is the key determinant in cosmetic outcomes of SIH. Concavities of the face including the medial canthus and conchal bowl often heal imperceptibly. Defects on convex surfaces such as the nasal tip and malar cheek can heal poorly with depressed scars. Flat areas of the cheeks, forehead, and chin heal favorably but cosmesis can be unpredictable. These regions are often described by NEET (concavities of the nose, eyes, ears, and temple), NOCH (convexities of nose, oral lips, cheek, chin, and helix), and FAIR (flat areas of the forehead, antihelix of the ear, eyelids, and rest of the nose, lips, and cheeks). We review the limited literature describing SIH based on regional anatomy of the face. Complications of SIH include exuberant granulation tissue, hypopigmented or telangiectatic scars, and distortion of free lid margins. SIH should be an integral part of the surgeon's reconstructive algorithm after skin cancer removal.

Keywords

second intention - wound healing - Mohs surgery
 

  • References

  • 1 Miller SJ. Healing by second intention following Mohs micrographic surgery. Arch Otolaryngol Head Neck Surg 1997; 123: 886-887
    CrossrefPubMedSearch in Google Scholar
  • 2 Ellner KM, Goldberg LH, Sperber J. Comparison of cosmesis following healing by surgical closure and second intention. J Dermatol Surg Oncol 1987; 13: 1016-1020
    CrossrefPubMedSearch in Google Scholar
  • 3 Mohs FE. Chemosurgery, Microscopically Controlled Surgery for Skin Cancer. Springfield, IL: Charles C Thomas; 1978
    Search in Google Scholar
  • 4 Zitelli JA. Wound healing by secondary intention. A cosmetic appraisal. J Am Acad Dermatol 1983; 9: 407-415
    CrossrefPubMedSearch in Google Scholar
  • 5 Zitelli JA. Secondary intention healing: an alternative to surgical repair. Clin Dermatol 1984; 2: 92-106
    CrossrefPubMedSearch in Google Scholar
  • 6 Schreml S, Szeimies RM, Prantl L, Landthaler M, Babilas P. Wound healing in the 21st century. J Am Acad Dermatol 2010; 63: 866-881
    CrossrefPubMedSearch in Google Scholar
  • 7 Li J, Chen J, Kirsner R. Pathophysiology of acute wound healing. Clin Dermatol 2007; 25: 9-18
    CrossrefPubMedSearch in Google Scholar
  • 8 Lambert WC, Cohen PJ, Klein KM, Lambert MW. Cellular and molecular mechanisms in wound healing: selected concepts. Clin Dermatol 1984; 2: 17-23
    PubMedSearch in Google Scholar
  • 9 Leibovich SJ, Ross R. The role of the macrophage in wound repair. A study with hydrocortisone and antimacrophage serum. Am J Pathol 1975; 78: 71-100
    PubMedSearch in Google Scholar
  • 10 Lambert WC, Cohen PJ, Lambert MW. Role of the epidermis and other epithelia in wound healing: selected concepts. Clin Dermatol 1984; 2: 24-33
    PubMedSearch in Google Scholar
  • 11 Falanga V, Zitelli JA, Eaglstein WH. Periodic synopsis: wound healing. J Am Acad Dermatol 1988; 19: 559-563
    CrossrefPubMedSearch in Google Scholar
  • 12 Pollack SV. The wound healing process. Clin Dermatol 1984; 2: 8-16
    PubMedSearch in Google Scholar
  • 13 Odland PB, Murakami CS. Healing by secondary intention. Oper Tech Otolaryngol--Head Neck Surg 1993; 4: 54-60
    PubMedSearch in Google Scholar
  • 14 Mott KJ, Clark DP, Stelljes LS. Regional variation in wound contraction of Mohs surgery defects allowed to heal by second intention. Dermatol Surg 2003; 29: 712-722
    CrossrefPubMedSearch in Google Scholar
  • 15 McGrath MH, Simon RH. Wound geometry and the kinetics of wound contraction. Plast Reconstr Surg 1983; 72: 66-73
    CrossrefPubMedSearch in Google Scholar
  • 16 Lawrence CM, Comaish JS, Dahl MGC. Excision of skin tumours without wound closure. Br J Dermatol 1986; 115: 563-571
    CrossrefPubMedSearch in Google Scholar
  • 17 Walling HW, Sniezek PJ, Friedrichs AM, Christensen DR, Whitaker DC. Guiding sutures to promote optimal contraction of a large surgical defect prior to delayed grafting. Dermatol Surg 2005; 31: 109-111
    PubMedSearch in Google Scholar
  • 18 Christenson LJ, Phillips PK, Weaver AL, Otley CC. Primary closure vs second-intention treatment of skin punch biopsy sites: a randomized trial. Arch Dermatol 2005; 141: 1093-1099
    CrossrefPubMedSearch in Google Scholar
  • 19 Deutsch BD, Becker FF. Secondary healing of Mohs defects of the forehead, temple, and lower eyelid. Arch Otolaryngol Head Neck Surg 1997; 123: 529-534
    CrossrefPubMedSearch in Google Scholar
  • 20 Becker GD, Adams LA, Levin BC. Mohs wounds of the forehead: healing by secondary intention. J Wound Care 1998; 7: 497-500
    PubMedSearch in Google Scholar
  • 21 Becker GD, Adams LA, Levin BC. Nonsurgical repair of perinasal skin defects. Plast Reconstr Surg 1991; 88: 768-776 ; discussion 777–778
    CrossrefPubMedSearch in Google Scholar
  • 22 Fox SA, Beard C. Spontaneous lid repair. Am J Ophthalmol 1964; 58: 947-952
    PubMedSearch in Google Scholar
  • 23 Mehta HK. Surgical management of carcinoma of eyelids and periorbital skin. Br J Ophthalmol 1979; 63: 578-585
    CrossrefPubMedSearch in Google Scholar
  • 24 Moscona R, Pnini A, Hirshowitz B. In favor of healing by secondary intention after excision of medial canthal basal cell carcinoma. Plast Reconstr Surg 1983; 71: 189-195
    CrossrefPubMedSearch in Google Scholar
  • 25 Cordoro KM, Russell MA. Minimally invasive options for cutaneous defects: secondary intention healing, partial closure, and skin grafts. Facial Plast Surg Clin North Am 2005; 13: 215-230 , v
    CrossrefPubMedSearch in Google Scholar
  • 26 Lowry JC, Bartley GB, Garrity JA. The role of second-intention healing in periocular reconstruction. Ophthal Plast Reconstr Surg 1997; 13: 174-188
    CrossrefPubMedSearch in Google Scholar
  • 27 Mehta HK. Spontaneous reformation of lower eyelid. Br J Ophthalmol 1981; 65: 202-208
    CrossrefPubMedSearch in Google Scholar
  • 28 Levasseur JG, Mellette Jr JR. Techniques for reconstruction of perialar and perialar-nasal ala combined defects. Dermatol Surg 2000; 26: 1019-1023
    CrossrefPubMedSearch in Google Scholar
  • 29 Pipitone MA, Gloster Jr HM. Repair of the alar groove with combination partial primary closure and second-intention healing. Dermatol Surg 2005; 31: 608-609
    PubMedSearch in Google Scholar
  • 30 Diwan R, Tromovitch TA, Glogau RG, Stegman SJ. Secondary intention healing. The primary approach for management of selected wounds. Arch Otolaryngol Head Neck Surg 1989; 115: 1248-1249
    CrossrefPubMedSearch in Google Scholar
  • 31 Becker GD, Adams LA, Levin BC. Outcome analysis of Mohs surgery of the lip and chin: comparing secondary intention healing and surgery. Laryngoscope 1995; 105: 1176-1183
    CrossrefPubMedSearch in Google Scholar
  • 32 McCarn KE, Park SS. Lip reconstruction. Facial Plast Surg Clin North Am 2005; 13: 301-314 , vii
    CrossrefPubMedSearch in Google Scholar
  • 33 Krunic AL, Weitzul S, Taylor RS. Advanced reconstructive techniques for the lip and perioral area. Dermatol Clin 2005; 23: 43-53 , v–vi
    CrossrefPubMedSearch in Google Scholar
  • 34 Mason CL, Arpey CJ, Whitaker DC. Regional reconstruction. In: Robinson JK, Hanke CW, Sengelmann RD, Siegel DM, , eds. 1st ed. Surgery of the skin: Procedural Dermatology. Philadelphia, PA: Elsevier Mosby; 2005: 390-393
    Search in Google Scholar
  • 35 Gloster Jr HM. The use of second-intention healing for partial-thickness Mohs defects involving the vermilion and/or mucosal surfaces of the lip. J Am Acad Dermatol 2002; 47: 893-897
    CrossrefPubMedSearch in Google Scholar
  • 36 Leonard AL, Hanke CW. Second intention healing for intermediate and large postsurgical defects of the lip. J Am Acad Dermatol 2007; 57: 832-835
    CrossrefPubMedSearch in Google Scholar
  • 37 Becker GD, Adams LA, Levin BC. Spontaneous healing of Mohs wounds of the cheek: a cosmetic assessment. Dermatol Surg 1998; 24: 1375-1381 ; discussion 1382
    CrossrefPubMedSearch in Google Scholar
  • 38 Levin BC, Adams LA, Becker GD. Healing by secondary intention of auricular defects after Mohs surgery. Arch Otolaryngol Head Neck Surg 1996; 122: 59-66 ; discussion 67
    CrossrefPubMedSearch in Google Scholar
  • 39 Blackwell KE, Rawnsley JD. Aesthetic considerations in scalp reconstruction. Facial Plast Surg 2008; 24: 11-21
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg 1999; 121: 751-754
    CrossrefPubMedSearch in Google Scholar
  • 41 Svensjö T, Pomahac B, Yao F, Slama J, Eriksson E. Accelerated healing of full-thickness skin wounds in a wet environment. Plast Reconstr Surg 2000; 106: 602-612 ; discussion 613–614
    CrossrefPubMedSearch in Google Scholar
  • 42 Eaglstein WH. Effect of occlusive dressings on wound healing. Clin Dermatol 1984; 2: 107-111
    PubMedSearch in Google Scholar
  • 43 Whitaker DC, Grande DJ, Johnson SS. Wound infection rate in dermatologic surgery. J Dermatol Surg Oncol 1988; 14: 525-528
    CrossrefPubMedSearch in Google Scholar
  • 44 Maragh SLH, Brown MD. Prospective evaluation of surgical site infection rate among patients with Mohs micrographic surgery without the use of prophylactic antibiotics. J Am Acad Dermatol 2008; 59: 275-278
    CrossrefPubMedSearch in Google Scholar
  • 45 Rogers HD, Desciak EB, Marcus RP, Wang S, MacKay-Wiggan J, Eliezri YD. Prospective study of wound infections in Mohs micrographic surgery using clean surgical technique in the absence of prophylactic antibiotics. J Am Acad Dermatol 2010; 63: 842-851
    CrossrefPubMedSearch in Google Scholar
  • 46 Dixon AJ, Dixon MP, Askew DA, Wilkinson D. Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics. Dermatol Surg 2006; 32: 819-826 ; discussion 826–827
    CrossrefPubMedSearch in Google Scholar
  • 47 Brady JG, Grande DJ, Katz AE. The purse-string suture in facial reconstruction. J Dermatol Surg Oncol 1992; 18: 812-816
    CrossrefPubMedSearch in Google Scholar
  • 48 Albright III SD. Placement of “guiding sutures” to counteract undesirable retraction of tissues in and around functionally and cosmetically important structures. J Dermatol Surg Oncol 1981; 7: 446-449
    CrossrefPubMedSearch in Google Scholar
  • 49 Larson PO, Ragi G, Mohs FE, Snow SN. Excision of exposed cartilage for management of Mohs surgery defects of the ear. J Dermatol Surg Oncol 1991; 17: 749-752
    CrossrefPubMedSearch in Google Scholar
  • 50 Snow SN, Stiff MA, Bullen R, Mohs FE, Chao WH. Second-intention healing of exposed facial-scalp bone after Mohs surgery for skin cancer: review of ninety-one cases. J Am Acad Dermatol 1994; 31 (3 Pt 1) 450-454
    CrossrefPubMedSearch in Google Scholar
  • 51 Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg 1999; 121: 751-754
    CrossrefPubMedSearch in Google Scholar
  • 52 Mohs FE, Zitelli JA. Microscopically controlled surgery in the treatment of carcinoma of the scalp. Arch Dermatol 1981; 117: 764-769
    CrossrefPubMedSearch in Google Scholar
  • 53 Latenser J, Snow SN, Mohs FE, Weltman R, Hruza G. Power drills to fenestrate exposed bone to stimulate wound healing. J Dermatol Surg Oncol 1991; 17: 265-270
    CrossrefPubMedSearch in Google Scholar
  • 54 Robinson JK, Dillig G. The advantages of delayed nasal full-thickness skin grafting after Mohs micrographic surgery. Dermatol Surg 2002; 28: 845-851
    CrossrefPubMedSearch in Google Scholar
  • 55 Willard RJ, Dufresne Jr RG, Jellinek NJ. Repair of lateral sidewall and partial alar defects: nasalis island pedicle flap with partial second-intention healing. Dermatol Surg 2011; 37: 74-79
    CrossrefPubMedSearch in Google Scholar
  • 56 van der Eerden P, Simmons M, Vuyk H. Reconstruction of nasal sidewall defects after excision of nonmelanoma skin cancer: analysis of uncovered subcutaneous hinge flaps allowed to heal by secondary intention. Arch Facial Plast Surg 2008; 10: 131-136
    CrossrefPubMedSearch in Google Scholar
  • 57 van der Eerden PA, Verdam FJ, Dennis SCR, Vuyk H. Free cartilage grafts and healing by secondary intention: a viable reconstructive combination after excision of nonmelanoma skin cancer in the nasal alar region. Arch Facial Plast Surg 2009; 11: 18-23
    CrossrefPubMedSearch in Google Scholar
  • 58 Campbell T, Eisen DB. Free cartilage grafts for alar defects coupled with secondary-intention healing. Dermatol Surg 2011; 37: 510-513
    CrossrefPubMedSearch in Google Scholar