LETTER TO THE EDITOR
Adhesive Retention Tape Supporting Atrophic Skin on a Tripolar Advancement Flap: A Novel Wound Closure Option for Atrophic Skin in an Aging Population To the Editor: Cutaneous surgery on the elderly is problematic for several reasons. There are age-related changes in all stages of wound healing, resulting in delayed healing.1 Furthermore, diseases that affect wound healing are more prevalent and have a greater impact on the elderly compared to the young.2 The repair of defects following removal of cutaneous malignancies in the elderly may be complicated by atrophic skin (that may tear or may not support sutures), resulting in difficulty in closing moderately sized wounds, resulting in the need for skin grafts (either split skin or full thickness) or healing via secondary intention. This results in increased morbidity for the patient and potential development of complications. We report a new option in closing these difficult wounds that require a flap closure by use of an adhesive retention tape to support sutures in atrophic skin. The Hypafix (BSN medical, Hamburg, Germany) skin support technique was originally described by Foster and Chan with a primary closure3; however, we describe adapting this technique for use in an advancement flap. Our patient presented for the excision of two biopsyproven, well-differentiated squamous cell carcinomas. The first lesion was located on the right forearm, measured 18 mm in diameter, and was excised with a 5 mm clinical margin. The resulting defect was not suitable for a primary closure, and a tripolar advancement flap was designed to close the forearm defect (Figure 1A). Initial closure of the lesion began with placement of interrupted dermal sutures (4.0 Vicryl). Hypafix supporting tape was cut into triangular shapes and placed onto each of the three poles of the flap (Figure 1B). Interrupted external sutures were then applied (4.0 Novafil), with each suture passed through the Hypafix prior to and after exiting the skin, with an external knot tied above the Hypafix (Figure 1C, Figure 2). A further excision was conducted on the posterior right lower leg, where Hypafix was also used to reinforce a side-to-side closure. DOI 10.2310/7750.2014.13205 # 2014 Canadian Dermatology Association
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Sutures were removed after 10 days, and the patient was again reviewed after a further 5 days (Figure 3). Hypafix consists of a white nonwoven polyester substrate coated with a polyacrylate adhesive, providing secure and reliable dressing retention.4 Sterile Hypafix is used to minimize intraoperative contamination of the wound and allow for closure in a sterile environment. The ease of this technique allows itself to be modified for use in a flap closure, and although the technique detailed above is for an advancement flap, the adhesive retention tape support would also lend itself to a transposition, rotation, or island pedicle flap. This technique is a simple method for reinforcing skin that would be liable to tearing due to skin fragility and atrophy and thus allows wounds to be closed in a simple manner. As such, it has become commonly used within our department. Potential adverse reactions or complications are mostly limited to contact dermatitis to the adhesive tape and secondary infection if the tape becomes compromised. Skin reinforcement has been attempted in other ways. Davis and colleagues reported the use of Steri-Strips for reinforcement by placement of the strips across the wound followed by suturing through the Steri-Strips.5 Foster and Chan also reported the use of adhesive support tapes in the context of a side-to-side closure, with the tape placed parallel to the wound edges. The use of adhesive tape in a tripolar advancement flap, however, has expanded the possibilities of supporting atrophic and fragile skin in challenging wound closures. The ease of this technique allows itself to be modified for use in flap closure, and although the technique detailed above is for an advancement flap, the adhesive retention tape support would also lend itself to a transposition, rotation, or island pedicle flap. Peter Peters Queensland Institute of Dermatology Greenslopes, Queensland, Australia Department of Dermatology University of Queensland School of Medicine Brisbane, Queensland, Australia Lisa Abdel-Malek Karyn Lun Queensland Institute of Dermatology Greenslopes, Queensland, Australia
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 1 (January/ February), 2015: pp 8–9
Letter to the Editor
Figure 1. A, Design of the flap surrounding the defect. B, Stylized location of the Fixomull adhesive tape around the various edges of the flap design. C, Location of the sutures on the varying edges of the tripolar advancement flap. Sutures extend into and through the Hypafix support tape.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References
Figure 2. Actual wound closure with adhesive support tape sutured in place to support atrophic skin.
1. Gosain A, DiPietro LA. Aging and wound healing. World J Surg 2004;28:321–6, doi:10.1007/s00268-003-7397-6. 2. van De Kerkhof PCM, van Bergen B, Spruijt K, Kuiper JP. Agerelated changes in wound healing. Clin Exp Dermatol 1994;19:369– 74, doi:10.1111/j.1365-2230.1994.tb02684.x. 3. Foster RS, Chan J. The Fixomull skin support method for wound closure in patients with fragile skin. Australas J Dermatol 2011;52: 209–11, doi:10.1111/j.1440-0960.2011.00773.x. 4. BSN medical. Hypafix product description. Available at: http:// www.bsnmedical.com/products/acute-wound-care/fixation/wide-areafixation/ (accessed November 2013). 5. Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip combination for the management of lacerations in thin-skinned individuals. J Emerg Med 2011;40:322–3, doi:10.1016/j.jemermed.2010.05.077.
Figure 3. Healing 5 days postremoval of sutures and Hypafix supporting tape.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 1 (January/ February), 2015: pp 8–9
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Adhesive Retention Tape Supporting Atrophic Skin on a Tripolar Advancement Flap: A Novel Wound Closure Option for Atrophic Skin in an Aging Population To the Editor: Cutaneous surgery on the elderly is problematic for several reasons. There are age-related changes in all stages of wound healing, resulting in delayed healing.1 Furthermore, diseases that affect wound healing are more prevalent and have a greater impact on the elderly compared to the young.2 The repair of defects following removal of cutaneous malignancies in the elderly may be complicated by atrophic skin (that may tear or may not support sutures), resulting in difficulty in closing moderately sized wounds, resulting in the need for skin grafts (either split skin or full thickness) or healing via secondary intention. This results in increased morbidity for the patient and potential development of complications. We report a new option in closing these difficult wounds that require a flap closure by use of an adhesive retention tape to support sutures in atrophic skin. The Hypafix (BSN medical, Hamburg, Germany) skin support technique was originally described by Foster and Chan with a primary closure3; however, we describe adapting this technique for use in an advancement flap. Our patient presented for the excision of two biopsyproven, well-differentiated squamous cell carcinomas. The first lesion was located on the right forearm, measured 18 mm in diameter, and was excised with a 5 mm clinical margin. The resulting defect was not suitable for a primary closure, and a tripolar advancement flap was designed to close the forearm defect (Figure 1A). Initial closure of the lesion began with placement of interrupted dermal sutures (4.0 Vicryl). Hypafix supporting tape was cut into triangular shapes and placed onto each of the three poles of the flap (Figure 1B). Interrupted external sutures were then applied (4.0 Novafil), with each suture passed through the Hypafix prior to and after exiting the skin, with an external knot tied above the Hypafix (Figure 1C, Figure 2). A further excision was conducted on the posterior right lower leg, where Hypafix was also used to reinforce a side-to-side closure. DOI 10.2310/7750.2014.13205 # 2014 Canadian Dermatology Association
8
Sutures were removed after 10 days, and the patient was again reviewed after a further 5 days (Figure 3). Hypafix consists of a white nonwoven polyester substrate coated with a polyacrylate adhesive, providing secure and reliable dressing retention.4 Sterile Hypafix is used to minimize intraoperative contamination of the wound and allow for closure in a sterile environment. The ease of this technique allows itself to be modified for use in a flap closure, and although the technique detailed above is for an advancement flap, the adhesive retention tape support would also lend itself to a transposition, rotation, or island pedicle flap. This technique is a simple method for reinforcing skin that would be liable to tearing due to skin fragility and atrophy and thus allows wounds to be closed in a simple manner. As such, it has become commonly used within our department. Potential adverse reactions or complications are mostly limited to contact dermatitis to the adhesive tape and secondary infection if the tape becomes compromised. Skin reinforcement has been attempted in other ways. Davis and colleagues reported the use of Steri-Strips for reinforcement by placement of the strips across the wound followed by suturing through the Steri-Strips.5 Foster and Chan also reported the use of adhesive support tapes in the context of a side-to-side closure, with the tape placed parallel to the wound edges. The use of adhesive tape in a tripolar advancement flap, however, has expanded the possibilities of supporting atrophic and fragile skin in challenging wound closures. The ease of this technique allows itself to be modified for use in flap closure, and although the technique detailed above is for an advancement flap, the adhesive retention tape support would also lend itself to a transposition, rotation, or island pedicle flap. Peter Peters Queensland Institute of Dermatology Greenslopes, Queensland, Australia Department of Dermatology University of Queensland School of Medicine Brisbane, Queensland, Australia Lisa Abdel-Malek Karyn Lun Queensland Institute of Dermatology Greenslopes, Queensland, Australia
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 1 (January/ February), 2015: pp 8–9
Letter to the Editor
Figure 1. A, Design of the flap surrounding the defect. B, Stylized location of the Fixomull adhesive tape around the various edges of the flap design. C, Location of the sutures on the varying edges of the tripolar advancement flap. Sutures extend into and through the Hypafix support tape.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References
Figure 2. Actual wound closure with adhesive support tape sutured in place to support atrophic skin.
1. Gosain A, DiPietro LA. Aging and wound healing. World J Surg 2004;28:321–6, doi:10.1007/s00268-003-7397-6. 2. van De Kerkhof PCM, van Bergen B, Spruijt K, Kuiper JP. Agerelated changes in wound healing. Clin Exp Dermatol 1994;19:369– 74, doi:10.1111/j.1365-2230.1994.tb02684.x. 3. Foster RS, Chan J. The Fixomull skin support method for wound closure in patients with fragile skin. Australas J Dermatol 2011;52: 209–11, doi:10.1111/j.1440-0960.2011.00773.x. 4. BSN medical. Hypafix product description. Available at: http:// www.bsnmedical.com/products/acute-wound-care/fixation/wide-areafixation/ (accessed November 2013). 5. Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip combination for the management of lacerations in thin-skinned individuals. J Emerg Med 2011;40:322–3, doi:10.1016/j.jemermed.2010.05.077.
Figure 3. Healing 5 days postremoval of sutures and Hypafix supporting tape.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 19, No 1 (January/ February), 2015: pp 8–9
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