Re: Healing by second intent

70 year old man with history of multiple non-melanoma skin cancers presented for a routine skin check. A skin examination revealed a  nodule on the left temporal region adjacent to the lateral canthus. The nodule was around 5 mm in size and non tender on palpation. (Figure 1) A shave skin biopsy was performed and confirmed the diagnosis of a nodular basal cell carcinoma (BCC).

Question 1
What are the treatment options ? What are the disadvantages and advantages of the treatment options?

Question 2
What are the wound closure options at this site ?

Question 3
What are the advantages and disadvantages of healing by second intent ?

Question 4
What factors can we use to predict the cosmetic outcome when we use healing by second intent?

Question 5
What dressing is appropriate and what instructions do you give the patient for post-op wound care?

Answer 1

The preferred treatment for most BCCs are complete excision because it has the highest 5 year cure rate. (BCC guideline). Other treatment options include topical treatment such as imiquimod or efudix, cryotherapy, curettage and cautery and phototherapy. Table 1 listed the advantages and disadvantages of each treatment options.

The BCC is located at the high risk zone (figure 2) on the face. The recurrence rate is higher in the high risk zone. Therefore, excision was chosen as the treatment option to provide the highest cure rate.

 The Telederm plastic surgeon was consulted for advice because the lesion was located at a cosmetically sensitive area.


Answer 2

The surgical options include:

1. Ellipse excision with primary closure. The lesion is closed to the lateral cants of the left eye. Ellipse excision with primary closure may distort the shape of the left eye and most people would consider this cosmetically unacceptable.

2. Excision with full thickness graft. This will provide reasonable cosmetic outcome. However, the procedure requires a doctor with more surgical experience, it takes longer time and more costly.

3. Excision with healing by second intent. This will provide reasonable cosmetic outcome in concaved area on the face. However, it takes longer to heal and the patient will need to be  motivated to clean and dress the wound daily.

After considering the local resources, costs and patient preferences, we treated the lesion with excision with healing by second intent.

Answer 3

The advantages of healing by second intent:

• It can provide reasonable cosmetic outcomes, and under certain circumstances SIH can offer cosmetic outcomes that are equal or superior to those achieved by primary closure, grafts, and flaps. (4-6)
• Low complication rate and the avoidance of complex procedures in patients who are at risk of long operation time. (7)

The disadvantages:

• prolonged healing time
• the need for daily wound care, and occasionally unpredictable cosmetic results. 
• The cosmetic outcome can only be assessed after complete wound healing

Answer 4

The factors which can affect cosmetic outcome:

• Location is probably the most important factor. Concave area tends to do better than convex area. 
• The size of the lesion. (Wound smaller than 2.5 cm tends to do better)
• Aged skin, from our experience, tends to do better. This was also suggested by few other authors 
• The willingness and motivation of the patient to look after the wound. Some patients may not have the dexterity to change dressing daily or does not have the motivation to do it. 

Answer 5

Currently there is no evidence showing using a particular type of dressing facilitates wound healing.
Cochrane review showed that using gauze is associated with more pain and discomfort. The dressing we used jelonet and prima pore on this patient. We told the patient to change the dressing after shower daily and clean the wound with soap and water. The patient was reviewed weekly and after 4 weeks. (Figure 4)

We found that healing by second intent is a technique that is being under utilised in general practice. It has been described for the last 50 years. Healing by second intent provides the best cosmetic outcome on concaved area on the face.


Key points:

• Healing by second intent often produce good cosmetic outcome especially in concaved area on the face. 
• Healing by second intent is under utilised in general practice 
• In selected cases, the cosmetic outcome can be better by skin graft/skin flap. 

References:

4. Zitelli JA. Secondary intention healing: an alternatvie to surgical repair. Clin dERMATOL 1984:2:92-106
5. Moscona R, Pnini A, Hirshowitz B. In favour of healing by secondary intention after excision of medial cantonal basal cell carcinoma. Last Reconstr Surg 1983:71:189-95.
6. Bernstein G. Healing by secondary intention. Dermatol Clin 1989:7:645-60.
7/ Goldwyn RM, Rueckert F. The value of healing by secondary intention for sizeazble defects of the face. Arch Sug 1977:112: 285-92.