A 50 y/o patient presents with a 3 year h/o right cheek growing lesion biopsied by outside office on 11/8/21 showing atypical lentiginous melanocytic proliferation. Incisional biopsy of right malar cheek done on 11/18/21 showing severely atypical lentiginous junctional melanocytic hyperplasia with margins involved. Excision and reconstruction with cerclage of right malar cheek severe atypia was performed, and scar revision 10 weeks later.
Atypical pigmented lesions and melanomas are not typically treated with Mohs surgery. They cannot be processed and interpreted with the same level of certainty as non-melanoma skin cancers, so the standard of care is to treat them with excision. However, this presents a challenge for reconstruction. If you reconstruct the defect right away, you likely extend the incisions and rearrange and/or remove extra healthy tissue to maintain an aesthetic contour and closure. If the margins come back positive, you have to treat the area again, re-design the reconstruction, and potentially take out even more healthy tissue. Alternatively, if you do not reconstruct the defect right away, a patient has to tend to an open wound or a xenograft closure until the pathology comes back. This can be psychologically distressing for some patients.
An interesting alternative option in the setting of “delayed” final closure for margin evaluation is the cerclage or purse-string closure. A purse string closure is “defined as a surgical suture passed as a running stitch in and out along the edge of a circular wound in such a way that when the ends of the suture are drawn tight the wound is closed like a purse.” It can provide partial or complete closure of a wound, and always significantly reduces the size of the defect. Benefits of cerclage closure are: no tissue is cut or removed during the closure, a patient does not have an open wound until pathology results are received, and sometimes it heals with impressive cosmesis. If there are positive margins of the pigmented lesion, the surrounding tissue was not altered and it is easy to take an additional margin and perform a final closure. The main downside of a cerclage closure is that because it “cinches” the tissue together, it can look lumpy. In high tension or dynamic areas, the lumps often settle out over time. However, in some areas, the contour is suboptimal without further standing cone excisions. If the cosmesis is unsatisfactory, a secondary scar revision can be performed and is often much simpler with fewer and shorter incisions.