Primary surgical closure versus second-intention healing (SIH) after Mohs micrographic surgery: Patient satisfaction and clinical implications
Authors: William G. Stebbins, Victor Neel
Journal: Journal of the American Academy of Dermatology (2016)

To the Editor: We thank Dr Kantor for his thoughtful commentary1Kantor J. Utilizing the Patient Attitudes to Scarring Scale (PASS) to develop an outcome measure for postoperative scarring: A study in 430 patients.J Am Acad Dermatol. 2016; 74: 1280-1281.e2Abstract Full Text Full Text PDF Scopus (5) Google Scholar regarding our study.2Stebbins W.G. Gusev J. Higgins II, H.W. Nelson A. Govindarajulu U. Neel V. Evaluation of patient satisfaction with second intention healing versus primary surgical closure.J Am Acad Dermatol. 2015; 73: 865-867.e1Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Previous studies have examined the cosmetic acceptability and functional outcome of second-intention healing (SIH) on various subunits of the head and neck, with delineation of specific areas that are highly amenable to SIH.3Zitelli J.A. Wound healing by secondary intention. A cosmetic appraisal.J Am Acad Dermatol. 1983; 9: 407-415Abstract Full Text PDF PubMed Scopus (193) Google Scholar, 4Becker G.D. Adams L.A. Levin B.C. Nonsurgical repair of perinasal skin defects.Plast Reconstr Surg. 1991; 88: 768-778Crossref PubMed Scopus (31) Google Scholar However, there are few studies directly examining the quality of life (QOL) impact, or patient satisfaction, with SIH versus surgical closure. Over the past few years, there has been an increased emphasis on dermatologic health-related QOL, although Mohs-specific research in this area still remains fairly minimal. Dr Kantor references a recent letter to the editor from Dr Dzubow5Dzubow L.M. Patient contribution to reconstructive decision: the purse-string closure.JAMA Dermatol. 2015; 151: 1142-1143Crossref Scopus (4) Google Scholar questioning the potential psychological impact on certain patients resulting from caring for a second-intention wound for a prolonged amount of time compared with primary closure. This was, in fact, one of the questions we had when we conceived of our study, namely: is there a discernable QOL impact (psychological or otherwise) on those patients allowed to heal by SIH? Although prior studies have presented useful data regarding the cosmetic acceptability of the resultant scar after primary surgical closure and SIH, there was a gap of knowledge regarding patient satisfaction when the 2 modalities were compared. Given our positive experience using SIH with a variety of wounds over a 10-year period in an academic setting, our goal was to evaluate patient satisfaction with primary surgical closure versus SIH in appropriately chosen subjects. Many of the early pioneers in Mohs micrographic surgery, including Frederic Mohs6Mohs F.E. Chemosurgery.Clin Plast Surg. 1980; 7: 349-360PubMed Google Scholar himself, preferentially used SIH. There were practical and technical reasons for this, including improved vigilance for recurrence of certain high-risk tumors. When the fresh tissue technique was introduced, Mohs surgeons began to incorporate more complex and creative wound repair options. This led to a decrease in the use of SIH and a commensurate increase in linear closures, flaps, and grafts. Currently, on average only 18% to 33% of Mohs defects are allowed to heal by second intention,7Moreno-Arias G.A. Izento-Menezes C.M. Carrasco M.A. Camps-Fresneda A. Second intention healing after Mohs micrographic surgery.J Eur Acad Dermatol Venereol. 2000; 14: 159-165Crossref PubMed Scopus (28) Google Scholar, 8Casey A.S. Kennedy C.E. Goldman G.D. Mohs micrographic surgery: how ACMS fellowship directors practice.Dermatol Surg. 2009; 35: 747-756Crossref PubMed Scopus (21) Google Scholar with some practitioners closing almost every wound surgically. The decision regarding how to allow the wound to heal is complex and involves a discussion between the physician and the informed patient. This retrospective study demonstrates that once the healing process had been completed, the vast majority of patients with wounds allowed to heal by SIH had a high level of satisfaction, equivalent to those who underwent surgical closure. As Dr Kantor mentions, success of either technique depends on choosing the appropriate closure for a given patient and wound type. Our intention was not to conclude that for any wound, SIH and closure are equivalent in terms of patient satisfaction or cosmetic outcome. It was rather to describe our findings that when applying accepted principles for when and where to allow wounds to heal by second intention on the face, the vast majority of patients do not experience any negative QOL impact. On the contrary, they were found to be quite satisfied with the wound-care process in the short-term, and with the resultant long-term cosmetic outcomes. Utilizing the Patient Attitudes to Scarring Scale (PASS) to develop an outcome measure for postoperative scarring: A study in 430 patientsJournal of the American Academy of DermatologyVol. 74Issue 6PreviewTo the Editor: Dermatologists perform more cutaneous surgical excisions than any other specialist group in the United States1; therefore, developing meaningful outcome measures—and ultimately core outcome measures and outcome sets—is of vital importance to clinical research in our field.2 Currently, several scales exist to assess postoperative scarring. The Patient and Observer Scar Assessment Scale and the Vancouver Scar Scale are 2 of the most frequently used scales for postoperative scarring in dermatology3,4; while these scales provide useful information, both were originally developed for burn scar evaluation rather than for assessing linear postoperative scars, and neither scale was developed through eliciting patient input regarding esthetic priorities. Full-Text PDF