|Year : 2018 | Volume
| Issue : 1 | Page : 16-20
Reverdin pinch grafts for surgical closure after removal of nonmelanoma skin cancer lesions of the leg
Frank Hofmann1, Ammar Faisal Hameed2, Thomas Schleussinger3, Field Lawrence4
1 Gesundheitszentrum Bad Reichenhall Klinik For Dermatology and Allergology, Bad Reichenhall, Germany
2 Department of Dermatology, Hautpraxis Schongau, Schongau, Germany; Department of Dermatology, University of Baghdad, Baghdad, Iraq
3 Department of Dermatology, Hautpraxis Schongau, Schongau, Germany
4 Stanford University, San Francisco, California; University of Texas, San Antonio, Texas; University of California, San Francisco, California, USA
|Date of Web Publication||31-Jan-2018|
Dr. Ammar Faisal Hameed
Burrgener Str. 13, 86956 Schongau, Germany
Source of Support: None, Conflict of Interest: None
Background: Surgical closure after removal of nonmelanoma skin cancer on the leg can be challenging. Objective: Reverdin pinch grafting is an old skin transplant approach to treat leg ulcers. We present our experience using Reverdin pinch graft to close leg surgical defects following excision of nonmelanoma skin cancers. Patients and Methods: This was a retrospective study of 35 patients with medium-large sized defects with a median ± standard deviation of 20 ± 2.7 mm. Pinch grafts harvested from the thigh were used to cover the surgical leg defects with a 6-year follow-up period. Results: The average healing time after pinch grafting was 4 weeks ± 1.12 weeks. Ten patients (28.6%) had a failure of one or two single pinch grafts. There was no hypertrophic or keloid scarring in any grafted patients. Wound infection occurred in two patients (5.7%) and postoperative hemorrhage in only one patient (2.8%). Basal cell carcinoma arose in one patient (2.8%). Conclusion: Reverdin pinch graft technique is an easy and effective closure option for medium-large surgical defects of the leg after nonmelanoma skin cancer excision.
Keywords: Pinch graft, Reverdin graft, skin cancer
|How to cite this article:|
Hofmann F, Hameed AF, Schleussinger T, Lawrence F. Reverdin pinch grafts for surgical closure after removal of nonmelanoma skin cancer lesions of the leg. J Dermatol Dermatol Surg 2018;22:16-20
|How to cite this URL:|
Hofmann F, Hameed AF, Schleussinger T, Lawrence F. Reverdin pinch grafts for surgical closure after removal of nonmelanoma skin cancer lesions of the leg. J Dermatol Dermatol Surg [serial online] 2018 [cited 2018 Feb 22];22:16-20. Available from: http://www.jddsjournal.org/text.asp?2018/22/1/16/224392
| Introduction|| |
Cutaneous cancer is a worldwide health problem, especially in fair skin inhabitant countries such as the United States, European countries, and Australia.
Surgery is the gold standard therapy to reduce the mortality and morbidity of skin cancer.
Available surgical approaches include primary closure, healing by secondary intention, split-thickness skin graft, full-thickness skin graft, and skin flaps. Notably, surgical interventions in the leg carry some difficulties which may be attributed to the relatively poor healing environment and the direct effect of this region by underlying diseases such as diabetes, peripheral vascular, and neurological disease.
Primary closure is considered the treatment of choice due to the low risk of postoperative complications as well as the favorable cosmetic appearance. However, this procedure is dependent on the availability of sufficient loose skin in the surroundings so that the dermatologic surgeon can approximate the wound edges directly without any excessive tension.
Jacques-Louis Reverdin, a Swiss surgeon, published a surgical method in 1872 to treat venous ulcers by transplanting skin pieces through shaving the skin after pinching it between the index finger and thumb. At one time, Reverdin grafts were obtained by pinching up the uppermost layer of skin with forceps and scissor to cut the superficial grafts.
Davis has further modified this method through a fine hypodermic needle to elevate the skin, thus facilitating the cut with the scalpel so that the margins of the grafts are quite thin, but the thickness gradually increases toward the center to include a variable thickness of the corium. This technique is currently known as pinch grafting. We present our experience using Reverdin pinch grafts to close surgical defects of the lower leg between the knee and ankle after removal of nonmelanoma skin cancer (NMSC).
| Patients and Methods|| |
This was a retrospective study of 35 patients treated with Reverdin pinch grafting method at our department in Hautarztpraxis-Schongau in Germany between 2010 and 2016. All patients signed the consent form before surgery. After excision of the NMSC, patients left with medium-large leg surgical defects of 11–45 mm diameter were included in this study. Small defects of <11 mm diameter or large surgical leg defect of more than 45 mm diameter were excluded from the study.
Scientific calculator was used to perform the simple statistical analysis. The study proposal was already approved by the Department of Dermatology, College of Medicine at Baghdad University and its Ethical Approval committee.
Preoperative assessment included a medical history with emphasis on comorbidities like diabetes mellitus and peripheral vascular diseases. Doppler studies were ordered if indicated. Antiplatelet or anticoagulant medications were also documented, and patients were routinely allowed to continue their medications.
Standard surgical room equipment included disinfectant, local anesthetic, needles, and compression dressings. Under local anesthetic, lidocaine 1% with adrenaline 1:200,000, tumor excision with appropriate safety margin according to the recommended guidelines was performed, 3 mm for clinically suggestive basal carcinoma and 5 mm for clinically favorable squamous cell carcinoma (SCC). A donor site on the anterior thigh of the same leg was marked out and infiltrated with local anesthetic. The pinch grafts were harvested from the thigh using either a needle penetrating the skin horizontally or forceps to elevate a cone of the skin followed by transverse tangential shaving of the pinch grafts through using a No. 11 scalpel blade [Figure 1] and [Figure 2].
|Figure 1: The use of a needle and scalpel No. 11 to harvest the pinch graft from the thigh|
Click here to view
|Figure 2: The use of forceps to pinch the graft from the thigh with tangential cut through using scalpel blade No. 11|
Click here to view
Each pinch graft was approximately 8–10 × 6–8 mm and composed relatively of full-thickness skin in the center and a split-thickness graft at the periphery. Depending on the area to be covered, a variable number of Reverdin pinch grafts were placed on the wound bed piece-by-piece in a mosaic pattern with a spacing of approximately 5 mm between [Figure 3].
|Figure 3: Multiple pinch grafts placed in the position to cover a surgical defect on the lower leg|
Click here to view
Postoperatively, the wound was protected with nonadhesive silver-coated gauze. Sterile cotton gauze was subsequently fixed in place by adhesive plaster with adequate pressure on the wound. After excluding peripheral arterial occlusive disease, compression was applied to the lower leg using one or two bandages [Figure 4]. The compressive bandage was renewed after 3 or 4 days. The wound dressing itself was replaced after 7–10 days but not earlier. After the first replacement, it was replaced twice a week for the next 2–3 weeks and then weekly, if required. The graft donor site wound is serially padded with silver-coated gauze, sterile cotton gauze, and an adhesive plaster.
|Figure 4: Compression is applied to the lower leg using one or two bandages|
Click here to view
The only restrictions on activities were bathing/showering and physical activities, such as sport, cycling, and long walks, to minimize the risk of wound infection or protracted wound healing. The wounds were checked twice each week in the first month then weekly until 3 months, then monthly for the next 6 months. The scars were inspected irregularly for a follow-up period of 1–6 years.
| Results|| |
The range of patients' age was 46–93 years (median 75.4 years ± standard deviation [SD] of 9.88) with a female predominance of 56%.
After skin tumor excision on the lower leg, the wound sizes ranged from 17 to 30 mm with a median of 20 mm ± SD of 2.7 mm. The histology was reported as follows: 12 (34%) basal cell carcinomas, 14 (40%) SCCs, 8 (22%) Bowen's disease (SCC in situ), and 1 (2.8%) keratoacanthoma [Table 1].
The average healing time, defined as the time point where no further wound care was required anymore, was 4 weeks ± 1.12 weeks with a range of 3–7 weeks.
In 10 of 35 patients (28.6%), partial failure of one or two single pinch grafts per defect was observed. This presented as black-brown crusting of one or two pinch grafts and healed by granulation without the need for debridement. There were no cases of total graft failure. No keloid or hypertrophic scarring was observed among all treated patients up to 6-year follow-up [Figure 5] and [Figure 6].
|Figure 5: Healing of Reverdin pinch grafts after 1 year of performing the surgery|
Click here to view
Two of 35 patients (5.7%) were prescribed systemic antibiotics for possible wound infection. Postoperative hemorrhage occurred in one patient (2.8%) requiring further hemostasis, 3 h later. This patient was taking rivaroxaban. Although a total of six patients (17%) were taking other anticoagulants such as phenprocoumon or aspirin, no other cases of postoperative hemorrhage were observed.
Basal cell carcinoma occurred adjacent to the scar on the lower leg in one patient (2.8%). In this case, it was not obvious if this was a recurrence or a new basal cell carcinoma as initial histology was reported as having clear margins.
There were no cases of severe protracted wound healing and no total surgical site failure, defined as loss of half the grafted tissue or the need for further graft surgery. In all 35 patients, we never observed any complications at the donor sites.
| Discussion|| |
Small surgical defects, <11 mm in diameter, on the lower leg, such as after skin cancer excision are usually closed by primary side-to-side closure. This is an established method to close small defects as it results in fast wound healing with fewer complications whereas larger lower leg defects of more than 45 mm diameter generally require skin grafts or flaps for closure. However, they require special surgical skills and extended periods of immobilization with possible protracted wound healing, deep venous thrombosis, and surgical site failure.,
A prospective observational study of Stankiewicz et al. included 73 participants with lower limb defects, with either primary side-to-side closure or by split-skin graft. They reported an overall surgical site failure rate of 53.4%, with a higher failure rate in the grafted wounds than with primary closures, 66% versus 26.1%.
Halo grafting after surgical removal of NMSC has the advantage of avoiding two surgical sites with a healing time of 3–4 weeks comparable to our results. However, postoperative bleeding and infection rates were higher than in our small series. There remains debate about using the tumor peripheral tissues as donor graft because of the concept of field cancerization.,
To the best of our knowledge, this is the first published report using Reverdin pinch grafts as an alternative, simple closure method for medium-large defects (11–45 mm) following excision of NMSC on the lower leg. It is an inexpensive, simple, and easy technique without serious complications. It can be performed in offices by surgically trained medical staff with no need for hospitalization or immobilization, and it is especially useful for defect closure in elderly patients where other surgical options are limited. Partial graft failure occurred in only ten patients (28.6%).
However, we acknowledge our study has limitations. This was a retrospective series of nonconsecutive patients, and the number of patients was small.
First described by the Swiss surgeon Jacques-Louis Reverdin in 1869, Reverdin's invention opened a new era to apply autologous tissue transplantation for management and acceleration of wound healing process. The pinch graft technique had widely used in European countries as a simple and effective treatment option for leg ulcers of different underlying pathologies. Nonetheless, it has gradually substituted by the newly and more convenient leg ulcer management.
Depending on the underlying cause of leg ulcer, a total cure rate ranged between 38% and 56% and the time required for complete healing after using this technique to treat leg ulcers was 9.4 weeks.
The median healing time demonstrated in our study was 4 weeks which is significantly shorter than that needed for leg ulcer. Such longer resolution phase for pinch grafting of leg ulcers can be explained by the associated pathologic processes of the different types of leg ulcer.
Lawrence Field already demonstrated the success and good outcome of closing leg wounds with pinch grafts harvested from the thigh or anterior abdomen in his presentation at the 18th Annual Meeting of International Society for Dermatologic Surgery.
Our data suggest that pinch grafting is a very useful method to spare time and money where the patients can be comfortable at home during the resolution phases. Hospitalization and immobilization are not required, thereby decreasing its associated problems. Furthermore, it is an applicable and easy procedure for any dermatologist with sufficient surgical knowledge.
We acknowledge this work to Dr. Jack-Reverdin, who opened the doors for the concept of tissue grafting, where his ancient method is still valid and applicable even in the era of modern medicine.
| Conclusion|| |
The Reverdin pinch graft technique will not replace primary side-to-side closure for small leg defects as wound healing, and cosmetic outcome is still superior. However, for medium-large defects on the lower leg in patients with coexisting morbidities or elderly patients, it is an effective, easy to perform, and relatively safe closure method to consider. Further studies involving larger sample sizes or having head-to-head comparison to other surgical approaches of the leg are recommended.
The author would like to thank Dr. Delwyn Dyall-Smith, a dermatologist from Australia, who helped us in the scientific and linguistic corrections.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lomas A, Leonardi-Bee J, Bath-Hextall F. A systematic review of worldwide incidence of nonmelanoma skin cancer. Br J Dermatol 2012;166:1069-80.
Viertel Centre for Research in Cancer Control (VCRCC). Summary Report 2004-2008; 2014. Available from: http://www.cancerqld.org.au
. [Last accessed on 2014 Mar 04].
Amici JM, Rogues AM, Lasheras A, Gachie JP, Guillot P, Beylot C, et al.
A prospective study of the incidence of complications associated with dermatological surgery. Br J Dermatol 2005;153:967-71.
Marek DJ, Copeland GE, Zlowodzki M, Cole PA. The application of dermatotraction for primary skin closure. Am J Surg 2005;190:123-6.
Reverdin JL. Sur la greffe epidermique. Arch Med General Paris 1872;19:276-303.
Davis JS. The use of small deep skin grafts. JAMA 1914;63:985-9.
Cancer Council Australia and Australian Cancer Network. Basal Cell Carcinoma, Squamous Cell Carcinoma and Related Lesions – A Guide to Clinical Management in Australia. Sydney; 2008. Available from: http://www.cancer.org.au
. [Last accessed on 2010 Jul 20].
Oien RF, Hansen BU, Håkansson A. Pinch grafting of leg ulcers in primary care. Acta Derm Venereol 1998;78:438-9.
Audrain H, Bray A, De Berker D. Full-thickness skin grafts for lower leg defects: An effective repair option. Dermatol Surg 2015;41:493-8.
Achauer BM, Guyuron B, Coleman JJ, Ericson E, Russell CR, Vander Kolk CA. Plastic Surgery: Indications, Operations and Outcomes. St. Louis: Mosby; 2000.
Dixon AJ, Dixon JB. Reducing opposed multilobed flaps results in fewer complications than traditional repair techniques when closing medium-sized defects on the leg after excision of skin tumor. Dermatol Surg 2006;32:935-42.
Stankiewicz M, Coyer F, Webster J, Osborne S. Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients. Dermatol Surg 2015;41:775-83.
Fietz D, Sivyer G, O'Brien D, Rosendahl C. The halo split skin graft in the management of non-melanoma skin cancer of the leg: A retrospective study. Dermatol Pract Concept 2013;3:43-9.
Paul SP, Phil M. “Halo” grafting – A simple and effective technique of skin grafting. Dermatol Surg 2010;36:115-9.
Ahnlide I, Bjellerup M. Efficacy of pinch grafting in leg ulcers of different aetiologies. Acta Derm Venereol 1997;77:144-5.
Vilalta A, Molgó M, Martí RM, Mascaró JM. Free laminar thin band graft – A surgical therapeutic variant in the treatment of leg ulcers. J Dermatol Surg Oncol 1987;13:1344-7.
Christiansen J, Ek L, Tegner E. Pinch grafting of leg ulcers. A retrospective study of 412 treated ulcers in 146 patients. Acta Derm Venereol 1997;77:471-3.
Field L. Full Thickness Grafts – Tricks and Caveats, Presentation at 18th
Annual Meeting of International Society for Dermatologic Surgery. Amsterdam, Netherlands; 1997.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]