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has been highest in patients receiving warfarin.2–4 Clopidogrel also has been associated with risk of postoperative hemorrhage.2 Although risk of postoperative hemorrhage may be a little higher in patients receiving aspirin, a statistically significant association has never been demonstrated.2,3

4. Otley CC, Fewkes JL, Frank W, Olbricht SM. Complications of cutaneous surgery in patients who are taking warfarin, aspirin, or nonsteroidal anti-inflammatory drugs. Arch Dermatol 1996;132(2):161–6. 5. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, et al. Perioperative management of antithrombotic therapy: antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl 2):e326S– 50S.

Of frequent debate among dermatologic surgeons is what should be done with regard to anticoagulant therapy before dermatologic surgery. Bleeding after surgery is potentially inconvenient to manage and may expose patients to additional procedures or affect final cosmetic outcome, but postoperative bleeding from a dermatologic procedure is easier to manage than a stroke or embolus that may happen during discontinuation of drugs. In 2012, the American College of Chest Physicians recommended continuing warfarin or aspirin perioperatively and optimizing local hemostasis during minor dermatologic procedures.5 There may be instances in which reduction or cessation of anticoagulation is warranted. In such instances, the decision is best made on an individual basis with the explicit involvement of the prescribing provider. Cessation of anticoagulation before dermatologic surgery does not appear warranted under usual circumstances.

JENNA L. O’NEILL, MD ARASH TAHERI, MD Department of Dermatology Center for Dermatology Research School of Medicine Wake Forest University Winston-Salem, North Carolina JAMES A. SOLOMON, MD, PHD Division of Dermatology Department of Medicine College of Medicine University of Central Florida Lake Nona, Florida; Division of Dermatology Department of Medicine College of Medicine University of Illinois Urbana-Champaign, Illinois; and Ameriderm Research Ormond Beach, Florida

References DANIEL J. PEARCE, MD Department of Dermatology Center for Dermatology Research School of Medicine Wake Forest University Winston-Salem, North Carolina

1. Merritt BG, Lee NY, Brodland DG, Zitelli JA, et al. The safety of Mohs surgery: A prospective multicenter cohort study. J Am Acad Dermatol 2012;67(6):1302–9. 2. Bordeaux JS, Martires KJ, Goldberg D, Pattee SF, et al. Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications. J Am Acad Dermatol 2011;65(3):576–83. 3. Lewis KG, Dufresne RG Jr. A meta-analysis of complications attributed to anticoagulation among patients following cutaneous surgery. Dermatol Surg 2008;34(2):160–4.

Successful Treatment of Nonhealing Scalp Wounds Using a Silicone Gel The scalp may be prone to poor healing because surgical wound closures are often under high tension in this area, and the scalp is prone to diffuse

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actinic damage. Silicone may have properties that are ideal for the encouragement of healing in scalp wounds. We encountered four cases of nonhealing

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scalp wounds, all of which were characterized by exuberant granulation tissue and a lack of epidermal migration present for at least 2 months after an inciting event. For each patient, applying a filmforming silicone-based gel (Stratamed, Stratpharma, Basel, Switzerland) directly over the wound as monotherapy, without a secondary dressing, was associated with better wound healing.

Case 1 An 89-year-old man had Mohs surgery for squamous cell carcinoma of the scalp. The defect was repaired using a full thickness skin graft that partially necrosed. Exuberant granulation tissue was treated with intermittent debridement for 4 months. At that point, the patient presented with a nonhealing wound (Figure 1) and began daily treatment with the silicone gel. Improvement was noted after 1 week, with less granulation tissue and epithelial migration noted at the edges (Figure 2). Approximately 7 weeks after starting the silicone gel, most of the wound had healed, although small areas remained unhealed. These areas had exposed bone, devoid of periosteum. The patient was instructed to continue use of the silicone gel and was seen 6 months later with complete healing.

Figure 1. Eighty-nine-year-old man 4 months after surgery before starting therapy with silicone gel.

Case 2 A 90-year-old man presented with a nonhealing wound 2 months after Mohs surgery for squamous cell carcinoma. Over the following 2 years, the wound was unsuccessfully treated with intermittent debridement using silver nitrate, two attempts at skin grafting, and a topical steroid for a period. The steroid led to some improvement, though a relapsing course was noted while it was used. Skin biopsies at the times of the grafts showed 1) an area of squamous cell cancer in situ with abundant

Figure 2. Eighty-nine-year-old man 1 week after using the silicone gel twice daily. Note the areas of crusting, which were devoid of periosteum.

Figure 3. Ninety-year-old man 2 years after surgery before starting therapy with the silicone gel.

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granulation tissue and 2) only abundant granulation tissue. 2 years after the original surgery, the patient presented with a non-healing wound (Figure 3), at which point he began daily application of the silicone gel. At first, the patient also used a topical steroid daily. After 3 weeks, he presented with little to no excessive granulation tissue and evidence of epidermal migration. He then discontinued the steroid and continued use of the silicone. Two weeks later nearly complete healing was noted (Figure 4). The patient was seen every 2 weeks, achieving and maintaining complete healing for 2 months until he died from unrelated causes.

Case 3 A 73-year-old man had Mohs surgery for a squamous cell carcinoma of the scalp followed by a primary closure. He presented 2 months after Mohs surgery with a non-healing wound. The wound was treated with mupirocin 2% ointment daily for 1 month without improvement. At this point, the patient began daily treatment with the silicone gel. Two weeks later the patient showed improvement, with evidence of epithelial migration. Two weeks after that, the lesion was completely healed, at which point he stopped using the silicone gel. The wound remained healed until follow-up 6 months later.

Figure 4. Ninety-year-old man 5 weeks after using the silicone gel twice daily.

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Case 4 An 85-year-old woman presented with a nonhealing wound characterized by exuberant granulation tissue 2 months after electrodesiccation and curettage of a basal cell carcinoma of the temporal scalp. She began daily treatment with the silicone gel. At 6 weeks, the lesion was improved, with epithelial migration present and less granulation tissue. After missing several follow-up appointments, she was seen 6 months after starting the silicone gel, and her wound was completely healed. She stated that she had used the gel until the wound healed.

Discussion In these cases, nonhealing wounds developed in elderly patients with thin hair and actinic damage. Scalp wounds with intact periosteum left to heal by secondary intention have been shown to take an average of 7 weeks to heal.1 Nonhealing scalp wounds may take months or years to heal, as seen in our cases. Treatments are usually directed at the excessive granulation tissue with destruction using silver nitrate, curettage, or pulsed dye laser.2 Topical steroids have been used with good effect,3 probably because of their antiinflammatory and antiangiogenic effects. The topical gel used for our patients uses the unique properties of silicone in a formulation that may be ideal for these wounds. Nonhealing wounds are characterized by a lack of epidermal migration. Silicone-based dressings may favorably influence the electrical charges of a wound environment, which have been shown to influence epidermal migration.4 The silicone gel used for these patients is semiocclusive, maintaining moisture while being permeable to gases. Although moisture has been shown to be beneficial to wound healing, we hypothesize that the permeability and exchange of gases contributes to a better environment for epidermal migration in nonhealing wounds.5 Because of the hydrophobic nature of silicone, the film does not firmly adhere to underlying

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granulation tissue, which may allow epidermal migration to occur unimpeded underneath. A unique attribute of the silicone gel used for these patients is that it does not require a secondary bandage. It dries to form a bacteriostatic film, which may decrease exposure to bacteria, antigens, and irritation, inhibiting inflammation and, in turn, angiogenesis. This property may inhibit exuberant granulation tissue, which may inhibit epidermal migration. Although we believe that this gel was a major reason why all four patients had improvement and healing of their scalp wounds after a prolonged period of nonhealing, this case series was limited because it consisted of a small number of patients who underwent various prior treatments, one patient used a corticosteroid concomitantly, and there were no controls. A larger study without as many variables would be needed to determine whether a siliconebased gel should be standard treatment for nonhealing scalp wounds and possibly other wounds characterized by exuberant granulation tissue and epidermal migration arrest.

2. Wang SQ, Goldberg LH. Pulsed dye laser for the treatment of hypergranulation tissue with chronic ulcer in postsurgical defects. J Drugs Dermatol 2007;6:1191–4. 3. Jaffe AT, Heymann WR, Lawrence N. Epidermal maturation arrest. Dermatol Surg 1999;25:900–3. 4. Pullar CE, Isseroff RR. Cyclic AMP mediates keratinocyte directional migration in an electric field. J Cell Sci 2005;118:2023–34. 5. Mustoe TA. Evolution of silicone therapy and mechanism of action in scar management. Aesthetic Plast Surg 2008;32: 82–92.

EDWARD C. MONK, MD Westmed Medical Group New Rochelle, New York ERNEST A. BENEDETTO, MD Dermatologic Surgicenter Philadelphia, Pennsylvania ANTHONY V. BENEDETTO, DO, FACP, FCPP Westmed Medical Group New Rochelle, New York and Dermatologic Surgicenter Philadelphia, Pennsylvania The Stratamed material was supplied free of charge by Stratpharma, Basel, Switzerland.

References 1. Becker GD, Adams LA, Levin BC. Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngol Head Neck Surg 1999;121:751–4.

Transpositional Modification of the Posterior Auricular Pull-Through Flap: A New Twist Anterior auricular reconstruction is challenging because of the immobility of the skin of the conchal bowl and antihelix. Secondary intention and fullthickness skin grafts are commonly used but can result in undesirably long healing times for those who are hearing aid dependent or use custom-fitted ear protection.1,2 The “flip flop” or revolving door posterior auricular pull-through flap provides a local reconstructive flap option,1,3,4 but it is limited to use in areas of the ear closely associated with the scalp because of its short central pedicle. Here, we review and demonstrate the proper use of a novel

transpositional sling modification of the posterior auricular pull-through flap. This modification allows for greater pedicle length, thus minimizing tension, maximizing blood supply, and preventing attenuation of lateral auricular projection.

Relevant Anatomy Unlike anterior auricular skin, the skin of the posterior auricle is freely mobile.3,4 The vestigial auricularis posterior muscle lies deep to a loose subcutaneous layer in the posterior auricular sulcus. Arterial

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Successful treatment of nonhealing scalp wounds using a silicone gel.

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