Delayed surgical closure (secondary intention) using the Figueiredo technique: a case series study

Submitted on: 04/01/2023
Approved on: 07/03/2023

Financial support: None.
Conflict of interest: None.
How to cite this article: Carrai LHM, Rodrigues EF, Lima TFM, Sasseron MGM, Gomes Neto A. Delayed surgical closure (secondary intention) using the Figueiredo technique: a case series study. Surg Cosmet Dermatol. 2023;15:e20230212.

Abstract

Surgical wounds, when not amenable to primary healing, can be treated using surgical flaps or grafts, increasing surgery complexity and costs. Seeking to facilitate and optimize access to surgical treatment of malignant neoplasms of the skin, the dressing using the Figueiredo technique is a good therapeutic option due to its easy execution and reproducibility, low cost, and effectiveness. We report a series of cases using this technique after the excision of non-melanoma skin tumors in the extremities.

Keywords: Wound closure techniques; Surgical oncology; Skin neoplasms; Extremities

INTRODUCTION

The search for techniques to close significant skin defects is a challenge for surgeons. In 1984, the Bogotá bag technique was described for large abdominal defects. It consists of placing a sterile urine collection bag at a cost lower than other materials. It proved to be a simple and effective technique for a complex problem.¹

After the publication and description of the Figueiredo technique in 2017, the technique was expanded to fingertip repairs to avoid deformities due to non-treatment or poor handling of this type of lesion. The results were satisfactory with functional maintenance of the affected segment.²

In traumas with injuries to the nail bed, the bed was repaired and then protected with a polypropylene prosthesis obtained from the saline solution bag. After cutting the material in the exact shape of the wound’s bloody area, simple stitches were enough to fix the material on the edge of intact skin, thus accommodating the prosthesis perfectly without pressing the lesion.²

Unreliable recipient bed, repeated movement, trauma in the area, or infected wound contraindicate the skin graft.^3,4 The lower limb is a challenging site to graft because of the inevitable shear forces associated with walking. It led to the common practice of postoperative immobilization to increase graft success. Studies show that total skin grafting and slope immobilization increased graft take rates.⁵

Given the data, the Figueiredo technique became an interesting proposal to close extensive defects in extremities in dermatological surgery.

METHODS

We collected data from August 2021 to May 2022. Table 1 describes the inclusion and exclusion criteria.

Tumor excision was performed with 4 mm margins for basal cell carcinomas (BCC) and 5 mm margins for squamous cell carcinomas (SCC), following the National Comprehensive Cancer Network (NCCN) protocols. We made a cut on one side of the sterile saline bag with an extra margin of up to 5 mm from the defect. We chose the external face of the bag, without ink printing, to be in contact with the wound and fixed the dressing using simple stitches and nylon thread 0.5 to 1 cm apart until the dressing was comfortably accommodated. Patients were instructed not to wet or redo the external dressing during the first seven postoperative days. The proposed maintenance of the polypropylene cover was six weeks, following the Figueiredo technique description.

Description of cases

1 - An 80-year-old man presented a 2 cm plaque on the back of his left hand. We performed the excision with a margin of 5 mm, followed by closure with a polypropylene dressing. Anatomopathological examination demonstrated well-differentiated SCC with free surgical margins. The patient evolved uneventfully. He removed the polypropylene cover on the 28th postoperative (PO) day, with complete healing on the 35th postoperative day (Figure 1).

2 - An 89-year-old woman had an 8 cm tumor in the distal portion of her left arm. We performed the exeresis with a 5mm margin and closure with a polypropylene dressing. The anatomopathological examination was compatible with well-differentiated SCC with free margins. She evolved uneventfully (Figure 2).

3 - A 92-year-old woman presented an 8 cm tumor on the back of her right hand. She underwent excision with a margin of 5 mm and closure with a polypropylene dressing. The anatomopathological examination was compatible with well-differentiated SCC with free margins. On the 20th PO day, due to signs of surgical wound infection, we instituted antibiotic therapy with amoxicillin/clavulanate 500/125 mg every eight hours for seven days, with a good response. The dressing was removed on the 48th PO day. We observed the complete healing of the surgical wound (SW) on the 120th PO day (Figure 3).

4 - An 86-year-old man had a 1.5 cm plaque on the posterior side of his left leg. Incisional biopsy was compatible with well-differentiated SCC. We performed the exeresis with a margin of 5 mm, followed by closure using the Figueiredo technique. After an uneventful evolution, he removed the polypropylene dressing on the 61st PO day. We observed complete healing of the SW on the 120th PO day.

5 - An 88-year-old woman presented a 2.5cm plaque on her right leg. We performed the exeresis with a margin of 4 mm and dressing using the Figueiredo technique. The anatomopathological examination resulted in solid expansive BCC with free margins. The dressing was removed on the 56th PO day, followed by complete healing verified in the evaluation six months after the operation (Figure 4).

6 - A 94-year-old woman had a 3 cm plaque in the region of the left calcaneus. We conducted an incisional biopsy, and the histology was compatible with multifocal superficial BCC. Excision with a margin of 4 mm was performed and closed with a polypropylene dressing. The patient evolved uneventfully, and she removed the dressing on the 56th PO day with complete healing of the surgical wound.

DISCUSSION

Skin tumors of the extremities excised with adequate margins can generate an extensive primary defect with no possibility of primary healing. The alternatives are grafts, flaps, or healing by secondary intention.

In elderly patients, graft closure can present complications resulting from the deficient vascular supply in the extremities, making it challenging for the graft to take.^6,7 Also, we would have to perform a second surgical defect to obtain adequate skin thickness for grafting (donor area). Flaps are identically challenging in these regions: significant defects require long surgical times and large rotations, usually from adjacent areas that are equally photodamaged. Both techniques demand adequately trained and qualified professionals, in addition to a physical structure that includes a complete operating room, factors that, within the scope of the Brazilian public health system, commonly require long waiting times before arriving at a Service for more complex cases.

Healing by secondary intention with special dressings makes it difficult and expensive to treat the patient, burdening the public service since it uses complex and expensive materials and requires a nursing team duly trained in dressings to perform them.^8,9

The Figueiredo technique uses simple materials and does not require an advanced surgical method. This resource allows early skin tumor excision without the need for a tertiary-level service of the Brazilian health system, resulting in lower cost, higher resolution, and lower morbidity for patients.

We know that one of the key factors for proper lesion healing is adequate wound bed humidity. It is believed that the ideal amount of water favors chemotaxis and keratinocyte migration, leading to lesion closure.^9,10 The polypropylene cover used in the Figueiredo technique protects the surgical wound and creates an adequate humidity environment, benefiting the healing process by secondary intention.

In this case series, only one participant had a surgical wound infection, as described in table 2. We believe this complication occurred due to the hygiene care of the surgical wound. Because of the appearance of the dressing and the low level of education of the participants, some of them were afraid to conduct this cleaning at home.

We conclude that the closure of surgical wounds using the Figueiredo technique brings a new perspective, especially in terms of public health. Regarding the target audience (elderly, with comorbidities, low socioeconomic status), the Figueiredo technique is a fast, easy to access, and simple postoperative management, making it a good option, generating less morbidity for patients.

REFERENCES:

1. Neto JRT, Barreto AP, Prodente ACL, Santos AM, Santiago RR. Uso da peritoneostomia na sepse abdominal. Rev Bras Coloproct. 2007;27(3):278-83.

2. Figueiredo LA, Ribeiro RS, Melo ALB, Lima AL, Terra BB, Ventim FC. Uso da prótese de polipropileno para o tratamento das lesões em ponta de dedo. Descrição de técnica cirúrgica e resultados. Rev Bras Ortop. 2017;52(6):685–92.

3. Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg. 2011;127(1):5e-22e.

4. Sanniec K, Nguyen T, van Asten S, Fontaine J, Lavery LA. Split-thickness skin grafts to the foot and ankle of diabetic patients. J Am Podiatr Med Assoc. 2017;107(5):365-8.

5. Struk S, Correia N, Guenane Y, Revol M, Cristofari S. Full-thickness skin grafts for lower leg defects coverage: interest of postoperative immobilization. Ann Chir Plast Esthet. 2018;63(3):229-33.

6. Saliba-Jr OA, Giannini M, Rollo HA. Métodos de diagnóstico não-invasivos para avaliação da insuficiência venosa dos membros inferiores. J Vasc Bras. 2007;6(3):267-76.

7. Haddad-Filho D, Siervo JV, Nascimento JB, da Silva EL, Vieites L. Alternativas de retalhos cutâneos para lesões dermatológicas na perna. Surg Cosmet Dermatol. 2017;9(3):247-51.

8. Abbade LPF, Frade MAC, Pegas JRP, Dadalti-Granja P, Garcia LC, Bueno Filho R, et al. Consensus on the diagnosis and management of chronic leg ulcers - Brazilian Society of Dermatology. An Bras Dermatol. 2020;95(Suppl 1):1-18.

9. Malagutti W, Kakihara CT. Curativos, estomias e dermatologia: uma abordagem multiprofissional. São Paulo: Martinari; 2014.

10. Madden MR, Nolan E, Finkelstein JL, Yurt RW, Smeland J, Goodwin CW, et al. Comparison of an occlusive and a semi-occlusive dressing and the effect of the wound exudate upon keratinocyte proliferation. J Trauma. 1989;29(7):924-30.

AUTHORS' CONTRIBUTION:

Larissa Helena Marques Carrai 0000-0002-3851-4344
Approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; data collection, analysis, and interpretation; active participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical revision of the manuscript.

Evelyn Freitas Rodrigues 0000-0002-7540-2448
Approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; data collection, analysis, and interpretation; active participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical revision of the manuscript.

Thais Feres Moreira Lima 0000-0002-3170-9034
Approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; data collection, analysis, and interpretation; active participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical revision of the manuscript.

Maria da Glória Martin Sasseron 0000-0002-3170-9034
Approval of the final version of the manuscript; study design and planning; preparation and writing of the manuscript; data collection, analysis, and interpretation; active participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical revision of the manuscript.

Antonio Gomes-Neto 0000-0003-2349-1351
Approval of the final version of the manuscript; study design and planning; data collection, analysis, and interpretation; active participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical literature review; critical revision of the manuscript.