Postoperative Pallor as a Sign of Impending Necrosis

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Tissue necrosis due to suture tension is always a risk in high-tension closures on the scalp. It can be frustratingly difficult to gauge the maximal allowable tension in any given area, or the risk of ischemia and necrosis for any given scalp closure. Furthermore, suture techniques can contribute to this risk, further expanding on the unpredictable nature of scalp necrosis after simple repair. Herein, the authors describe a sign of impending necrosis on the scalp after primary closure of a Mohs surgery defect.
A 51-year-old man presented to the author's Mohs surgery clinic with a basal cell carcinoma on the vertex scalp. After 3 stages, the final defect measured 3.2 cm × 2.2 cm. A simple linear closure option was selected and approximation of skin edges was easily demonstrated with gentle manual force applied to the wound edges. The wound was closed with a running 4-0 Monocryl transepidermal suture, with placement of 2 simple interrupted Monocryl sutures to refine epidermal alignment. No buried subcutaneous sutures were used. At suture removal 2 weeks postoperatively, an area of full-thickness tissue necrosis completely surrounding the repair was noted. Photographs taken immediately postoperatively were scrutinized, and findings consistent with pallor and ischemia were observed (Figure 1). The presence of pallor surrounding the repair had been attributed to vasoconstriction due to epinephrine at the time of closure. However, photographs demonstrated that it was not present just before suturing. In actuality, it indicated tissue ischemia, and this sign should have served as a warning for impending necrosis.
In this particular case, easy approximation was noted before closure, and tension on the wound edges due solely to the resistance of tissue movement cannot explain the necrosis that occurred. A contributing factor may have been that the running spiral nature of the continuous suture technique was sufficient to tamponade the skin edge vessels, resulting in the observed necrosis. Interrupted simple, galeal,1 or pulley sutures2 may be better suited for scalp closure because of this risk, as these options place the force vectors parallel to the tissue movement and vasculature. Alternatively, it may be prudent to reexamine the closure within a day or 2 postoperatively to watch for necrosis and dehiscence. Regardless of the cause, the appearance of pallor at the time of scalp closure should be heeded as a warning, with immediate opening of the wound and alternative suturing considered.
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