Cutting Edge: Practical Tips for Surgical Management of Skin Cancer

Todd Schlesinger, MD emphasized that optimal reconstruction begins before the first incision, with careful attention to tissue mechanics and wound tension. He highlighted practical techniques such as identifying lines of maximal extensibility rather than relying solely on relaxed skin tension lines, maintaining closure tension below 4 N/cm to prevent hypertrophic scarring, and strategic undermining to preserve perforator vessels. Flap refinements, including the use of M-plasty at pivot points, were presented as effective methods to improve reach and reduce contour deformities, while advanced suturing techniques such as the set-back dermal approach were shown to offload tension and promote durable eversion.

The session also addressed situations in which grafts offer advantages over flaps, particularly in cosmetically sensitive areas or medically complex patients. Key pearls included epidermal fenestration to prevent graft lift-off and the use of vacuum-assisted bolsters during the critical first 72 hours to support graft imbibition. Postoperative scar optimization strategies were reviewed, including prolonged taping for mechanical support and proactive counseling that scar maturation may take up to 18 months, helping to align patient expectations with normal wound biology.

Beyond reconstruction, Dr Schlesinger stressed the importance of integrated oncologic planning. Surgeons were cautioned against operating first in advanced disease, instead coordinating neoadjuvant systemic therapy or radiation when appropriate and using immunostains for precise melanoma margin assessment. Regulatory updates on skin substitutes and the role of adjuvant photodynamic therapy for surrounding actinic damage further reinforced a comprehensive, multidisciplinary approach to skin cancer management.