Charlene DeHaven demonstrates a simple cosmeceutical regimen to improve results following a malignancy excision from the face/lip and rotation flap graft reconstruction
Improvements in post-surgical results are desired by both physicians and patients. The psychological effects following plastic surgery to the face include social avoidance, anxiety, depression, and post-traumatic stress disorder (PTSD)1. These emotional difficulties are elevated for post-traumatic facial wounds compared to cancer treatment but are still of significant incidence in the post-reconstructive cancer patient. The subsequent emotional effects are more frequently witnessed in female patients1. A simple cosmeceutical regimen that improves post-reconstructive results and scarring could be helpful in these situations.
Following an excision of facial malignancy, healing time and outcome vary according to tumor invasion, defect size, graft type, and complications. For wounds with photos of the cheek and upper lip of similar size treated with rotation flap grafts, even allowing for increased healing time, cosmetic results were inferior compared to the patient in this case report2. In the referenced article by Markus, results at two to six months post-rotation flap grafts were not as cosmetically acceptable as in this case at 15 days in spite of very similar clinical situations.
Rotation flap grafts allow for mobilization of adjacent tissue with an intact blood supply to cover surgical and traumatic defects3. Their wide vascular supply makes for fewer ischemic complications, but they are otherwise subject to the same types of complications as other facial reconstructive grafts2. These include wound dehiscence, hematoma, infection, unacceptable scar outcome with aesthetic concerns, chronic pain, vermillion border misalignment, and flap necrosis4. In addition, rotation flap grafts may be complicated more frequently by tenting, bleeding, and nerve damage related to the extensive undermining and trimming2.
Patient description and diagnosis
A 51-year-old female with Fitzpatrick II skin type had noticed a lesion just above the vermillion border of her right upper lip 4 years prior to surgery. During that time, she had consulted with dermatologists about the lesion multiple times and had several scraping biopsies — all of which returned negative for malignancy. The lesion was also cold cauterized several times. She was told it was a scar from a prior injury although she did not recall a prior injury there and pressed the issue. A punch biopsy in September 2016 showed sclerosing basal cell carcinoma. Mohs surgery was recommended and performed in the operating suite in October 2016 with flap graft reconstruction by a plastic surgeon the following day on post-operative Day 1. Sutures were removed on post-surgical Day 8 for the face and Day 14 for the lip.
This patient had generally healed well in the past from prior surgeries. One prior ankle scar had been hypertrophic.
Postoperative wound care
The patient’s plastic surgeon recommended their usual initial wound care, which consisted of covering the wound with petrolatum-based Aquaphor (Beiersdorf Inc., Wilton, CT, USA) during the first 12 hours following the initial surgery. On post-operative Day 1, flap graft reconstruction was performed in the operating suite. Following graft placement, the patient’s regimen consisted of cleaning the wound with hydrogen peroxide morning, evening, and several more times throughout the day, as well as application of a cosmeceutical post-procedure healing balm every 2 hours. On Day 3, the patient discontinued wound cleaning with hydrogen peroxide and used a cosmeceutical cleanser in the morning and evening. Also on Day 3, she began applying one drop of a cosmeceutical serum four times per day to the wound followed by the post-surgical healing balm. On Day 8, after removal of the facial sutures, she decreased application of the serum and healing balm to morning and evening. Lip sutures were removed on Day 14, and she began applying a cosmeceutical sunscreen in the morning prior to going outside. Figure 1 consists of images taken at each of these time periods.
Post surgical regimen instructions
- Day 0: Mohs surgery excision of sclerosing basal cell carcinoma. Cover wound with petrolatum jelly for the following 12 hours
- P/O Day 1: Reconstruction of upper-lip and face with rotation flap graft. Clean wound with hydrogen peroxide BID and several more times throughout the day. Apply a generous amount of cosmeceutical post-procedure balm to the surgical site every 2 hours
- Day 3: Discontinue cleaning with hydrogen peroxide. Clean wound gently BID with cosmeceutical cleanser. Apply one drop cosmeceutical serum to scar area followed by generous amount cosmeceutical post-procedure balm four times each day. Always keep wound moist with post-procedure balm.
- Day 8: Facial sutures removed. Decrease application of cosmeceutical serum and post-procedure balm to BID
- P/O Day 14: Lip sutures removed. Apply cosmeceutical sunscreen SPF30 prior to going outside. Return to usual cosmeceutical regimen.
Discussion and summary
The cosmeceutical products used contained ingredients targeted to the following actions*:
- Gentle but thorough skin cleansing — botanically based alpha-hydroxy acids and beta-hydroxy acids
- Skin barrier protection and fortification — bio-identical botanical skin barrier lipids
- Orderly collagen synthesis and prevention of hypertrophic scarring— copper tripeptide-1 growth factor5 that has regulatory approval in all countries
- Antioxidant protection — botanical antioxidants
- Anti-inflammatory protection — these include botanical anti‑inflammatories/antioxidants
- The prevention of post-inflammatory hyperpigmentation — botanical lighteners/brighteners (non-hydroquinone)
- Sun protection — micronized zinc oxide, micronized titanium dioxide, micronized encapsulated octinoxate, and SPF30
- DNA damage protection6 — botanical antioxidants, sunscreen actives, Extremozymes™.
This case report of rotation flap graft reconstruction following Mohs surgery for sclerosing basal cell carcinoma of the face and lip demonstrated accelerated surgical recovery. This is thought to be related to a regimen of post-operative wound care incorporating cosmeceutical products. This case report suggests that improvements in surgical results can be achieved with a well-designed post-surgical cosmeceutical regimen.
Limitations of this article include that it is a single case report lacking a large sample size. The patient herein had Fitzpatrick II skin and had healed without complications from prior surgeries except that one prior ankle scar had been initially hypertrophic.
Declaration of interest Dr. DeHaven is Clinical Director for INNOVATIVE SKINCARE, USA, maker of iS CLINICAL products.
Figure 1 © Dr DeHaven
* Products used were manufactured by INNOVATIVE SKINCARE, USA, maker of IS CLINICAL cosmeceuticals.