Check Out This LARGE Forehead Mohs Defect and How it Was Repaired 😳!

Above is a case study of one of the largest forehead Mohs defects I have repaired of date.

As you can see, her forehead did not have much reservoir, was taut, and I was unable to completely close the defect primarily.  Instead of performing a flap (which would have involved creating a secondary defect and a larger repair) or have the wound heal by second intention (which would have required longer healing time, more wound care, and possible contraction), I chose to repair this oh-so-large wound with a…BUROW’S GRAFT.

WATCH VIDEO

Watch this video I created to help you understand how to perform this technique 🎥 HERE.

Just a pearl to remember…If you ever come across a very high tensioned surgical wound like this...SAVE THE DOG EARS (you may need em’!)!

Another important highlight is that you are able to code this repair as a graft repair (opposed to a primary closure repair) and reimbursement is credited much higher (always get credit for all your hard work and skill! You deserve it!)

Here are pearls to remember when it comes to use of a Burow’s Graft…

APPLICATION 

  • For high tensioned areas that cannot be completely closed primarily
  • Dog ear(s) used as a Full-Thickness-Skin-Graft (FTSG)
  • A great alternative option if a flap or second intention healing is not ideal

Additionally, I like this option because it is the patient's own skin (the dog ears) that would have, otherwise, been discarded.

A second wound did not have to be created in order to get that donor skin.

The patient will not have any part of the wound exposed.

The wound will heal faster if the graft "takes" (is viable) and less wound care needs to be performed.

Also, worst case scenario, if the graft does not "take" (necrosis), it will form a scab. We typically keep the scab there and use it as a “biological", natural dressing so the wound is not exposed.  The wound will granulate underneath. Once the wound is healed underneath, we allow the scab to naturally fall off.  

So either way, the patient will eventually heal and no loss there because…again…the dog ear(s) would have been discarded anyway…and if the graft ends up not "taking", the scab serves another purpose 🙌🏼.

With a Burow’s Graft, you can use both dog ears (as I did in this large forehead case study) or one dog ear, depending on the size of the defect. 

LEG CASE STUDY UTILIZING A BUROW'S GRAFT

Here is an example of a lower leg Mohs defect repaired with a Burow's Graft where I used both dog ears.

 

In the picture on the left, it shows you where the dog ears were removed (blue dotted lines) at the superior and inferior apex of the wound.

In the middle picture you can see that once the defect was closed, I was not able to close the wound completely due to the marked tension.

In the very right picture, I sutured both dog ears together (using 5-0 Plain Gut), and then used it as a FTSG closing the remaining defect. 

SCALP CASE STUDY UTILIZING A BUROW'S GRAFT

Here is another Burow's Graft repair example on a scalp Mohs defect utilizing only the inferior dog ear ...

You can see the graft sewn in place in the middle picture.  

In the right picture, it is the patient's 1 week postop follow up. The graft "took" (is viable) beautifully as you note the purple-colored skin (a reassuring color at this point in healing). 

TAKE HOME POINTS

So, for a recap…

These are the reasons you can opt to choose this repair.  The benefits of a Burow’s Graft repair are:

  • Donor site is retrieved from the dogear (s) that would have, otherwise, been discarded 
  • A second wound does not need to be created in order to obtain donor skin
  • Allows area of wound that cannot be completely closed to heal faster 
  • FTSG enables coverage opposed to having an opened & exposed wound
  • FTSG potentially becomes a biological dressing if graft does not "take" (necrosis)

LEVERAGE YOUR SKILLS

If you found this article helpful and want to dive deeper into building your confidence in your surgical skills, I created an advanced suturing course tailored specifically for dermatology NPs/PAs that will break down how to perform this technique along with other suture techniques, step-by-step.  

The course will help you minimize scarring and improve your patients’ outcomes. If this sounds like a course that will help leverage your skills, click HERE to learn more!

Serving with GRATITUDE,

Theresa Talens DNP, FNP-C (TheresaSurgDermNP)

P.U.L.S.E. Dermatology & Procedures, Inc.