Management of a Necrotic Flap in a Cutaneous Squamous Cell Carcinoma Requiring Adjuvant Radiation Therapy

Mohs micrographic surgery (MMS) is the standard of care for operable high-risk cutaneous squamous cell carcinomas (CSCC) [1], and adjuvant radiation therapy (RT) has been shown to reduce the risk of locoregional recurrence in select high-stage tumors [2]. Adjuvant RT is initiated as early as possible for maximum benefit, ideally within 6 weeks of surgery [3]. For this reason, layered closures, flaps, and grafts are preferred over secondary intention healing. Optimal repair type also depends on the size, depth, and location of the defect; for example, grafts are typically avoided in defects with exposed calvarium. Surgical site necrosis can prolong healing, impair free margins, and lead to poor functional and cosmetic outcomes. The traditional approach is to allow for secondary intention healing and consider revision at a later date [4]. However, this is not a suitable approach for cases requiring adjuvant RT, as prolonged healing times can delay the initiation of treatment. In these cases, we advocate for a short period of secondary intention healing followed by debridement and surgical revision. A 77-year-old man with a Brigham and Women's Hospital Stage T2b CSCC (3.7-cm diameter, poor differentiation, depth to subcutis, and perineural invasion [PNI] measuring 0.12 mm in the subcutis) of the right cheek underwent 2 stages of MMS with clear margins. The defect was repaired with a rotation flap, and the patient was referred for adjuvant RT. Unfortunately, he presented the following week with extensive flap necrosis (Figure 1a). Mechanisms were unclear, as he was a non-smoker, was not diabetic, and the necrosis was already advanced at presentation; vasculopathy, infection, hematoma, and excessive undermining were all potential contributing factors. Initial management included oral doxycycline, dilute vinegar soaks, and meticulous wound care. Two weeks later, the wound had improved with a less adherent eschar and granulation tissue (Figure 1b). The patient underwent sharp debridement of the overlying eschar, gentle curetting of the wound base and edges, and full thickness skin grafting from the neck. The graft healed in 3 weeks, and the patient was able to start adjuvant RT 6 weeks after MMS (Figure 2a). The patient did not experience any healing complications during RT (Figure 2b). This strategy allowed the patient to start RT within the optimal timeframe and achieved a good functional and cosmetic outcome. Furthermore, this outpatient procedure was performed under local anesthesia, minimizing cost and morbidity. Limitations of this approach include a higher risk of graft failure on an inflamed, necrotic site; however, the steps outlined above minimize this risk. Careful patient selection and close follow-up are paramount. Further research is needed to determine guidelines for optimal management of flap necrosis, particularly in the setting of adjuvant RT. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.