Candy Closure: A Novel Technique for Closing Small Skin... : Journal of Marine Medical Society (2024)

INTRODUCTION

The proper assessment of the defect and selection of appropriate closure techniques decides the outcome of the closure of the defect. Primary closure involves direct approximation of the wound edges.^[1] Local advancement flaps are helpful tools in the armamentarium of reconstructive surgeons for primary closure. Many types of advancement flaps or sliding flaps are described. These flaps are moved by sliding or stretching of the skin.^[2,3] These flaps rely on the elasticity of the skin and redundant skin available close to the defect.^[4,5] Advancement flaps are random pattern flaps that draw blood supply from cutaneous skin vasculature.^[6-9]

Local advancement flaps offer benefits in the form of skin texture and color match and no donor site morbidity.^[1] These flaps are also helpful in hiding scars. Advancement flaps are generally named for the shape of the closed incision including the U-plasty, H-plasty, T-plasty, V-Y, Y-V, and east-west flap.^[4-6]

In our study, we describe a local advancement flap called the candy closure technique for closing defects using local tissue. In this technique, the defect is created in a rhomboid fashion, and the surrounding skin is used to close the defect using the advancement technique.

Objective

The objective of this study was to study the efficacy of the candy closure technique for the closure of small defects.

MATERIALS AND METHODS

This is a prospective study where patients are selected for excision of the lesion and closure of defect using local tissue using an advancement technique called candy closure technique. The study was conducted at the Multispecialty Hospital of the Indian Defense Forces from July 2018 to August 2023 for 5 years. All the patients presented with lesions that can be excised and defects that can be created or present with defects that can be covered with local flap are included in this study. The defect was closed using the candy closure technique.

Inclusion criteria

1. Patients with lesions that can be excised and defects can be closed using the candy closure technique
2. Patient with a defect that can be covered with candy closure technique.

Exclusion criteria

Patients with lesions or defects which is large and surrounding skin is not redundant to cover the defect.

Indication of candy closure technique

1. Defect where surrounding skin is redundant and can be used to cover the defect without tension on the suture line.

Contraindication

1. Defect where surrounding skin is not redundant for closure
2. Large defect that cannot be covered using the candy closure technique.

Candy closure technique

The procedure was performed under local anesthesia, regional anesthesia, or general anesthesia depending on the condition, age, and desire of the patient. The lesion was excised in rhomboid geometry. The lesion was excised in total. If the defect is present the defect is converted to a rhomboid shape. The sides of the rhomboid were measured. The flap was planned as per relaxed skin tension line and redundant skin in the surrounding area. After planning the flap was marked. Two triangles were marked on either side of the defect. The side of the triangle is 70% of the size of the side of the rhomboid. The triangles were excised up to the same depth of the defect. The final defect looks like a candy (i.e. why the name). Point 1 will close with B, Point 2 with Point C, Point 3 with Point D, and Point 4 with Point E. The final closure will look like a zigzag line. Figure 1 shows the diagrammatic representation in. The final suture line is tension-free. The case of an infected sebaceous cyst in the intermammary region is shown in Figures 2-12. More cases are shown in cases 2,3 and 4 in Figures 13-15.

The data were collected over 1 year of follow-up and postoperative complications. The data collected were subjected to descriptive and statistical analysis using XL stat software.

RESULTS

In our study, a total of 43 patients were included. The age of the patients ranges from 21 years to 63 years with average age of 36.37 years. There were 29 males and 14 females. The distribution of diagnosis is shown in Table 1. The most common diagnosis was infected sebaceous cyst 22 (51%), discharging sinus 5 (12%), carbuncle 4 (9%), nonhealing ulcer 9 (21%), and others 3 (7%).

The minimum size of the lesion was 1 cm × 1 cm and maximum size of the lesion was 8 cm × 8 cm and the average size of the lesion was 3 cm × 3 cm. The size of the defect ranges from 1.5 cm × 2 cm to 8 cm × 8 cm.

The distribution of defects as per location is depicted in Table 2. The most common location was back 18 (42%). The length of the scar varies from a minimum of 6 cm and a maximum of 19 cm with an average of 12.32 cm. The suture was removed from 14 days to 21 days with an average time of 15 days. Two patients had developed suture giveaway, one patient had seroma formation and one patient had delayed suture healing. The rest of the patients did not have any complications and recovered without any difficulty. The quality of the scar was fair in 9 patients and good in 34 patients.

None of the patients had any loss of flap. The scar was acceptable to all the patients. None of the patients had any recurrence of sebaceous cyst or postoperative surgical site infection.

DISCUSSION

Local advancement flaps are a useful tool for reconstructing skin defects.^[4] The advancement flap is characterized by sliding or stretching of the skin along a vector. This type of flap therefore relies on the elasticity of the skin and/or skin redundancy to facilitate closure of the defect.^[6,7,9] For reconstruction of tissue defects, several types of flaps are described such as local flaps, regional flaps, and free flaps. Flap surgery has many disadvantages, including a big scar and additional graft surgery.^[13] There are many benefits of advancement flaps like, skin color and texture match, minimum morbidity, and less scar load for the patient.^[4-6,10] Advancement flaps are named for the shape of the closed incision including the U-plasty, H-plasty, T-plasty, V-Y, Y-V, and east-west flap.^[4-6]

Here, we have described a flap called candy closure for closing defects using the advancement flap technique. In our study, we have operated on 43 cases.: In this study, the majority of patients were diagnosed with an infected sebaceous cyst (22), carbuncle (4), and a non-healing ulcer (9). All the patients recovered well without any loss of flap or any major complications. Only 4 patients had minor complications such as delayed suture healing, suture giveaway, and seroma formation. All the surgeries were performed in local anesthesia as a daycare procedure. The range of scar length varies from 6 cm to 19 cm. The defect was closed primarily using surrounding skin and the dressing was removed after 48–72 h. There was no requirement for frequent dressings, split skin graft, and flaps from regional or distant areas. This leads to an early return to work and high satisfaction with the patient. The scar is also less and the procedure is more acceptable to the patient.

Primary tissue motion is the direction in which the flap moves. The counter-movement of the surrounding tissue is called secondary tissue motion. There is no significant alteration in the direction or magnitude of the primary tension vector.^[9,11,12] For a given defect the site and magnitude of maximal tension required is identical to linear closure in advancement flap.^[10,12] The standing cones (Dog ear) may be created by an advancement flap.^[12]

In this technique the flaps are not raised but advanced and reappropriated and moved into each other. The vascularity of the flaps was not compromised and resulted in a robust flap with no loss of flap. Primary tissue tension is also distributed to both sides of the suture line. There is no formation of standing cones (Dog ear) in this technique. The scar is in a zigzag pattern which results in a broken and acceptable scar.

This procedure is better while closing small defects and where surrounding skin is redundant and can be moved in the primary direction. The skin match is good with an acceptable scar. The tension over the suture line is minimal and it leads to an acceptable scar. In comparison to the rhomboid flap, this is a better technique as the flap is not elevated so the vascularity of the flap is not compromised and no or minimal tension as there is no pivot point is formed. This will lead to better healing of the suture. Every procedure has its disadvantages. Advancement flaps can be done in the area where the surrounding skin is lax and redundant as is the case with candy closure.

CONCLUSION

Here, we conclude that candy closure is a safe and effective method of closing skin defects if the surrounding skin is lax and redundant. The number of cases in this study is less and further study with a large number of cases can establish the fact.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES