INTRODUCTION

Squamous cell carcinoma (SCC) is a malignant tumor of epidermal keratinocytes that invades the dermis and can generate metastases. It has a higher incidence in individuals over 50 years old, with the main etiologies being: sun exposure and carcinogenic agents¹.

The most affected sites are the scalp, back of the hands, lower lip, ears, face, buccal mucosa, and external genitalia¹.

The clinical characteristics of the lesion range from erythematous papules or plaques with a scaly or crusted surface to hyperkeratous nodules, often with a verrucous appearance¹.

A biopsy confirms the diagnosis, and the staging is performed according to the TNM table. In addition to tumor resection, lymph node dissection and treatment of metastases may occur, if necessary².

This study aims to describe the suture by Góes et al.³ as a complement to the parascapular flap4, used reconstructively after the excision of SCC.

CASE REPORT

The patient, 50 years old male, white civil construction assistant, sought care due to an ulcerated lesion measuring 5.7 x 5.2 cm on the left shoulder, with the appearance of SCC, confirmed by biopsy (Figure 1).

Figure 1 - Ulcerated lesion measuring 5.7 x 5.2cm.

Figure 1 - Ulcerated lesion measuring 5.7 x 5.2cm.

Preoperative tests (laboratory and cardiological) were performed, which were normal and with surgical risk grade 1. After the demarcation of the tumor area with oncological safety margins, the patient underwent general anesthesia and was positioned in the right lateral decubitus position (Figure 2).

Figure 2 - Patient in surgical positioning.

Figure 2 - Patient in surgical positioning.

The lesion was resected with oncological margins and sent for anatomopathological examination, with the result of invasive squamous cell carcinoma grade 3 of differentiation, invasion to the subcutaneous tissue (Class V), free margins, no angiolymphatic involvement detected, and no perineural invasion.

A parascapular flap⁴ was demarcated, measuring (21cm x 6.5cm), based on the parascapular artery, a branch of the left axillary artery (Figure 3).

Figure 3 - Demarcation of the parascapular flap.

Figure 3 - Demarcation of the parascapular flap.

The flap was elevated and rotated to reach the left shoulder region (Figures 4 and 5) and sutured to its new bed with nylon 3-0 and 4-0. This completely covered the tumor resection area.

Figure 4 - Elevation and rotation of the parascapular flap.

Figure 4 - Elevation and rotation of the parascapular flap.

Figure 5 - Elevation and rotation of the parascapular flap.

Figure 5 - Elevation and rotation of the parascapular flap.

The donor area of the flap was repaired by advancing the local flaps and suturing with 3-0 and 2-0 nylon (Figure 6).

Figure 6 - Donor region repair with 3-0 and 2-0 nylon.

Figure 6 - Donor region repair with 3-0 and 2-0 nylon.

After 24 hours, there was a suture dehiscence in the distal part of the flap and pain at its extremity due to venous congestion (Figure 7).

Figure 7 - Dehiscence at the distal end of the parascapular flap.

Figure 7 - Dehiscence at the distal end of the parascapular flap.

Cyclic and continuous traction of the cutaneous margins3 was used to close the bloody area and a small part was partially left for healing by second intention (Figure 8).

Figure 8 - Use of the Góes Suture for partial closure of the dehiscence.

Figure 8 - Use of the Góes Suture for partial closure of the dehiscence.

The distal end of the parascapular flap⁴ with venous congestion evolved to dry necrosis of an area larger than the initial one, which did not require debridement (Figure 9).

Figure 9 - Dry necrosis at the distal end of the parascapular flap.

Figure 9 - Dry necrosis at the distal end of the parascapular flap.

The patient was followed up, requiring radiotherapy treatment, with good evolution and adequate surgical wound healing (Figures 10 and 11).

Figure 10 - Late postoperative after radiotherapy.

Figure 10 - Late postoperative after radiotherapy.

Figure 11 - Late postoperative after radiotherapy.

Figure 11 - Late postoperative after radiotherapy.

DISCUSSION

The literature cites numerous methods for covering the reported defect, including skin graft⁵, latissimus dorsi myocutaneous flap⁶, trapezius myocutaneous flap⁷, and microsurgical flaps⁸. The preference for the parascapular flap⁴ is due to its greater ability to cover large areas, in addition to muscle preservation compared to other myocutaneous flaps, which generate great functional loss, requiring long periods for compensation, as is the case with the latissimus dorsi⁶ and trapezium flaps⁷.

Treatment with microsurgery⁸ is highly specialized, and our Service does not have the proper equipment, so we cannot perform it.

Due to the patient’s profession (civil construction assistant), the skin graft⁵ would inevitably suffer loss with the work activity, causing a poor prognosis.

The parascapular flap⁴ is described in the literature with a length of up to 30 cm. Considering the patient’s height of 1.82m, the length of the flap was adequate for its use, with the advantage of ensuring thick coverage - resistant to trauma and without muscle mobilization, allowing the patient to return to activities early.

Wound closure by skin traction, recommended in 2004 by Carlos Henrique Fröner S. Góes et al.³, was performed in the ward on the second postoperative day to correct the dehiscence. For this purpose, Prolene 2 thread was used, with insertion in the area posterior to the detachment, exteriorizing it inside the wound, towards the other margin, and the thread is wrapped through the needle with a catheter segment. A “U” was completed bilaterally by returning the thread in reverse. The two threads on each side were pulled simultaneously, bringing the edges together with a certain point of maximum tension. Through repeated traction, greater skin relaxation and the possibility of partial closure were promoted. This avoided performing a new procedure in a surgical center, which would cause great emotional stress to the patient and higher costs to the institution that maintains it.

The suture proved an efficient method, promoting partial closure of the defect (80% of the dehiscence area), ease, and reduced time to perform in addition to one-time residual defect correction.

CONCLUSION

The suture proposed by Góes et al.³ proved to complement the parascapular flap⁴ in covering the resection of large tumor areas, with the advantages of being low-cost and easy to perform. In addition, skin traction provided satisfactory correction of large postoperative dehiscence using a parascapular flap⁴.