Excision of Invasive Squamous Cell Carcinoma Complicated by Osteomyelitis and Tobacco Use: A Case Report

TL;DR

A 76-year-old man with a history of tobacco use developed a rare complication of osteomyelitis after treatment for invasive skin cancer.

Contribution

This case report highlights the rare but serious complication of osteomyelitis following Mohs surgery and wound healing in a tobacco user.

Findings

The patient developed a Pseudomonas aeruginosa infection and calvarial osteomyelitis after wound repair with biologic prosthetics.

Tobacco use and biologic prosthetics may have contributed to delayed healing and bacterial biofilm formation.

Successful recovery was achieved through excision, flap reconstruction, and antibiotic treatment.

Abstract

Squamous cell carcinoma (SCC) is a common type of skin cancer that can be treated through surgical excision using Mohs micrographic surgery (MMS) which results in minimal scarring and low complications. Soft tissue defects as a result of MMS that are too large to be primarily closed can be repaired with secondary intention healing through the use of biologic prosthetics that promote dermal regeneration and tissue remodeling with high success rates. Other non-surgical treatment options include chemotherapy (topical or systemic), radiation, or immunotherapy for advanced skin cancers. In this case, our patient is a 76-year-old male with a history of tobacco use who presented with ulcerative SCC and developed a necrotic soft-tissue infection of Pseudomonas aeruginosa complicated by calvarial osteomyelitis six weeks following wide excision of scalp SCC and wound defect repair with application of Integra® Bilayer Wound Matrix (Integra LifeSciences, Princeton, New Jersey, United States) to promote re-vascularization and tissue regrowth. The patient is currently recovering well after the excision of the necrotic scalp lesion and second-stage reconstruction with right scalp fasciocutaneous flap and full-thickness skin graft with proper antibiotic administration. Complications were likely due to delayed wound healing from post-operative cigar use increasing his risk for infection and application of biologic prosthetics that potentially served as a nidus for bacterial adherence and biofilm production of P.
aeruginosa, which led to osteomyelitis, an exceedingly rare complication for patients that undergo MMS.

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