Below-knee dermatologic surgery: Prevention of surgical complications, wound healing, and reconstructive techniques-A narrative review.

BACKGROUND

Below-knee dermatologic surgery is associated with an increased risk of surgical site infection, wound dehiscence, and postoperative pain. Optimizing perioperative care and reconstructive strategies is particularly important in older patients undergoing skin cancer surgery.

METHODS

A narrative literature review was conducted in April 2025 using PubMed and Google Scholar. Clinical trials, observational studies, systematic reviews, and meta-analyses addressing complications, perioperative interventions, wound healing, and reconstruction following lower-leg dermatologic surgery were evaluated.

RESULTS

Preoperative cleansing with 4% chlorhexidine, perioperative compression, monofilament sutures, and zinc oxide dressings may help reduce postoperative complications. Routine perioperative antibiotic prophylaxis is not recommended. Neoadjuvant intralesional methotrexate or 5-fluorouracil may reduce tumor size, simplify surgical reconstruction, or avoid surgery in selected patients with cutaneous squamous cell carcinoma. Direct closure is the preferred reconstructive approach when feasible. Alternatives include secondary intention healing, pinch grafts, split-thickness and full-thickness skin grafts, and local flaps, particularly the keystone flap. Based on the available evidence and clinical experience, a practical management algorithm is proposed.

CONCLUSIONS

Below-knee dermatologic surgery requires individualized perioperative management and careful selection of reconstructive techniques. Antiseptic cleansing, compression therapy, appropriate suture selection, and selected reconstructive approaches may improve outcomes. However, much of the available evidence is derived from retrospective studies, highlighting the need for prospective investigations.