Abstract

Auricular (ear) wounds following Mohs micrographic surgery (MMS) are challenging to manage due to limited soft tissue and the avascular nature of cartilage. Secondary intention healing (SIH) is commonly used but often requires 6–10 weeks for closure. A collagen–Mānuka honey–hydroxyapatite dressing (CHD) has been developed to support wound repair and may shorten healing time with favorable scarring outcomes. We report three auricular MMS cases managed with the CHD applied at home every 3–4 days under a hydrocolloid cover.

Initial defects measured 6.25 cm², 3.61 cm², and 1.0 cm². All wounds demonstrated healthy granulation at two weeks and were epithelized by day 28 with minimal to no scarring. These results compare favorably with a recent multicenter study in which 54 auricular wounds treated with SIH had a mean healing time of 56.9 days. CHD-assisted SIH may reduce healing time, lower the need for clinic visits, lower the financial burden on the healthcare system, and provide a practical patient-directed option for auricular wound management.

Keywords:Mohs Surgery; Articular Defects; Collagen; Medical Grade Mānuka Honey; Wound Healing; Secondary Intention Healing

Abbreviations:MMS: Mohs Micrographic Surgery; MMPs: Matrix Metalloproteases; CHD: Collagen–Honey–Hydroxyapatite Dressing; DME: Durable Medical Equipment; SIH: Secondary Intention Healing

Introduction

The auricular region presents unique challenges for dermatologic surgery due to its complex three-dimensional anatomy, minimal soft tissue coverage, and underlying cartilaginous framework. Cartilage is avascular, relying on diffusion from the perichondrium for nutrient supply, which limits its healing potential compared with vascularized tissues [1]. As a result, wounds involving auricular cartilage are prone to delayed healing, complications such as chondritis, and aesthetic deformity [2]. Traditional reconstructive options such as full-thickness skin grafts often have poor take on avascular cartilage, limiting their reliability in this location [3].

Mohs micrographic surgery (MMS) is the standard of care for high-risk, non-melanoma skin cancers on cosmetically and functionally sensitive sites, including the ear. However, reconstructive planning following MMS in this region remains complex due to the limited availability of local tissue, increased likelihood of wound dehiscence, and the suboptimal outcomes with grafting techniques [4]. While various approaches have been described-including local flaps, delayed closure, and traditional secondary intention healing-clinical outcomes are inconsistent, and an evidence-based, reliable solution for auricular cartilage defects remains elusive.

A promising bioengineered option to overcome these challenges is VERIS™ (SweetBio, Inc., Memphis, TN, USA), a natural, advanced wound dressing formulated from a collagen derivative, Mānuka honey, and hydroxyapatite. Each component plays a distinct, synergistic role in wound repair: collagen supports fibroblast migration, adhesion, and proliferation while modulating excess matrix metalloproteases (MMPs) [5-7]; Mānuka honey delivers antibacterial, anti-inflammatory, and growth factor– enhancing effects [8-11]; and hydroxyapatite provides structural reinforcement, additional sites for cell adhesion, and stimulation of angiogenesis and re-epithelialization [12-16]. Collectively, this collagen–honey–hydroxyapatite dressing (CHD) has been validated through multiple peer-reviewed studies, demonstrating both in vitro bioactivity and clinical efficacy across chronic ulcer and MMS wound models.

Preclinical data show that the CHD reduces gram-negative and gram-positive bacterial burden by 99.99% within 24 hours [17], suppresses macrophage production of MMP-9 (a key mediator of chronic wound pathology), and enhances fibroblast secretion of pro-healing growth factors including FGFb, VEGF, TNFα, SCF, and TGFβ [18,19]. Clinically, CHD treatment has been associated with accelerated wound healing, achieving up to twice the closure rate in chronic ulcers [20], mean closure times of 4.1 weeks in private practice podiatry [21], and full closure in 6 weeks for advanced secondary intention MMS wounds [22]. In a randomized controlled trial of MMS patients, CHD use was also correlated with statistically significantly reduced postoperative pain compared to standard of care [23].

In routine practice, the CHD is delivered through a durable medical equipment (DME) model with direct home shipping, ensuring timely access and reducing the need for repeat clinic visits. It is insurance-reimbursable, affordable, and supported by simple, image-based instructions for ease of use. In the present cases, the CHD was dispensed directly by the treating physician under a patient-pay model, providing the same benefits of immediate access and straightforward application. These case studies evaluate the clinical efficacy of an affordable, easy to use, at-home, patient-administered CHD wound dressings following auricular MMS.

Materials and Methods

Three patients underwent MMS for skin cancer on the ear, with wounds left to heal by advanced secondary intention healing. The physician provided the CHD to the patients to take home immediately after surgery via a patient pay model. Patients were instructed to apply for the CHD every 3-4 days and were scheduled for routine wound evaluations at standard follow-up visits (week 2 and 4). DuoDERM® Extra Thin hydrocolloid dressing (Convatec, Bridgewater, NJ, USA) was used as the secondary dressing to cover the CHD. All patients provided consent for the use of clinical images and de-identified data in this report.

Results

Patient 1 was an 85-year-old male with hypertension and a history of smoking. MMS was performed on the left ear, resulting in a post-operative wound measuring 2.5 × 2.5 cm. By week 2, the wound area had decreased by 36% to 2.0 × 2.0 cm and epithelialized by week 4.

Patient 2 was a 69-year-old female with a history of auricular MMS previously treated with a full-thickness skin graft (FTSG). That graft had healed poorly, and the patient expressed a desire to avoid grafting for future surgeries. In this new case, MMS was performed on the left ear, specifically the triangular fossa–superior antihelix, with a post-operative wound measuring 1.9 × 1.9 cm. By week 2, the wound area had decreased by 20% to 1.7 × 1.7 cm and epithelialized by week 4.

Patient 3 was a 47-year-old male who was immunocompromised due to long-term Imuran therapy for ulcerative colitis diagnosed at age 13. MMS was performed on the right ear, superior conchal bowl, creating a post-operative wound measuring 1.0 × 1.0 cm. By week 2, the wound area had decreased by 40% to 0.6 × 0.6 cm and achieved closure by week 4.

Across all three patients, the wounds demonstrated favorable granulation at week 2 with minimal to no visible scarring at week 4 (Figure 1).”.

Discussion

Secondary intention healing (SIH) is a reliable option for auricular Mohs defects but is associated with prolonged closure times compared to other facial sites. Prior studies report healing intervals up to 10 weeks for full epithelialization [24,25]. In a recent multicenter analysis of 306 postoperative cutaneous surgical wounds, Gil-Lianes et al [26], reported a mean healing time of 56.9 days among 54 auricular cases, with defect size identified as a key determinant of outcome. Wounds ≤ 5.28 cm² were significantly more likely to close within 66 days, whereas larger wounds required longer [26].

In contrast, the present series achieved epithelialization by day 28 across three auricular defects measuring 1.0 cm², 3.61 cm², and 6.25 cm². These results demonstrate epithelialization four weeks earlier (2 times faster) than the average auricular outcome reported by Gil-Lianes et al., despite patient comorbidities including advanced age, prior poor graft take, and chronic immunosuppression. Importantly, in this series the CHD was dispensed directly to patients for self-application at home under a patient-pay model. This approach enabled consistent wound care without the need for frequent in-clinic dressing changes, reducing the treatment burden while maintaining excellent healing outcomes.

In standard practice, reconstruction with a full-thickness skin graft for auricular defects is reimbursed at $957.40 USD under CPT 15260 (Medicare, Arizona, USA), but this technique requires creating a second surgical site to harvest the graft, introducing an additional wound for the patient to heal, and grafts often demonstrate poor take on auricular cartilage. By contrast, in this case series the CHD treatment averaged only $125 USD for the entire treatment, required no graft harvest, and avoided the morbidity of a secondary donor site. The CHD therefore provides significant cost savings to the healthcare system (averaging $832 USD per patient) while eliminating the need for a secondary donor site and its associated risks of pain, delayed healing, and graft failure.

Conclusion

These findings suggest that CHD-assisted SIH not only shortens healing time for auricular MMS wounds compared with historical controls but also provides a practical, affordable, and patientcentered modality that can be safely managed outside the clinic. Across three diverse patients, including one elderly, one with a prior failed graft, and one immunocompromised, all wounds achieved epithelialization by 4 weeks, a markedly accelerated timeline relative to the expected 6–10 weeks for auricular SIH.

The ability for patients to self-apply the dressing at home, with minimal clinical oversight, highlights the potential of this approach to reduce healthcare utilization, improve patient satisfaction, and broaden access to advanced wound care. The CHD’s in vitro bioactive properties, combined with ease of use and compatibility with standard secondary dressings, may explain the consistent outcomes observed even in high-risk clinical scenarios.

Future prospective studies with larger cohorts are needed to confirm these results, quantify long-term cosmetic and functional outcomes, and evaluate cost-effectiveness compared to traditional reconstructive strategies. If validated, CHD-assisted SIH could represent a paradigm shift in managing auricular MMS defects by accelerating healing, reducing treatment burden, and lowering costs to the healthcare system.

Author Disclosures

A.D. is a consultant to SweetBio, Inc. I.R. and R.B. are employees of SweetBio, Inc. N.D, which declaress no conflicts of interest related to this work.

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