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The "east-west" advancement flap for nasal defects: reexamined and extended

Mon, 06/02/2014 - 3:06pm

Describes how the "east-west" advancement flap with modifications can be used broadly for nasal defect surgery.

Ethical mentorship: the dilemma of success or failure

Mon, 06/02/2014 - 3:06pm

Mentorship has enhanced many careers, and it can be important in both job satisfaction and enjoyment; however, mentorships are complex human relationships and, as such, can be successful or can fail to be successful. This contribution explores some of the factors that facilitate both the success or failure of ethical mentorship relationships in medicine.

Dermal melanoma in a transplant patient

Mon, 06/02/2014 - 3:06pm

Case study: A 37-year-old white woman on over 10 years of immunosuppressive therapy for two successive renal transplants was seen in our dermatology clinic for a tender lesion on her left eyebrow which had grown rapidly over the previous few months.

Isotretinoin and iPledge: a view of results

Mon, 06/02/2014 - 3:06pm

Since its approval by the Food and Drug Administration (FDA) in 1982, isotretinoin has positively affected the lives of countless patients. Of course, any pharmaceutical agent has both its desired effect as well as undesirable side effects. The prescription of any given drug for any individual patient depends on the risk-benefit analysis for that patient. The side effect of teratogenicity has naturally moved to the forefront of safety standards for isotretinoin. It is important to remember that fetal exposure is the problem, not pregnancy itself, and all attention and efforts should be focused on preventing such exposure.

In the United States, 4 programs have been developed over time in an effort to prevent fetal exposure. These programs have been evaluated in terms of the numbers of pregnancies that occur, which is used as a proxy for potential fetal exposure. As we discuss the problem of teratogenicity with isotretinoin and the various programs to protect against it, we will use the term “pregnancies” as a representation of fetal exposure.

Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications

Mon, 06/02/2014 - 3:06pm

BACKGROUND: Few prospective studies have evaluated the safety of dermatologic surgery.

OBJECTIVE: We sought to determine rates of bleeding, infection, flap and graft necrosis, and dehiscence in outpatient dermatologic surgery, and to examine their relationship to type of repair, anatomic location of repair, antibiotic use, antiplatelet use, or anticoagulant use.

METHODS: Patients presenting to University of Massachusetts Medical School Dermatology Clinic for surgery during a 15-month period were prospectively entered. Medications, procedures, and complications were recorded.

RESULTS: Of the 1911 patients, 38% were on one anticoagulant or antiplatelet medication, and 8.0% were on two or more. Risk of hemorrhage was 0.89%. Complex repair (odds ratio [OR] = 5.80), graft repair (OR = 7.58), flap repair (OR = 11.93), and partial repair (OR = 43.13) were more likely to result in bleeding than intermediate repair. Patients on both clopidogrel and warfarin were 40 times more likely to have bleeding complications than all others (P = .03). Risk of infection was 1.3%, but was greater than 3% on the genitalia, scalp, back, and leg. Partial flap necrosis occurred in 1.7% of flaps, and partial graft necrosis occurred in 8.6% of grafts. Partial graft necrosis occurred in 20% of grafts on the scalp and 10% of grafts on the nose. All complications resolved without sequelae.

LIMITATIONS: The study was limited to one academic dermatology practice.

CONCLUSION: The rate of complications in dermatologic surgery is low, even when multiple oral anticoagulant and antiplatelet medications are continued, and prophylactic antibiotics are not used. Closure type and use of warfarin or clopidogrel increase bleeding risk. However, these medications should be continued to avoid adverse thrombotic events. All rights reserved.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: time to ban the tan

Mon, 06/02/2014 - 3:06pm

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning. All rights reserved.

Columellar advancement flap for midline nasal defects

Mon, 06/02/2014 - 3:05pm

Dermatologic surgeons frequently encounter nasal tip defects after Mohs micrographic surgery. Correction of these defects presents a unique challenge. Slight flaws in design or technique may induce functional and aesthetic penalty. We present the columellar advancement flap, a novel repair option for nasal tip defects. When used appropriately, this technique results in concealed incision lines, preserved nasal symmetry, and optimal color and texture match. Additional advantages include reduction of “columellar sag” and increase of the nasolabial angle, resulting in more aesthetically pleasing nasal appearance.

Failed treatment of amelanotic lentigo maligna with imiquimod followed by pigment production

Mon, 06/02/2014 - 3:05pm

A melanotic lentigo maligna (ALM) represents a small subset of lentigo maligna (LM) that lacks pigment. At least 2 cases of ALM responsive to imiquimod therapy with short-term follow-up have been reported. We report herein a case of ALM that failed to respond to imiquimod treatment. Furthermore, after therapy was initiated, the ALM began to produce pigment and transformed to LM.

Squamous cell carcinoma tumor thrombus encountered during Mohs micrographic surgery

Mon, 06/02/2014 - 3:05pm

We present a unique case of complete vascular occlusion by squamous cell carcinoma (SCC) encountered during Mohs micrographic surgery.

Verrucous carcinoma of the scalp

Mon, 06/02/2014 - 3:05pm

Verrucous carcinoma is a distinctive form of low-grade squamous cell carcinoma. It typically involves the oral cavity, larynx, esophagus, and skin. Cutaneous lesions typically arise in the genitocrural area and plantar surface of the foot, with rare case reports of verrucous carcinoma arising elsewhere on the body. Human papillomaviruses, predominately types 6 and 11, have been associated with some case reports. We present a case of verrucous carcinoma arising on the scalp with negative human papillomavirus testing in a relatively young patient.

Advancement flap for the reconstruction of nasal ala and lateral nasal tip defects

Mon, 06/02/2014 - 3:05pm

Repair of nasal ala and lateral nasal tip defects provide unique reconstructive challenges. This article describes a one-staged advancement flap for repair of such defects. The flap may be medially-based, laterally-based, or bilaterally-based. Sharp undermining is recommended, and a standing cone must be removed superior to the defect, perpendicular to the alar rim. Temporary alar rim flattening is accepted, and normalizes with time. This reconstruction has provided excellent functional and cosmetic results for defects measuring tip.

Pregnancy and dermatologic surgery

Mon, 06/02/2014 - 3:05pm

The physiologic changes of pregnancy and risks to the fetus require attention during dermatologic surgery. Elective surgery should be performed in the second trimester or the postpartum period. Cosmetic work should occur after delivery to avoid hypertrophic or hyperpigmented scars. Skin preparatory agents and anesthetics may have fetal implications and should be chosen with care. Antibiotic selection for any infections must take into account possible maternal and fetal risks. Attention to detail and awareness of the changes in pregnancy should lead to safe surgery in the pregnant patient.

Euro-what

Mon, 06/02/2014 - 3:05pm

Escharotic and other botanical agents for the treatment of skin cancer: a review

Mon, 06/02/2014 - 3:05pm

A growing era of alternative medicine is upon us. All who practice medicine have a small population of patients who eschew Western medicine and prefer alternative approaches, including botanical remedies, to treat their medical problems. Many alternative practitioners advertise and sell products on the Internet. Indeed, this trend now includes a growing number of topical treatments for skin cancer, including escharotic agents.

Self-treatment of skin cancer requires a substance that will destroy tissue, usually indiscriminately. Escharotic agents are caustic, corrosive substances that produce a thick coagulated crust (an eschar) and subsequently a scar.

The following case illustrates one representative situation.

Surgical pearl: The use of endarterectomy scissors in dermatologic surgery

Mon, 06/02/2014 - 3:05pm

Surgical scissors are a necessary component of the surgical tray. It is optimal to maintain one plane of cutting or dissection when excising a lesion or undermining tissue. This is particularly important when removing a melanoma, large lesion, or Mohs micrographic surgery layer. Traditionally iris, gradle, and Stevens tenotomy scissors have been the preferred instruments for cutaneous surgery in small shallow areas. These instruments accommodate more delicate anatomic areas well. Many dermatologic surgeons use Metzenbaum or Mayo scissors when undermining larger, deeper defects and cutting thicker, more resilient skin (such as that on the scalp, back, or extremities). These scissors have a longer shank and tips than the aforementioned instruments and are more efficient in cutting and manipulating deeper tissue and larger lesions. In certain situations, however, their long tips may feel clumsy and provide less precise cutting and undermining. When used to cut the subcutaneous tissue, these scissors tend to catch a nodule of fat deep in the defect instead of maintaining a level, even cutting surface through the fat.

The significance of tumor persistence after incomplete excision of basal cell carcinoma

Mon, 06/02/2014 - 3:05pm

BACKGROUND: Physicians inevitably receive a pathology report after excision of a basal cell carcinoma that indicates that it is incompletely excised. The physician and patient are then left with the dilemma of whether immediate re-excision or close clinical follow-up is indicated.

OBJECTIVE: Our purpose was to identify characteristics of incompletely excised basal cell carcinomas that are at low risk for recurrence.

METHODS: We retrospectively reviewed the charts and pathology slides of all incompletely excised basal cell carcinomas from 1991 to 1994 in a university hospital tumor registry.

RESULTS: Incompletely excised basal cell carcinomas of superficial or nodular subtype, less than 1 cm in diameter, located anywhere except the nose or ears, with less than 4% marginal involvement on the initial inadequate excision had no evidence of tumor persistence.

CONCLUSION: When physicians receive a pathology report indicating the incomplete excision of a basal cell carcinoma, they face the dilemma of further management. The majority of patients should undergo immediate re-excision or Mohs micrographic surgery because tumor persistence was found in 28% of cases. Occasionally, for a small group of select patients, close clinical follow-up may be indicated if the risk of recurrence is very low.

Basal cell carcinoma metastatic to the parotid: report of a new case and review of the literature

Mon, 06/02/2014 - 3:05pm

Basal cell carcinoma is the most common of the cutaneous malignancies, accounting for 65 to 75% of all skin cancers. The natural history of this disease is one of chronic local invasion. Metastatic basal cell carcinoma is a rare clinical entity, with a reported incidence of only 0.0028 to 0.5%. Approximately 85% of all metastatic basal cell carcinomas arise in the head and neck region. We present a case of basal cell carcinoma that spread to the parotid gland in a man who had multiple lesions on his scalp and face. We also review the literature on metastatic basal cell carcinoma of the head and neck, and we discuss its epidemiology, etiology, histopathology, and treatment.

The heterogenous nature of in vivo basal cell carcinoma

Mon, 06/02/2014 - 3:05pm

BACKGROUND: There have been nearly 70 different histologic subtypes of basal cell carcinoma (BCC) described. Some of the subtypes have been shown to have clinical relevance. The degree to which one type may merge to another, within the same tumor mass, has been poorly studied.

OBJECTIVE: To determine if BCCs maintain biopsy histology throughout the entire architecture of the tumor.

METHOD: Tumors were evaluated with a prospective histologic analysis of all primary BCCs using the Mohs "removal in layers" technique. All BCCs that required more than a single Mohs stage to clear were included in analysis.

RESULTS: One hundred forty-nine tumors were examined. Fourteen of these were of mixed histologic subtype on biopsy and were not included in the analysis. Six biopsy specimens were inadequate to make a subtype diagnosis and were excluded from calculation. Of the remaining 129 tumors 59% maintained their biopsy diagnosis at first Mohs stage, and 49% at the second Mohs stage. Infiltrative tumors were the most likely to maintain their histologic subtype classification. Of the tumors that showed nodular BCC on biopsy, 13% were infiltrative or micronodular at first Mohs stage.

CONCLUSION: While many BCCs demonstrate a single histological subtype, roughly 40% change in their microscopic appearance at the subclinical extension. This finding has the potential to alter therapy.

The immunohistochemical characteristics of the basosquamous cell carcinoma

Mon, 06/02/2014 - 3:05pm

BACKGROUND: The basosquamous cell carcinoma (BSCC) is a poorly defined and often misunderstood cutaneous malignancy.

OBJECTIVE: The purpose of this study was to compare, using immunohistochemical techniques, the BSCC, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC).

METHODS: BSCC occurring at Pennsylvania State University over the past 10 years were identified. Choosing seven BCC, and nine SCC as controls, all specimens were stained for keratin, lack of apoptosis, glycoproteins, and altered gene products using the avidin/biotin and strep-avidin immunoperoxidase techniques. Each malignancy was then graded for the percentage of cells stained with each marker.

RESULTS: Of the markers studied, all stained to varying degrees the malignant aspects of the specimens. There were similar patterns between tumors, with the BSCC showing a transition zone between typical BCC and SCC. This was most striking for Ber-EP4, where over two-thirds of the BCC stained, none of the SCC, and half of the BSCC showed reactivity.

CONCLUSION: BSCC has staining patterns similar to both the BCC and SCC. The presence of a transition zone does not support the concept that all BSCC are collision tumors, but rather a differentiation of one tumor into another. We confirm earlier reports that Ber-EP4 could be used to distinguish between classic BCC and SCC. AE1/AE3, bcl-2, TGF-alpha, and p53 were not helpful in separating the tumors.