Alexander Bogdanov-Berezovsky

Clinical and pathological findings in reexcision of incompletely excised basal cell carcinomas

In common practice, patients with incompletely excised basal cell carcinomas (BCCs) are referred to elective reexcision. In previous reports, it was observed that tumor cells are found in only 50% of the reexcised specimens. The authors performed a retrospective analysis of a large series of patients to evaluate clinical and pathological findings in patients who underwent reexcision of incompletely excised BCCs. A total of 1,478 BCCs arising in 1,278 patients were excised by plastic surgeons in a plastic and reconstructive surgery department during a 4-year period. In 159 patients (10.8%), the excision was incomplete according to the pathological report. These tumors were defined as an incompletely excised BCCs. One hundred of the 159 patients with incompletely excised BCCs (62.9%) were reoperated. Residual tumor cells were found in 28 of 100 patients (28%) within the pathological specimen of the reexcised tissue (defined as positive reexcision, or +veRE). There was no correlation between +veRE and the age or sex of the patient. Location of the BCCs in the cheeks, eyelids, or ears was associated with a low percent of +veRE (10.0%, 13.3%, and 22.2% respectively). Pathological factors associated with a low percent of +veRE were dermal inflammatory infiltrate in the pathological specimen (p = 0.003) and sun damage pathological changes (p = 0.03), but there was no correlation with the pathological subtype distribution of the tumors. The authors conclude that lack of tumor cells at reexcision of incompletely excised BCCs is associated with location of the tumors in the cheeks, eyelids, and ears, and with pathological findings of dermal inflammatory infiltrates or sun damage changes. The roles of inflammatory and solar changes in the destruction of residual carcinoma cells should be investigated further.

Admission Cell Free DNA as a Prognostic Factor in Burns: Quantification by Use of a Direct Rapid Fluorometric Technique

Background. Despite great advances in the treatment of burn patients, useful prognostic markers are sparse. During the past years there has been increasing interest in circulating plasma cell free DNA as a potential marker for tissue injury. We have developed a rapid direct fluorescent assay for cell free DNA quantification that allows obtaining accurate, fast, and inexpensive measurements. Objective. To use this technique for measuring plasma cell free DNA levels in burn patients and to further explore the use of cell free DNA as a potential marker of patient outcome in burns. Methods. Cell free DNA levels obtained from 14 burn victims within 6 hours of injury and 14 healthy controls were quantified by a direct rapid fluorometric assay. Results. Patient admission cell free DNA levels were significantly elevated compared with that of controls (1797 ± 1523 ng/mL versus 374 ± 245 ng/mL, P = 0.004). There are statistically significant correlations between cell free DNA admission levels and burn degree (Spearmans correlation = 0.78, P = 0.001), total body surface area (Spearmans correlation = 0.61, P = 0.02), and total burn volume (Spearmans correlation = 0.64, P = 0.014). Conclusions. Admission cell free DNA levels can serve as a prognostic factor in burns and future routine use can be made possible by use of our direct rapid fluorometric assay.

Lymph Node Metastasis in Cutaneous Head and Neck Squamous Cell Carcinoma.

BACKGROUND Cutaneous squamous cell carcinoma (CSCC), the second most common cancer in whites, may result in nodal metastasis in 4% of patients. In the last decade, sentinel lymph node biopsy (SLNB) became the common practice for treating patients with invasive skin cancers such as melanoma, although its use in patients with CSCC is still under debate. OBJECTIVE To find the rate of cervical lymph node metastasis in the series of patients with CSCC of the head and neck and to identify those who may need SLNB. MATERIALS AND METHODS A retrospective data collection on all patients diagnosed with CSCC of head and neck during the years 1998 to 2005. RESULTS A total of 572 patients with 725 head and neck CSCC were included in the study group. During the follow-up period, 10 (1.3%) patients developed lymph node metastases and no patient developed distant metastases. The probability of lymph node metastasis within 6 years for T1 and T2 tumors was 1.09% and 5.46%, respectively (p = .0387). CONCLUSION Because of the relatively low incidence of cervical lymph node metastases in patients with CSCC of the head and neck, SLNB for clinically N0 patients is not justified.

Capsular Flap: New Applications

Breast augmentation with silicone implants is one of the most commonly performed procedures for women seeking improvement in their body image. Because the number of breast augmentation operations is growing, the number of subsequent reoperations is increasing. Causes for repeated operative procedures include infection, capsular contracture, silicone implant replacement, and breast reaugmentation. As the average volume of silicone implants used is steadily growing according to patients’ wishes and fashion requirements, the plastic surgeon often is asked to replace the silicone implants with larger implants. Replacing breast implants with a similar sized implant is a relatively simple operation, but insertion of larger implants may present a challenge due to insufficient soft tissue coverage of the lower pole of the larger breast implant, especially in thin subjects. Total coverage of the breast implant can be achieved by use of tissue substitutes (TS), such as acellular dermal matrices. Usage of TS, however, is prone to complications and very costly, and these factors influence the implementation of TS in a private practice setup. This report describes a capsular flap used to cover the lower pole of breast implants. The flap guarantees multilayered stable wound closure and prevents displacement of the inframammary fold. The capsular flap also was used to correct an inferiorly displaced inframammary fold as a consequence of the breast augmentation.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Accreditation of skin from a methanol-poisoned victim for banking and grafting

Background. Acute poisoning is a contraindication for organ and tissue donation. In this study the suitability of skin from a methanol-poisoned (MP) donor for future grafting and keratinocytes culturing was investigated. Methods. A patient was admitted with a methanol blood level of 2.7 mg/mL, which became undetectable after 4 days of treatment with 4-methylpyrazole (fomepizole). Upon declared brain death and family consent, organs and skin were harvested. For approving MP skin for grafting, the following parameters were studied: viability and plating efficiency of MP keratinocytes, integrity of MP skin after cryopreservation, and its performance as xenografts on wounds in a pig model. Nonpoisoned (NP) controls included skin of matching age, cryopreservation period, and NP keratinocytes. Results. No significant differences were observed for any parameter between NP and MP samples. Furthermore, in vitro exposure of NP keratinocytes and fibroblasts to <10 mg/mL methanol inhibited their growth by <20%, with an extrapolated LD50 of 100 mg/mL. A parallel exposure to formaldehyde, a spontaneous metabolite of methanol, yielded LD50 of 20 &mgr;g/mL and eradication of viability at 300 &mgr;g/mL. Conclusions. These results indicate that skin from a carefully monitored MP donor is suitable for banking toward massive burns and skin losses. This methodology may be applied to approve skin harvested from other types of poisoned donors for banking and future grafting.

Facial Reconstruction of a Mucormycosis Survivor by Free Rectus Abdominis Muscle Flap, Tissue Expansion, and Ocular Prosthesis.

Invasive sinonasal mucormycosis is a rare fungal infection that usually occurs in immunocompromised or diabetic patients, and it is often fatal. The authors present a case of a woman patient suffering from systemic lupus erythematosus and diabetes mellitus treated with prednisone, presenting with a rapidly progressive rhino-orbital-cerebral mucormycosis. She was successfully treated with combined intravenous antifungal therapy and radical debridement followed by complex defect reconstruction with a free vertical rectus abdominis myocutaneous flap, tissue expander, and ophthalmic prosthesis.

Utilization of Inferiorly Based Dermofat Flap in Breast Reconstruction after Simple Mastectomy due to Gigantomastia.

Gigantomastia (GM) is a rare disabling condition characterized by excessive breast tissue growth. To date, there is no universal classification and definition of GM. At present, GM is determined as weight over 1.5 kg per breast (Dancey et al., 2008) or 3% or more of the patients total body weight (Dafydd et al., 2011). The lack of generally acknowledged approach regarding GM is expressed by the different methods of its treatment ranging from hormonal prescription to mastectomy and subsequent complex breast reconstruction (Shoma et al., 2011). We describe a treatment approach, including simple mastectomy and immediate breast reconstruction by an inferiorly based dermofat flap with silicone implants and nipple grafting.

Bromelain‐based enzymatic debridement of chronic wounds: A preliminary report

Sharp debridement is currently considered most effective for debridement of chronic wounds; however, some patients do not have access to or cannot be treated by surgical methods. This study was designed to provide a first impression of the safety and efficacy of bromelain‐based enzymatic debridement of chronic wounds. Two consecutive single‐arm studies assessing the enzymatic debridement efficacy of a concentrate of proteolytic enzymes enriched in bromelain in chronic wounds was conducted in 2 medical centres. Patients were treated with up to 11 consecutive 4‐hour enzymatic debridement sessions and then treated until wound closure. Twenty‐four patients with chronic wounds of different aetiologies were enrolled. All wounds achieved an average of 68% ± 30% debridement in an average of 3.5 ± 2.8 enzymatic debridement 4‐hour sessions. Seventeen responding wounds (venous, diabetic, pressure, and post‐traumatic aetiologies) achieved an average 85% ± 12% debridement in 3.2 ± 2.5 applications. Seven non‐responding wounds (arterial and post‐surgical aetiologies) achieved an average 26% ± 13% debridement in 4.3 ± 3.5 applications. No treatment‐related serious adverse events were observed, and the only adverse event attributed to the enzymatic debridement was pain. These preliminary results indicate the potential safety and efficacy of bromelain‐based enzymatic debridement in chronic wounds. Larger controlled studies are needed to further investigate this indication.

Long-term pediatric skin eruption-related hospitalizations in offspring conceived via fertility treatment

Although concerns have been raised regarding the long‐term health risks of offspring conceived following fertility treatments, limited information is available regarding their health status beyond the neonatal period. We aimed to evaluate the risk of long‐term eruptive dermatological morbidity among children born following fertility treatments as compared to those conceived spontaneously.

Desmoid Tumor and Silicone Breast Implant Surgery: Is There Really a Connection? A Literature Review

BackgroundDesmoid tumors are borderline tumors of the connective tissue, arising in the musculo-aponeurotic stromal elements. A desmoid tumor (DT) has an infiltrative and locally aggressive growth pattern and usually does not metastasize; however, it has a high recurrence and complication rate. DT located in the breast (BDT) represents a rare extra-abdominal form. Recently, the presence of breast silicone implants was suggested by several researchers as a risk factor for developing BDT.ObjectivesThe goal of this review is to investigate the possible correlation between BDT and breast implant surgery.MethodsWe conducted a literature review of BDT-reported cases, associated with breast implant surgery.ResultsThe search revealed 36 cases of BDT associated with silicone breast implants.ConclusionsBased on the reviewed data, the incidence of BDT following breast implant surgery is lower than BDT in the general population. At the moment, a possible association between breast implants and the development of breast desmoid tumors cannot be unequivocally confirmed. A world registry with accurate documentation of each case of BDT associated with breast implant surgery should be performed for future investigation.Level of Evidence IIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.