Brian C. Leach

Skin cancer in organ transplant recipients: More than the immune system

Organ transplant recipients (OTRs) are at increased risk of developing nonmelanoma skin cancers. This has long been thought to be caused by immunosuppression and viral infection. However, skin cancer risk among individuals with AIDS or iatrogenic immunodeficiency does not approach the levels seen in OTRs, suggesting other factors play a critical role in oncogenesis. In clinical trials of OTRs, switching from calcineurin inhibitors to mammalian target of rapamycin inhibitors consistently led to a significant reduction in the risk of developing new skin cancers. New evidence suggests calcineurin inhibitors interfere with p53 signaling and nucleotide excision repair. These two pathways are associated with nonmelanoma skin cancer, and squamous cell carcinoma in particular. This finding may help explain the predominance of squamous cell carcinoma over basal cell carcinoma in this population. Mammalian target of rapamycin inhibitors do not appear to impact these pathways. Immunosuppression, viral infection, and impaired DNA repair and p53 signaling all interact in OTRs to create a phenotype of extreme risk for nonmelanoma skin cancer.

The spiral flap for nasal alar reconstruction: our experience with 63 patients.

Objective To describe our patient selection, design, execution, and results with the spiral flap for distal nasal surgical defects after Mohs micrographic surgery. Materials and Methods We performed a retrospective analysis of all spiral flaps performed over a 5‐year period. Sixty‐three patients were identified, and charts and photographs were examined. Surgical defects were classified according to alar location. All follow‐up encounters were reviewed to assess for complications and need for revisionary procedures. Intraoperative photographs were taken of representative cases to describe the surgical technique. Results Sixty‐three patients on whom the spiral flap was performed were identified over a 5‐year period. The flap was used to successfully reconstruct alar defects ranging in size from 5 to 15 mm in diameter. No persistent complications were noted. Conclusion The spiral flap is a reproducible, one‐stage flap for small to medium‐sized defects of the nasal ala and alar groove that consistently produces topographic restoration with minimal risk of aesthetic or functional complication.

Cranial Neuropathy as a Presenting Sign of Recurrent Aggressive Skin Cancer

OBJECTIVE The purpose of this study was to identify and characterize recurrent skin cancers of the head and neck presenting with cranial neuropathies and to review the presentation and the management for this rare subset of cutaneous neoplasms. MATERIALS AND METHODS A retrospective review was performed for all patients with previous related cutaneous neoplasms presenting with cranial neuropathies referred to a single academic tertiary-care head and neck tumor program from 1999 to 2007. Six cases of head and neck carcinoma with demonstrable cranial neuropathy were identified and analyzed by clinical history, radiographic and surgical findings, and treatment and survival data. A review of the literature, pertinent anatomy, imaging studies, and surgical/nonsurgical management are summarized for these aggressive neurotropic malignancies. RESULTS Cranial neuropathy was the presenting symptom of recurrent disease in all six patients. Four presented with multiple cranial neuropathies. All exhibited neuropathy of the trigeminal nerve (cranial nerve V). The tumors involved were squamous cell carcinoma (4) and melanoma (2). All patients were multiply symptomatic, presenting with a mean of three neurologic symptoms, including facial numbness (5), facial paralysis or weakness (3), facial pain (3), diplopia (3), paresthesia (3), hearing loss (1), or formication (2). Symptoms were present for an average of 7 months prior to diagnosis of perineural recurrence. Cranial nerve involvement was confirmed in all patients by magnetic resonance imaging, and five patients manifested histologic evidence of perineural tumor infiltration. Treatment consisted of various combinations of surgery, radiation, and chemotherapy for five patients, and one patient declined any intervention. Death rate subsequent to disease was 50%, and follow-up has continued within our institution on all patients for an average of 25.5 months (range, 3–72 months). CONCLUSION Cranial neuropathy is a rare presentation of recurrent cutaneous neoplasms of the head and neck. Given this infrequent occurrence and shared features of presentation, these highly morbid tumors are often mistakenly diagnosed as Bells palsy or trigeminal neuralgia. Our findings corroborate previous reports of diagnostic delay, increased tumor burden, and worsened morbidity and mortality associated with such cutaneous malignancies. The critical utility of radiologic imaging for staging and tumor delineation are also supported by our institutional data.

Antihelical Cartilage Grafts for Reconstruction of Mohs Micrographic Surgery Defects

OBJECTIVE To illustrate the safety, efficacy, and versatility of the antihelix as the preferred donor site for auricular cartilage autografts in the reconstruction of nasal and auricular Mohs micrographic surgery defects. MATERIALS AND METHODS Retrospective chart review of all cartilage autografts performed at the Medical University of South Carolina for the 5‐year period July 1, 2006, to June 30, 2011; 307 auricular cartilage autografts were performed in 297 patients. Each case was reviewed for demographic data, graft donor site, repair type, complications, and revisions. RESULTS Three hundred five of the grafts (99.3%) were harvested from the antihelix and the remaining two (0.7%) from the conchal bowl. The donor site complication rate was 3%. No patients experienced cosmetic or functional deformity of the donor ear. No patients experienced cartilage graft resorption or infection. CONCLUSION Antihelical cartilage grafts can serve as safe, effective, and versatile alternatives to septal, conchal bowl, and costal margin grafts. The authors feel strongly that the antihelix donor site should be favored when harvesting auricular cartilage for its easy accessibility, large dimension that may be harvested without aesthetic penalty, character of graft, and minimal operative morbidity.

Revisionary Technique for Alar Rim Notching: The Stair-Step Flap

Perhaps these words are more befitting the facial reconstructive surgeon than the master carpenter, for revision of the sequelae of improperly designed flaps or untoward reconstructive outcomes are some of the most challenging cases in a surgeon’s career. Undoubtedly, adherence to this adage, with careful preoperative planning and performance of repairs, will minimize unfavorable outcomes, but invariably all surgeons at some point will be the recipient of such a conundrum.

Applications of Burow's Grafts in the Reconstruction of Mohs Micrographic Surgery Defects.

BACKGROUND Surgical defects in anatomically challenging locations, such as near free margins or crossing cosmetic subunits, may present reconstructive challenges to the dermatologic surgeon. For selected defects, Burows grafts may produce functional and aesthetic results in a single operative session. OBJECTIVE To describe the applications of the Burows graft technique for the repair of defects after Mohs micrographic surgery. METHODS An institutional review board–approved retrospective database review of surgical defects repaired with Burows grafting after Mohs micrographic surgery at the Medical University of South Carolina was performed. The general technique of Burows grafting is described, emphasizing proper graft sizing and direction of tension vectors. Varying anatomic locations and defect types are presented, with site-specific considerations and operative photographs. RESULTS Burows grafting provides ideal color and textural match, preserves subunit boundaries, results in a compact single-site wound, and may avoid complications of alternate repair choices. The tension vectors produced in closing the grafts harvest site may be designed to prevent distortion of free margins. Burows grafting may be combined with hinge flaps to repair deep or avascular defects. CONCLUSION Burows grafts are reproducible, aesthetic, and useful reconstructive choices for a variety of surgical wounds.

Keratoacanthoma centrifugum marginatum: A diagnostic and therapeutic challenge

Keratoacanthoma centrifugum marginatum (KCM) is a rare variant of keratoacanthoma (KA) possessing several characteristics distinguishing it from typical KAs. Clinical presentation deviates from common KAs with lesions that continually expand peripherally.1, 2, 3 KCM also deviates from the usual histologic findings with a lack of some classic KA features. This is probably attributable to sampling issues given the size of the lesions and the limited capacity of a biopsy. Because of its rarity and lack of distinctive histopathologic features, KCM poses a difficult diagnostic challenge to clinicians and pathologists. Excellent communication and collaboration between the clinician and the pathologist is crucial for the correct and timely diagnosis, allowing for quick and proper treatment of the patient.

Dermatofibrosarcoma Protuberans: A Second Primary Tumor Displaying Bednar and Fibrosarcomatous Subtypes

ual de-epithelization of the pedicle. This introduces two problems. First, by placing the donor site in the retroauricular sulcus and de-epithelizing the pedicle, a vertically oriented secondary defect is created in the retroauricular sulcus. Closure of this donor site pulls the auricle toward the scalp, creating asymmetry of the lateral projection of the ears. Although pedicle length is sufficient, closure of the secondary defect pins the ear back. Second, manual de-epithelization of the pedicle creates an additional step that risks trauma to the vascular pedicle, endangering flap viability.