Donald J. Grande

Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread.

BACKGROUND Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor of the skin; its microscopic extent of invasion beyond the grossly visible tumor is frequently difficult to appreciate. Although wide local excision has been the standard treatment of DFSP, recurrence rates range from 11% to 53%. Because Mohs micrographic surgery allows the extent of excision to be tailored to the microscopic extent of tumor, we evaluated this technique for the treatment of primary and recurrent DFSP. OBJECTIVE Our purpose was to determine the local recurrence rate and microscopic extent of spread of primary and recurrent DFSP after treatment with Mohs micrographic surgery. METHODS The records of 58 patients with primary and recurrent DFSP treated with Mohs micrographic surgery at three institutions were reviewed and the macroscopic and microscopic extents of tumor were recorded. RESULTS One patient with a twice-recurrent DFSP had another recurrence after Mohs micrographic surgery, for an overall local recurrence rate of 2% (zero for primary tumors and 4.8% for recurrent tumors). There were no cases of regional or distant metastases. Macroscopic tumor size ranged from 0.3 x 0.6 cm to 30 x 20 cm, whereas microscopic (postoperative) size ranged from 1.8 x 1.0 cm to 35 x 40 cm. We calculated the likelihood that a given width of excision around the macroscopic tumor would clear the entire microscopic extent of tumor. Standard wide excision with a width of 1 cm around the primary tumor would have left microscopic residual tumor in 70.7%; a width of 2 cm, 39.7%; 3 cm, 15.5%; and 5 cm, 5.2%. Even an excision width of 10 cm would not have cleared the microscopic extent of some tumors, despite taking a huge excess of normal tissue. CONCLUSION Treatment of primary and recurrent DFSP by Mohs micrographic surgery results in a low recurrence rate because of the ability of the technique to permit the detection and excision of microscopic tumor elements in even the most asymmetric tumors. Whatever type of surgery is chosen to treat DFSP, it is necessary to assess the entire perimeter of the tumor for microscopic extension and to achieve tumor-free margins in all directions.

Electrolysis and thermolysis for permanent hair removal

The historical, legal, and theoretical aspects and clinical technics of both electrolysis and thermolysis are critically reviewed. The pitfalls of electronic tweezers and the dangers of self-electrolysis are discussed. Complications of electrolysis and thermolysis and the pathophysiology of hair regrowth are presented. In the United States, the lack of uniform training requirements and standards for electrologists may pose an unrecognized risk to public health. It is suggested that more responsible state legislation be enacted in order to decrease the present potential threat to the public health and safety.

An Interlocking Auricular Composite Graft

BACKGROUND Full‐thickness defects of the nasal alar rim are relatively common following Mohs micrographic surgery for the treatment of long‐standing or recurrent skin tumors. Composite grafts provide an excellent cosmetic and functional alternative for the repair of such defects. OBJECTIVE A useful technique of auricular composite graft placement for reconstruction of full‐thickness nasal alar rim defects is described. METHODS The cartilaginous portion of the graft is extended beyond the borders of the soft tissue defect so that two cartilaginous pegs frame the lateral aspects of the graft. These pegs are then inserted into pockets prepared within the alar tissue of both sides of the defect, such that the graft interlocks with its recipient bed. A series of diagrams as well as a set of photographs from a representative case are provided, along with accompanying commentary, so as to enable the surgeon to incorporate this technique easily into his/her practice. CONCLUSTION The interlocking auricular composite graft technique permits increased graft stability, with decreased shearing forces of the graft over its recipient bed, and a larger surface area for revascularization, resulting in an increased probability of graft survival. This technique provides an elegant single stage alternative to current reconstructive techniques for full‐thickness nasal alar rim defects measuring less than 1.5 cm in diameter.

Unilateral Dermatomal Superficial Telangiectasia Overlapping Becker's Melanosis

Report of a 46-year-old carpenter who revealed of the physical examination an extensive thread-like telangiectase in the distribution of C 4 -C 7 , and a large hypertrichotic, slightly hyperpigmented patch with well demarcated irregular borders on the left upper back and chest which was a Beckers melanosis

a Direct Comparison of Visual Inspection, Curettage, and Epiluminescence Microscopy in Determining Tumor Extent Before the Initial Margins Are Determined for Mohs Micrographic Surgery

BACKROUND Mohs micrographic surgery (MMS) is a tissue‐sparing technique for the removal of cutaneous malignancies. There is no standardized procedure for determining tumor extent before taking the initial margins during the first stage of Mohs. OBJECTIVE To compare visual inspection, curettage, and dermoscopy in determining tumor extent before initial margins are taken for MMS. METHODS Fifty‐four patients were randomized into three groups (visual inspection, curettage, or dermoscopy) before MMS for basal cell carcinomas on the nose. One of these three methods was used to delineate the biopsy site or residual tumor. The final number of stages and postoperative defect sizes were recorded. RESULTS There was no statistically significant differences for the final number of stages (p=.20) or the final defect sizes (p=.47) between the three arms. CONCLUSION There has been controversy as to whether presurgical curettage is appropriate before MMS. Some feel that curettage better delineates the tumor, leading to fewer stages, whereas others feel that curettage may falsely increase the final defect size, negating any tissue‐sparing advantages of the procedure. Our study did not demonstrate any differences in the final number of stages or postoperative defect sizes between the three test groups. 3Gen loaned the dermatoscope and camera for this study.

Using an absorbable purse-string suture to reduce surgical defects of the nose before placement of full-thickness skin grafts.

thickness nasal ala defects with a technique that uses both a partial-thickness auricular cartilage complex graft and a nasolabial flap. The curved contour of the auricular cartilage is similar to that of the nostril, which makes it a good donor for ala reconstruction. The nasolabial flap was able to provide an abundant blood supply to nourish the cartilage complex graft, and thereby keep the entire reconstructed ala alive. In the only case with partial flap necrosis, the patient was a heavy smoker before the operation and continued to smoke postoperatively against the advice, which may have negatively influenced the blood supply to the flap, contributing to necrosis. In addition, the partial-thickness auricular cartilage complex grafts can restore the lining and cartilage simultaneously. Although the cartilage graft contains 2 layers, its thickness is still relatively thin. This important feature eliminates the need for another ancillary operation to debulk and recontour the transplanted graft.

Low-grade myxofibrosarcoma presenting at the site of prior high-grade disease*

Myxofibrosarcoma is one of the most common soft tissue sarcomas occurring in older adults. It can arise de novo or can be radiation induced, and the term myxofibrosarcoma was originally devised to encompass a spectrum of myxoid tumors with characteristics similar to malignant fibrous histiocytoma (MFH). Confusion exists, however, regarding the distinction between microscopic grade and characteristics of myxofibrosarcoma and MFH. Correct classification is vital to prognosis, as the degree of myxoid change is inversely related to the incidence of metastasis. We present a case of a 76‐year‐old man with a history of high‐grade MFH of the left lower extremity, status post excision and radiation therapy, who presented 2 years later with a regional metastatic recurrence of high‐grade MFH to the left groin as well as new nodules adjacent to and within his prior excision and radiation site. These new nodules were determined to represent low‐grade myxofibrosarcoma. These new low‐grade lesions either represent a low‐grade recurrence of high‐grade sarcoma or a new, radiation‐induced soft tissue sarcoma occurring at the same site. Radiotherapy, however, is an unlikely cause; specific postradiation sarcoma criteria have not been fulfilled. This article discusses both the nosology and histopathological spectrum of these important soft tissue sarcomas, their aggressive and recurrent nature and their association with radiation therapy.

Concomitant Merkel Cell Carcinoma and Basal Cell Carcinoma Presenting as a Solitary Nodule

We report a case of a concomitant basal cell carcinoma (BCC) and Merkel cell carcinoma (MCC) presenting as a solitary tumor. Despite the rarity of MCC in general, the tumor has been reported to occur synchronously with numerous malignancies, including chronic lymphocytic leukemia, dermatofibrosarcoma protuberans, melanoma, squamous cell carcinoma (SCC), and sebaceous carcinoma. There is also a report of a large, ill-defined, ulcerated MCC containing foci of SCC and BCC. To our knowledge, this is only the second report of concomitant BCC and MCC and the only case identified in a single, clearly defined tumor.

Reconstruction of large facial defects after Mohs surgery

Educational objectives: To be familiar with indications for Mohs surgery and to have several options available for facial reconstruction after Mohs surgery.

Mohs Micrographic Surgery

Mikhail combined his expertise with that of other authors and produced a text that covers many of the essential aspects of the Mohs technique. This book is designed to appeal to a varied audience. Aspects of Mohs Micrographic Surgery would be appropriate for Mohs surgeons, dermatologists, surgeons, nurses, and technicians. There are Mohs-specific chapters on origin and progress, fixed-tissue technique, techniques and indications, clinicopathologic correlation, operative suite and laboratory setup and design, approach to specific tumors and sites, wound healing and dressings, and prosthetics. Brief chapters on topics in basic surgery include anatomy, anesthesia, instrumentation, preoperative evaluation, and medical and surgical complications. Additionally, Mohs Micrographic Surgery has chapters on data collection and analysis and medical photography. Reconstructive techniques other than healing by secondary intent are not covered in this text. The detailed chapter on the fixed-tissue technique and the frequent references and examples of this technique throughout the text provide