Glenn D. Goldman

Mohs Surgery Is Effective for High-Risk Cutaneous Squamous Cell Carcinoma

BACKGROUND Mohs micrographic surgery (MMS) is effective in the treatment of invasive cutaneous squamous cell carcinoma (SCC). High‐risk SCC has a more guarded prognosis. OBJECTIVES To report the outcome of patients with high‐risk SCCs treated with MMS. METHODS AND MATERIALS Two hundred fifteen patients with 260 high‐risk cutaneous SCCs were reviewed in a single‐center retrospective study, considering rates of recurrence, metastasis, and death. Cases were analyzed according to sex, age, immunocompetency status, tumor depth, lesion site, perineural disease, death rate, cause of death, secondary SCC, and melanoma. Seventy‐seven percent of patients were male; 23% were female. Average age was 70.6. Twenty percent of patients were immunosuppressed. Mean follow‐up was 3.9 years. RESULTS There were three local recurrences (1.2%). Twelve (4.6%) tumors involved named nerve trunks. In eight of these cases, adjuvant radiation therapy was employed. Six (2.3%) tumors metastasized, with one fatality from disease. Seventy‐five percent of patients developed another cutaneous SCC, and 7.7% developed a subsequent malignant melanoma. CONCLUSIONS MMS is an effective treatment for high‐risk cutaneous SCC. This represents the largest single‐center study of high‐risk SCC supporting the use of MMS. Adjuvant radiotherapy was reserved for large‐nerve perineural disease. There was a low recurrence rate and disease‐specific mortality. Prompt recognition of metastatic disease allowed for curative therapy. Patients with one high‐risk SCC are likely to develop secondary primary SCC and melanoma. The authors have indicated no significant interest with commercial supporters.

Mohs Micrographic Surgery: How ACMS Fellowship Directors Practice

BACKGROUND Mohs micrographic surgery (MMS) is widely employed in the removal of skin cancer. As this technique becomes more widely employed, it is useful to establish the patterns of care provided by American College of Mohs Surgery (ACMS)‐approved fellowship directors. OBJECTIVE To compile and analyze data collected annually by the ACMS to determine practice patterns and trends in MMS as performed by ACMS‐approved fellowship directors. MATERIALS AND METHODS A retrospective study of case logs from 50 fellowship directors obtained from the ACMS detailing case volume, type of cancer treated, location, lesion size, wound size, number of stages, referral percentage, and type of repairs performed. RESULTS Annual case volume per surgeon has increased linearly. The incidence of squamous cell carcinoma treated using MMS is rising steadily. The size of lesions treated using MMS has decreased slightly over several decades, as has the number of stages of MMS taken per lesion. The majority of MMS performed by fellowship directors is for skin cancer on the face. Dermatologic surgeons perform most of their own reconstructions. Academic and private fellowship practice patterns are nearly identical. CONCLUSIONS ACMS‐approved fellowship directors use MMS mainly for facial skin cancers, and they perform most of their own reconstructions. Practice patterns for most fellowship directors are similar. Private fellowships and academic fellowships are similar in scope and practice. The authors have indicated no significant interest with commercial supporters.

Development of cerebral air emboli during mohs micrographic surgery.

Gas embolism is the entry of gas, usually air, into the systemic circulation. Because gas emboli can have catastrophic effects on target tissues by causing end-artery obstruction with resultant ischemia and because gas emboli have been described after a number of minor and major invasive procedures in many medical and surgical specialties, all dermatologic surgeons should be aware of the potential development of this unusual surgical complication.

Tangential Shave Removal of Basal Cell Carcinoma

Objective To determine the outcome of tangential shave removal (TS) of basal cell carcinoma (BCC) on the trunk and extremities. Design Cohort study of patients with multiple truncal BCC treated using TS in an academic dermatologic surgery practice. Setting Academic institution referral practice. Patients Individuals with BCC referred to the dermatologic surgery unit for ongoing therapy of multiple lesions. Interventions TS of amenable superficial and nodular BCCs with twice‐annual follow‐up. Lesions were removed using a scalpel as a uniform‐depth mid‐to‐upper dermal shave and sent for routine pathology. Basic wound care was applied. Primary Outcome Measures Apparent cure rate and outcome of scars. Results One hundred eighty‐two BCCs were treated in 19 individuals. Patients were followed for an average of 5.2 years. One lesion recurred. Three specimens had positive margins requiring further surgery. Scarring was acceptable and similar to what is observed with curettage and electrocoagulation. Conclusions TS is a reasonable treatment for primary superficial and nodular BCC on the trunk and extremities.

Eyebrow Reconstruction After Removal of Melanoma in Situ

A 39-year-old woman presented with a 1.6by 1.0-cm brown and black patch in the left eyebrow. A broad shave biopsy revealed melanoma in situ. Excision was undertaken with Mohs surgery using the melanoma antigen recognized by T-cells-1 immunostain. Negative margins were achieved in three stages, resulting in a 3.4by 2.3-cm defect involving the entire central brow and a portion of the forehead (Figure 1). How would you reconstruct this defect?

An Elongated Leading Edge Facilitates Rotation Flap Closure: In Vivo Demonstration.

BACKGROUND Variation in the design of a rotation flap may affect wound closure tension. Lengthening the leading edge of a rotation flap has been a method of reducing the tension of closure in the primary motion. An in vitro study negating this tenant has been published. OBJECTIVE The authors set out to design an in vivo experiment to determine if lengthening the leading edge of a rotation flap has the effect of reducing closure tension in the primary motion of the repair. MATERIALS AND METHODS An animal study approved by Institutional Animal Care and Use Committee was undertaken in a pig model. A tension-measuring apparatus was designed using Teflon-coated wires and digital tensiometers. Rotation flaps of a standard design and with elongated leading edges were incised on the flanks of pigs under general anesthesia. Flap closure tensions were measured at points along the leading edge of the flap and in the secondary motion. RESULTS Elongating the leading edge of a flap led to a statistically significant reduction in closure tension in the primary motion of the flap and at the flap tip. The secondary motion closure tensions were essentially unaffected. CONCLUSION The authors confirm that elongating the leading edge of a standard rotation flap will reduce closure tension in the primary flap motion.

Treatment of Actinic Cheilitis.

Actinic cheilitis is described as a condition requiring treatment with “urgency.” In fact, AC is an indolent condition. The latency to development of lower lip squamous cell carcinoma (SCC), if that occurs, is decades. In mild cases, the use of sunscreen and emollients with occasional cryosurgery is a fitting treatment. There seems to be an overstated risk of progression to invasive SCC deriving from references, which are not applicable to typical patient populations. Specifically, the studies cited are of South American and Greek patient cohorts with severe sun exposure, patients diagnosedwith SCC inwhich AC is diagnosed, and several studies of oral leukoplakia, which is not AC and has a very different natural history. Actually, there are no good long-term longitudinal studies of untreated AC and no one knows the true rate of progression to SCC.

Reconstruction of the nasal infratip, columella, and soft triangle.

BACKGROUND Tumors of the soft triangle and distal nose are common, and the wounds created when removing them are among the more challenging defects to repair. OBJECTIVE Reconstruction of the soft triangle, infratip, and columella requires attention to form and function beyond what is usually needed in cutaneous surgery. The complexities of the anatomy demand meticulous planning and surgical execution. In this review, the goal is to provide the cutaneous surgeon with a logical approach to repair this challenging region. METHODS Skin grafts, composite grafts, local flaps, and pedicle flaps are presented with pearls and pointers. Cartilage grafting for stability is reviewed and detailed. A step-by-step approach allows the surgeon to plan appropriately and execute repairs with excellence. RESULTS Ten cases are reviewed in sequential photo format to demonstrate successful reconstruction of operative wounds from this challenging region of the nose. CONCLUSION The most distal nasal contours pose many challenges for reconstruction. Success depends on a good knowledge of anatomy, rigorous planning, and superior surgical skills. Skin grafts, composite grafts, local and interpolated flaps are all options that need to be considered when recreating the delicate folds and contours of this region. Cartilage support may be needed to maintain structural integrity. With care, excellent outcomes are predictably achieved.

Cryostat Injury with Distal Finger Amputation Repaired Using a Composite Graft

Cryostat injuries are not uncommon. Most involve minor cuts in which the main concern is microbial contamination. Cryostats are now designed with blade safety guards to prevent such injuries (Figure 1A and B). In our laboratory, an experienced technician suffered a substantial distal avulsion injury from a cryostat blade while cleaning the cryostat. This case highlights the importance of safety while cleaning a cryostat and reports the successful outcome of a fingertip reattached as a composite graft after amputation and freezing.