Joel Cook

Cutaneous blastomycosis: a diagnostic challenge

Primary cutaneous inoculation blastomycosis occurs less commonly than secondary blastomycosis, in which cutaneous lesions most often originate from a primary pulmonary infection which disseminates through the blood or lymphatics to involve the skin. In secondary cutaneous blastomycosis, the primary pulmonary infection is frequently subclinical at the time cutaneous lesions manifest. Here we report two cases that illustrate the difficulty in distinguishing between primary and secondary cutaneous involvement. We also review the expanding literature on blastomycosis since its identification over a century ago.

The safety of Mohs surgery: A prospective multicenter cohort study

BACKGROUND Complications associated with Mohs surgery have been evaluated by single-surgeon studies. While these studies provide evidence for the safety of the procedure, prospective, multicenter studies afford a higher level of clinical evidence and establish further the safety profile of Mohs surgery in the ambulatory setting. OBJECTIVE This study was designed to prospectively evaluate major and minor complications as well as postoperative pain associated with Mohs surgery. METHODS A multicenter prospective cohort study was conducted evaluating the rate of major and minor complications as well as postoperative pain associated with the treatment of skin cancer using Mohs surgery in 1550 patients with 1792 tumors. Follow-up was obtained in 1709 of the 1792 tumors treated (95.3%). RESULTS No major complications occurred during Mohs surgery or reconstruction. A total of 44 (2.6%) minor primary postoperative complications occurred during the study. On a scale from 0 to 10, the average peak postoperative pain level was 1.99. LIMITATIONS Limitations of the study include the variability of practice patterns across practice sites as well as the 4.7% of patients lost to follow-up. CONCLUSION Mohs surgery is performed with a high degree of safety and is well tolerated by patients.

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.

Safety of Staged Interpolation Flaps After Mohs Micrographic Surgery in an Outpatient Setting: A Single‐Center Experience

OBJECTIVE To establish the safety of staged interpolation flaps performed in an outpatient dermatologic clinic setting. METHODS A retrospective chart review was performed of patients who underwent staged interpolation flap reconstruction by a single dermatologic surgeon after tumor clearance using Mohs micrographic surgery from 2000 to 2012 at the Department of Dermatology, Medical University of South Carolina. RESULTS Six hundred fifty‐three staged flaps were performed in 639 patients (mean age 65) between June 2000 and November 2012. Types of flaps included paramedian forehead flaps (n = 291, 45%), two‐stage melolabial flaps (n = 256, 39%), retroauricular flaps (n = 58, 9%), interpolated paranasal flaps (n = 40, 6%), and Abbe or Abbe‐Estlander flaps (n = 8, 1%). No major complications were observed. Of the minor complications, problems related to bleeding were the most prevalent; active bleeding requiring physician intervention was seen in 8.4% and hematoma formation in 0.4% of flaps. Postoperative infections were seen in 1.7% of patients after the initial surgery and 3.4% after division of the pedicle. Primary or secondary dehiscence was seen in 0.5%. Partial full‐thickness flap necrosis was seen in 2.3% and total flap necrosis in 0.6%. CONCLUSION The rate of complications associated with dermatologic surgeons performing interpolated flaps in an outpatient setting under local anesthesia is low. Our complication rates are equal to or lower than published complication rates from other surgical specialties.

The Interpolated Paranasal Flap: A Novel and Advantageous Option for Nasal‐Alar Reconstruction

Because of a paucity of lax tissue, the nasal ala can prove to be a challenging subunit to repair. Small alar defects can often be reconstructed using local flaps, composite grafting, or skin grafting. There are pitfalls associated with full-thickness skin grafts and local flap repair of alar defects. Fullthickness skin grafting often fails to provide an optimal match of skin texture, contour, and color and thus may detract from the final cosmesis of the reconstruction (Figure 1A). Although flaps are more challenging from an operative technical standpoint, they cannot be surpassed in providing aesthetic and functional repair of nasal defects after tumor extirpation. Various local and staged interpolation flaps have been previously described to address alar defects. Local flap reconstruction of alar defects must be done with the knowledge that alar distortion and compromise of the nasal valve are potential complications that can arise when working in this area. Another risk of local flap reconstruction of alar defects is the blunting or loss of the alar groove (Figure 1A). This sequela is a near certainty when performing a single-stage melolabially based rhombic flap reconstruction of the ala (Figure 1A and B). For these aforementioned reasons, alar defects frequently necessitate importing discontiguous tissue using an interpolation flap.

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.

Giant fibrous hamartoma of infancy: A report of two cases and review of the literature

We present two unique cases of fibrous hamartoma of infancy defined by giant-sized and/or multicentric cutaneous and subcuticular lesions--features not, to our knowledge, reported to coexist. We review the nature of such tumors and examine the clinical implications of tumor size and multicentricity on risk for recurrence and likelihood of visceral involvement.

Using cartilage and skin grafts concurrently: an alternate route to repair.

&NA; The authors have indicated no significant interest with commercial supporters.

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.