T. Oliphant

Motor nerves of the head and neck that are susceptible to damage during dermatological surgery

As the incidence of non melanoma skin cancer rises, dermatologists will increasingly be called upon to perform excisions in the head and neck region. Damage to the motor nerves of the head and neck represents an important adverse event for patients, and a source of litigation for surgeons. Understanding the anatomy of this region is key to counselling patients about the possibility of motor nerve injury associated with particular skin surgical procedures. We describe the anatomy of the motor nerves of the head and neck that are most vulnerable to injury during dermatological surgery. The consequences of injury are outlined, and the surface anatomy and anatomical landmarks that may be used to identify the relevant danger zones are described.

Safety, complications and patients’ acceptance of Mohs micrographic surgery under local anaesthesia: results from the U.K. MAPS (Mohs Acceptance and Patient Safety) Collaboration Group

By virtue of its tissue sparing properties and assessment of 100% of the margin of excised specimens, MMS is regarded as the gold-standard surgical treatment of high-risk non-melanoma skin cancers of the head and neck. From its original inception in the 1940s, modern day MMS has evolved to become a fresh tissue surgical technique, using frozen section margin control performed under local anaesthesia in an out-patient or day-case setting. In the UK, the increasing burden of skin cancer has resulted in a greater demand for MMS with over 32 units across the country providing the technique. This article is protected by copyright. All rights reserved.

Dermoscopy prior to Mohs micrographic surgery does not improve tumour margin assessment and leads to fewer Mohs stages

DEAR EDITOR, Mohs micrographic surgery (MMS) is a time-consuming and expensive gold-standard treatment for difficult-totreat basal cell carcinoma (BCC). One factor that contributes significantly to the expense and duration is the number of stages required to obtain clear excision margins. Dermoscopy is a noninvasive and inexpensive procedure. It has been used principally for the diagnosis of pigmented lesions but is also useful when reviewing BCC. We have investigated whether the use of noncontact dermoscopy has an influence on the number of Mohs stages required for tumour clearance. We included 317 patients with head and neck BCCs excised by MMS, of whom 170 were male, 147 female, median age 72 years (range 30–91). Patients were randomized to either loupe-assisted naked-eye or noncontact dermoscopy (DermLite DL200 hybrid; DermLite, San Juan Capistrano, CA, U.S.A.) assessment of tumour margins prior to the debulking excision. Consultants and surgical fellows assessed the lesions and performed the surgery. We recorded the tumour clinical subtype, dimensions, anatomical location and histological subtype, and the total number of resection stages required for tumour clearance. Recurrent tumours were excluded. When determining the presence of BCC, the following classical patterns were used: arborizing telangiectasia, maple-leaf-like areas, large blue-grey ovoid nests, ulceration, multiple blue-grey globules and spoke-wheel areas. Results were analysed using a Poisson regression model: 244 (77%) of the 317 BCCs were classified by the operator as nodular, 37 (12%) as morphoeic and 23 (7%) as superficial. The mean tumour dimensions were 12 9 9 mm (range 3 9 3 mm to 60 9 46 mm). Figure 1 shows results for the number of stages for dermoscopy vs. naked-eye examination. A univariate Poisson regression model was fitted with an outcome of number of stages, and the following explanatory variables: use of dermoscopy, clinician seniority, clinical subtype, and histological growth pattern of tumour. There was no statistically significant relationship (P < 0 05) between number of stages and the four variables. A subgroup analysis looking at all types of histological growth pattern of BCC and the use of dermoscopy yielded no statistically significant results, nor did analyses looking at relationships between use of dermoscopy and anatomical location and clinical subtype. Our study has shown that the use of noncontact dermoscopy to identify tumour margins prior to the debulking excision does not reduce the number of stages required in MMS, irrespective of clinician experience, clinical subtype and tumour histological growth pattern. Our findings are similar to those of others. Histological types under those we called

Nasal anatomy for the dermatological surgeon.

The nose is an important site of skin pathology and skin cancer in particular, underlining the importance of the nose to the practice of dermatology. This article is intended to serve as an overview of the anatomy of the nose for dermatologists and dermatological surgeons. Areas of clinical relevance are emphasized with examples.

Score and shave technique with freehand scalpel for harvesting small split‐thickness skin grafts in dermatological surgery

We describe a technique of freehand scalpel harvesting, whereby the split-thickness skin graft (STSG) to be harvested is outlined and the margin scored with a scalpel prior to freehand scalpel harvesting. We term this technique ‘score and shave’, and describe it with illustrative cases in the reconstruction of surgical wounds following Mohs micrographic surgery (MMS) and standard excisional surgery. STSGs consist of the epidermis and a small amount of the underlying dermis, and they are classified according to their thickness. STSG has advantages compared with full-thickness skin graft (FTSG), including reduced metabolic demand, and therefore have an increased chance of graft take. They can thus be used to give coverage to large wounds, particularly those that do not have a robust vascular base. STSGs may be meshed to enable large surface area coverage and to allow the drainage of blood and exudates underneath the graft. The score and shave technique involves marking the donor site to the size of the STSG required with a surgical marker pen. The donor site is then injected with local anaesthetic. A no. 15 blade on a scalpel handle is used to score the perimeter of the graft to the appropriate level of the dermis (Fig. 1a). The blade is then used to harvest the STSG by laying it flat against the dermis, and using a smooth and gentle horizontal cutting motion parallel to the skin surface at the same depth throughout the graft until the STSG is released (Fig. 1b,c). The donor site will show pinpoint capillary bleeding points, which may be cauterized with aluminium chloride hexahydrate 20% solution, then a 3M Tegaderm transparent dressing is applied. The harvested STSG is then sutured to the recipient wound (Fig. 1d–f) using basting sutures, and this is followed by a pressure dressing. A bolster dressing is not used. We have used score and shave STSG in the reconstruction of wounds involving the pinna (Fig. 1d–f), the digits (Fig. 2a–c) and the feet. For auricular reconstruction, the sites used for harvesting score and shave STSGs included the postauricular neck and postauricular scalp areas. The donor site for the digits and feet were from the lateral thigh. We have noted good STSG cosmetic outcomes in the repair of small surgical wounds (up to 30 mm in diameter) of the ear, digit and foot. FTSGs consist of the epidermis and dermis. FTSGs have a higher metabolic demand, and therefore they are more prone to necrosis than STSG but contract less. FTSGs may be the repair of choice in some surgical wounds involving the ear, nasal tip, dorsum, ala and sidewall, periocular skin, limbs, and digits. Common donor sites for facial wounds include preauricular, postauricular and supraclavicular areas. Tools for harvesting STSG include hand-operated and electric dermatomes, which may be used in conjunction with biological dressings or tumescent anaesthesia. Freehand harvesting techniques using a scalpel or flexible razor blade are also reported. Snow et al. described freehand scalpel harvesting in 1991. They suggested using a no. 15 scalpel blade in a bevelled or vertical incision to enter the dermis and then slicing the upper dermis at a blunter vertical angle when at the desired level of the dermis to harvest the graft. They suggested that the angle allows for stabilization of the dermis as the graft is harvested, but decreases the velocity at which the graft is Correspondence: Dr Prativa S. A. Jayasekera, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK E-mail: prativaj@gmail.com

Squamous cell carcinomas in linear epidermal naevi

1 Van Voorhees A, Stenn KS. Histological phases of Bactriminduced fixed drug eruption. The report of one case. Am J Dermatopathol 1987; 9: 528–32. 2 Agnew KL, Oliver GF. Neutrophilic fixed drug eruption. Australas J Dermatol 2001; 42: 200–2. 3 Ozkaya E, B€ uy€ ukbabani N. Neutrophilic fixed drug eruption caused by naproxen: a real entity or a stage in the histopathologic evolution of the disease? J Am Acad Dermatol 2005; 53: 178–9. 4 Waldman L, Reddy SB, Kassim A et al. Neutrophilic fixed drug eruption. Am J Dermatopathol 2015; 37: 574–6.

An Unusual Periungual Lesion

History A 56-year-old female presented with a 3-month history of a painful, subungual lesion arising from the distal nail bed of the left hallux ( Fig. 1 ). Her past medical history included sarcoidosis, for which she was receiving treatment with oral prednisolone. On examination she had a firm, hyperkeratotic lesion, which was approximately 6 mm in diameter underneath the left great toenail ( Fig. 2 ).

Successful treatment of forehead lipoma depends on knowledge of the surgical anatomy: a step-by-step guide

We review the anatomy of the frontal scalp in relation to the clinical features and surgical management of frontalis‐associated lipoma. Awareness of this entity, coupled with sound regional anatomical knowledge, is essential to achieve good outcomes.

Diagnostic biopsy before Mohs micrographic surgery, frequency of change in diagnosis and impact on management.

DEAR EDITOR, Mohs micrographic surgery (MMS) is the most effective surgical method for complete removal of skin tumours. In the majority of cases the referring physicians rely on either the clinical characteristics of a tumour or a diagnostic biopsy, which provides histological confirmation of the diagnosis and may inform about the growth pattern of a tumour. We usually undertake debulk excision of the tumour before the first Mohs stage. A piece of the debulk specimen may be removed and placed ‘side on’ on a slide next to one of the blocks of the first Mohs stage to allow histological examination of vertical sections of the Mohs debulk specimen. The purpose of this study was to investigate the frequency of change in histological diagnosis in a group of patients undergoing MMS and to investigate whether a diagnostic biopsy prior to MMS would have led to a change in the patients’ management. A ‘change in diagnosis’ was recorded when a different diagnosis was reported on the Mohs debulk specimen following histological examination by a dermatopathologist. We performed a retrospective study of our consecutive MMS data over a period of 18 months (January 2011 to June 2012). Patient identification and all relevant information were collected from the Mohs maps, which are completed by the Mohs surgeon during MMS. The histological results of the Mohs debulk specimens were collected from the hospital’s electronic results system. In total 873 consecutive unselected cases of MMS were included in the study. The mean age of patients was 68 years (range 30–100). In 23 of 873 patients (2 6%) the histological diagnosis changed after MMS. The initial diagnosis at the time of referral for MMS was basal cell carcinoma (BCC) in 819 of 873 cases (94%). Other diagnoses included squamous cell carcinoma (SCC) (32 patients), dermatofibrosarcoma protuberans (n = 6), atypical fibroxanthoma (n = 3), desmoplastic trichoepithelioma (n = 5), lentigo maligna (n = 2), sebaceous carcinoma (n = 2), eccrine spiradenoma (n = 2), desmoid fibromatosis (n = 1) and primary mucinous carcinoma (n = 1). In 395 of 873 patients (45%) this diagnosis was reached following a diagnostic biopsy. Only 28 of 873 patients (3 2%) had incomplete excision of a BCC prior to MMS. No pre-MMS biopsy was done in 450 of 873 patients (52%). In 23 of 873 patients the diagnosis changed following examination of the MMS debulk specimen. Ten of the 23 patients had a diagnostic biopsy prior to referral for MMS, whereas 13 had no diagnostic biopsy performed. The clinical

Helical rim reconstruction utilizing a postauricular interpolation flap

DS01 Proposal for National Dermatology Surgery Safety Standards: development of a dermatology surgery standard operating policy with mandatory training of staff may be an important tool to prevent wrong-site surgery R. Bhutani, C. Machin, G. Stables, V. Goulden and A. Mitra Chapel Allerton Hospital, Leeds, U.K. Wrong-site surgery (WSS) is the second most common reported adverse event, and accounts for 20% of National Health Service dermatology legal claims. WSS is more of a risk in dermatology because of the difficulties in identifying skin biopsy sites, including variance of individual documentation; time lag between initial consultation and surgical procedure, often by different clinicians; and multiple lesions in close proximity confounded by background secondary changes. It has been shown that up to one-third of dermatology patients are unable accurately to identify their own initial skin biopsy site. We reported two cases of WSS in 2012 at our centre, where 5200 local-anaesthetic skin surgeries are performed per year. Our initial written local surgical standard operating procedure (SOP) was produced in 2013 with introduction of a surgical checklist and the development of triplicate carbon copies of a combined surgery/photography booking form, which included large body maps to facilitate transmission of correct site identification and documentation across all multiprocedural teams. Despite this we experienced two further cases of WSS in 2014. We present the subsequent procedural changes made through our clinical governance processes to prevent further WSS and improve our patient safety and quality standards. This includes the introduction of a ‘double check policy for lesion marking’, where photographers are instructed to send patients back to the clinician if the site is not properly marked with an arrow. Use of a mirror is mandatory to reconfirm the site with the patient prior to photography and surgery, and there is a final ‘surgical pause’ where the assistant calls out and reconfirms the site and procedure with the patient and surgeon. Human factor training is being organized. Our trust has now mandated annual training in our SOP for all multidisciplinary staff involved. Specific educational intervention using a training session has been associated with reduction in WSS in a dental outpatient setting. Following our first training in 2015, improvement in lesion marking was demonstrated from a photography audit. We have also developed an interactive, scenario based e-learning dermatology SOP module to ensure that training is updated and maintained in a robust manner. This will also generate measurable evaluation outcomes that can be linked to appraisals. In 2015 National Safety Standards for Interventional Procedures were produced, but these are not specific to dermatology. We propose that our speciality produces National Safety Standards for Dermatology Surgery with standardization of local SOPs and consideration of mandatory SOP training, which could reduce WSS and deliver a safer consistent patient service across the U.K.