Tatyana R. Humphreys

The Biomechanical Properties of the Skin

BACKGROUND The skin possesses unique biochemical properties that allow it to protect and conform to the body that it covers. Elements constituting the dermis—collagen and elastin—primarily afford these properties. OBJECTIVES To define these properties and explore their relevance with regard to aging skin and dermatologic surgery. MATERIALS AND METHODS In the first part of this review, the determinants of mechanical properties of the skin will be outlined, through an extensive review of the literature. General physical properties that explain the behavior of skin will be defined, and diseases that manifest the extremes of those properties will be discussed. In the second half of this discussion, the surgical implications of skin biomechanics will be reviewed. RESULTS Emphasis will be placed on understanding how dermatologic surgeons may optimally use skin properties to produce the best cosmetic and functional outcomes possible. CONCLUSION Understanding of the biomechanical properties of skin is paramount to obtain the best cosmetic outcomes in dermatologic surgery.

Cutaneous Metastasis of Chordoma

Background. Chordomas are rare neoplasms that arise from the notochord remnant. They develop in the sacrococcygeal (50%) or cervical (15%) region and are generally regarded as a locally aggressive tumor with a slow progressive growth rate and a metastatic incidence ranging from 3 to 48%. Skin involvement by chordoma is rare, but can occur by direct extension, by local recurrence and by metastases. Objective. To illustrate by a case report the clinical presentation and management of this disease. Methods. We present a case of sacral chordoma with metastases over a 10‐year period to the lungs, the soft tissue of the chest wall, the triceps tendon, and distant cutaneous metastases to the back and the nose. Results. The cutaneous metastases were treated by excision. Conclusion. Chordoma is a slow growing tumor of the notochord remnant that may metastasize to the skin. Physicians and pathologists should be aware of this entity.

Assessment of postoperative pain after Mohs micrographic surgery.

BACKGROUND Mohs micrographic surgery (MMS) has the highest cure rate for the treatment of cutaneous malignancies and is usually performed in an outpatient setting with local anesthesia. Although most patients experience minimal discomfort during the procedure, postoperative pain after MMS has not been well‐characterized. The objective of this study was to evaluate the amount of postoperative pain after MMS and to determine whether the degree of pain is correlated with factors such as tumor location, size, number of excisions, or age or sex of the patient. MATERIAL AND METHODS One hundred fifty‐eight patients with skin cancer treated with MMS were included in this study. Information recorded for each study participant included age, sex, diagnosis, tumor location, number of sites, number of Mohs excision stages, and type of repair performed. A daily log was given to patients to record the amount of pain experienced using the Wong‐Baker pain scale and any analgesics that were taken for the 8 consecutive days beginning on the day of surgery. RESULTS The majority of patients reported some degree of pain on day 0 (mean pain score 1.97 ± 1.46) and day 1 (mean pain score 1.15 ± 1.20); the fraction of patients reporting pain and the severity of that pain diminished steadily thereafter. By day 7, only 25 patients (16%) were experiencing any pain (average pain score 0.21). Only 26 patients (16%) required prescription analgesics on the day of surgery (day 0) and fewer on subsequent days. Seventy‐seven of the patients used acetaminophen on day 0 (55%), which rapidly declined each subsequent day. Greater reported pain was significant for scalp procedures and multiple same‐day procedures. No significant differences in pain scores were noted with regard to age or sex. CONCLUSION Postoperative pain after MMS was associated with only mild to moderate pain on the day of surgery and the first postoperative day. Most pain was effectively managed using oral acetaminophen, with a minority of patients requiring prescription analgesics. Surgery on the scalp was significantly more painful than on other sites. Patients can be reassured that MMS and reconstruction is well‐tolerated and associated with only mild to moderate discomfort postoperatively.

Mohs Micrographic Surgery for Squamous Cell Carcinoma Associated with Epidermolysis Bullosa

Aradhna Saxena, MD, Jason B. Lee, MD, and Tatyana R. Humphreys, MD, have indicated no significant interest with commercial supporters.

The role of imaging in the management of patients with nonmelanoma skin cancer: When is imaging necessary?

&NA; When treating aggressive skin cancers, pre‐ and postoperative imaging provides important information for treatment planning and multidisciplinary cooperation of care. It is important for dermatologists to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. We here address the most common indications for imaging in cutaneous oncology and how to best utilize the modalities available.

The role of imaging in the management of patients with nonmelanoma skin cancer: Diagnostic modalities and applications

While uncomplicated cases of nonmelanoma skin cancer can be treated with surgery, destruction, or topical therapy alone, advanced or neglected cases require more complex management decisions. Dermatologists and dermatologic surgeons should be familiar with the imaging techniques relevant to cutaneous oncology and their value in different clinical scenarios. Herein we review imaging modalities used in management of nonmelanoma skin cancer.

Mohs Micrographic Surgery for Hidradenocarcinoma on a Rhinophymatous Nose: A Histologic Conundrum

Nodular hidradenoma (NH) is a rare tumor of the eccrine sweat glands, first described by Keasbey and Hadley in 1954. NH usually presents as a nonspecific dermal nodule on the head and neck but may also be seen on the trunk and extremities. NH can be difficult to distinguish histologically from its malignant counterpart, nodular hidradenocarcinoma (HC). Originally called a clear cell eccrine carcinoma, HC has been variably termed malignant acrospiroma, malignant clear cell hidradenoma, and clear cell hidradenocarcinoma. NH and HC are characterized by lobular aggregations of cells in the dermis with variable proportions of basaloid polyhedral and round clear cells. Lumina and cystic spaces may also be seen, as well as foci of keratinization. The presence of cellular atypia and an infiltrative pattern suggest HC.

A Novel Technique for the Extraction of Larger Lipomas

Although benign, large lipomas may necessitate removal because of discomfort or decreased range of motion. Conventional excision of the subcutaneous mass may produce an unacceptably large scar. Dosage limits for 1% lidocaine may restrict the amount of local anesthetic that may be safely used, preventing complete excision of large lipomas requiring more than 50 mL of 1% lidocaine. The use of tumescent anesthesia pioneered by Dr. Jeffrey Klein for liposuction uses large volumes of dilute lidocaine solution to achieve local analgesia, minimize bleeding, and avoid the risk of lidocaine toxicity. Tumescent liposuction has also been used as an effective and less invasive technique for removal of large lipomas. However, the larger fat lobules and fibrous stroma that characterize lipomas restrict the utility of liposuction cannulas to extract them. Incomplete removal and possible regrowth are thus more likely. We describe the use of tumescent anesthesia with a novel extraction technique for the removal of lipomas larger than 4 cm.

Commentary: Does the Use of Toluidine Blue and Hematoxylin and Eosin Improve Tumor Detection by Mohs Surgery Trainees?

Despite the preponderant use of hematoxylin and eosin (H&E) staining forMohs frozen sections, the utility ofmetachromatic staining ofMohs sections with toluidineblue (T-blue)hasbeen established in the literature and by the experience of theMohs surgeons who use it routinely. In this article, Tehrani and colleagues describe greater mapping accuracy (98% vs 95%) on the part ofMohs fellows when examining slides stainedwithT-blue than thosewithH&E.Basal cellcarcinoma(BCC)accountedfor87%ofthetumors treated in the study. The authors concluded that additional T-blue-stained slides added accuracy to the fellows’ interpretation over that of H&E alone. The use of dual staining was endorsed for training purposes, but the study would have had greater value if it had examined the converse hypothesis as well (Does the use ofH&E improve accuracy over T-blue alone?) Onewould expect that T-blue alone would be equally accurate because the majority of tumors were BCC.

Commentary: Commentary for Secondary intention healing of nasal alar defects.

As reconstructive dermatologic surgeons, we are always seeking innovative ways to close the defects we create. We sometimes forget that the simplest option may be the best. Although traditional teaching tells us that concave skin surfaces such as the alar crease or medial canthus heal best by secondary intention, it often works well for convex surfaces as well, as Neuhaus and Yu demonstrated. In reality, whether secondary intention healing is the best choice will depend on a variety of factors, including the size and depth of the defect, the risk of bleeding during and after surgery, and the patient’s ability or willingness to perform prolonged wound care.