W. Hussain

Nasal reconstruction: a dermatological surgeon's approach to recreating the 'aesthetic king' of the central face.

By virtue of its central facial location the nose represents the most aesthetically critical structure of the face, where it is quite rightly regarded as the aesthetic ‘king’. However, the nose is also the most common location within the head and neck for the occurrence of nonmelanoma skin cancer. Its reconstruction is therefore frequently encountered by all surgical specialists involved in skin cancer management. The stakes are high when reconstructing the nose – its unique topography of convexities, curves, depressions and free margins means that any subtle alteration in its form often results in an unforgiving asymmetry that is readily apparent to the observer. Furthermore, the functional role of the nasal airway in nonmouth breathing, warming and humidifying inspired air by maintaining patency of the nasal vestibule should be respected during its repair. The history of nasal reconstruction goes back many thousands of years, with the first reports by Sushruta in India dating back to 600–700 BC. However, over recent years the reconstructive surgeon has seen a huge expanse in the art of nasal reconstruction with a seemingly overwhelmingly large number of options by which any particular nasal surgical defect may be repaired. Indeed, entering the search term ‘nasal reconstruction’ into a popular web search engine produced over three million hits, and almost ten thousand manuscripts were generated with the same search terms entered on PubMed.gov (numbers correct at submission on 10 February 2014). Among the wide variety of repair options available to the reconstructive surgeon for nasal defects, the principle of aesthetic subunit repair is one that provides a sound foundation upon which to base a chosen repair. First described by Millard and subsequently modified by Burget, the borders of the differing nasal subunits are an ideal location for the placement (and subsequent concealment) of scars. An aesthetic subunit reconstructed with skin of uniform pigmentation, degree of actinic change and sebaceous quality generally yields a superior result. In this surgical supplement of the British Journal of Dermatology, I am delighted that dermatological surgeons from across the globe accepted my invitation to present their approach to reconstructing surgical defects arising within the subunits of the nasal tip, dorsum, sidewall and ala. These sections are preceded by a clinically orientated review of relevant nasal anatomy for the dermatological surgeon. Notably the authors are all fellowship-trained Mohs micrographic surgeons. Why is this important? It is via the tissue-sparing properties of Mohs surgery that shallow and oddly shaped defect(s) spanning more than one cosmetic subunit are often created. The approach of a Mohs surgeon in nasal reconstruction may thus differ significantly from that taken by other surgical specialists. Furthermore, all the repairs discussed within this supplement (including interpolated flaps) have been performed by the authors under local anaesthesia. There are numerous data pertaining to the safety and acceptance of Mohs surgery and repair under local anaesthesia, and for those who still question the reconstructive repertoire of dermatological surgeons this supplement aims to illustrate what we actually do. No two patients or their defects are ever the same and there will always be several methods of ‘fixing a hole’. This clinically orientated supplement discusses approaches and clinical pearls by which those involved in, or with an interest in, nasal reconstruction may benefit.

‘Pin-point precision’ for pexing sutures

significant difference in SCC distribution in French men (L 55 3%, R 44 7%; P < 0 01) and a similar trend to right-sided SCC in U.K. men. Lateralization of nonmelanoma skin cancer (predominantly CIS) in OTRs has not previously been described. Its left-sided predominance in France compared with a right-sided dominance in the U.K. is consistent with exposure to UV radiation while driving. These data require validation, but indicate that exposure to UVA, through window glass while driving, is a potentially relevant risk for OTRs. Therefore, it is essential to recommend sunscreen application or other UV-protective measures in skin-cancer-prone individuals who spend significant time driving.

Patient satisfaction with post‐operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience

Backgroundu2002 Mohs micrographic surgery (MMS) is regarded as the gold standard for treating nonmelanoma skin cancers of the head and neck. Surgical interventions can generate anxiety for patients and efforts to minimize this may enhance their experience.

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. n nIn 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. n nThis article is protected by copyright. All rights reserved.

The "sine wave" flap for the repair of defects of the distal nose.

Case History An 80-year-old woman underwent Mohs micrographic tumor extirpation of an infiltrating basal cell carcinoma on the right nasal tip. Tumor-free margins were achieved after two stages and resulted in a 1.5by 2.3-cm deep defect down to perichondrium involving the nasal tip, lower nasal dorsum, and anterior ala and approaching the right nasal soft triangle (Figure 1). How would you reconstruct this defect?

The utility of the 'temporary marginal lid suture' in facilitating Mohs surgery for tumours involving the eyelid.

MADAM, The application of temporary sutures placed through the tarsus of the lower eyelid is well documented in the oculoplastic and dermatological surgery literature. They are generally used as suspension sutures (Frost sutures) to reduce the risk of ectropion due to wound contraction after reconstructive procedures involving the lower eyelid. The use of temporary sutures to facilitate Mohs surgical extirpation of eyelid tumours has not previously been described. Mohs surgical excision of skin cancers involving the eyelids presents unique challenges to the surgeon. The very thin, mobile nature of eyelid skin and the need to evert the lid to incise the conjunctiva for marginal lid tumours makes the incision of tissue difficult and the harvesting and orientation of an optimal Mohs surgery specimen technically demanding. Methods to facilitate stabilization of the tissue include the use of chalazion clamps, jaeger plates and manual stretching of the skin by the surgical assistant. We describe the use of a marginal eyelid suture to stabilize the eyelid, stretch the tissue and evert the lid when incising the conjunctiva, which in our experience is a useful tool to ensure highquality Mohs surgery specimens for frozen section tissue processing. After the periphery of the tumour has been marked and the area anaesthetized, a 6 ⁄0 monofilament suture of the surgeon’s choice is passed through the tarsal plate at the lid margin (Fig. 1a). In this particular example, the suture is passed through both the tumour and the tarsal plate. The needle is then removed and the suture left in place. During Mohs extirpation of the tumour, the surgical assistant controls the suture. Traction can be applied in such a way as to stabilize and stretch the eyelid skin and also to apply vertical traction when required (Figs 1b, 2a). We have found this technique useful for the first stage of Mohs micrographic surgery when treating marginal lid tumours of either the lower Table 2 The reported effects of stopping nicorandil Site Number of responses No improvement (%) Some improvement (%) Full improvement (%)

Mohs surgery spares the orbicularis oris muscle, optimizing cosmetic and functional outcomes for tumours in the perioral region: a series of 407 cases and reconstructions by dermatological surgeons

DEAR EDITOR, Mohs micrographic surgery (MMS) remains the gold standard in the management of nonmelanoma skin cancers (NMSCs) of the head and neck. Perioral defects pose a particular challenge for the reconstructive surgeon with over 100 procedures described in the literature. We undertook a retrospective review of all perioral cases managed with MMS over a 7-year period from January 2004 to December 2011. Data was collected from our electronic database, medical records and histopathology reports. The information collated included patients’ age and sex, anatomical region of the lesion, histological type of tumour, mode of anaesthesia, preand postoperative defect sizes, number of stages required to achieve tumour clearance and reconstructive techniques adopted. All surgical defects resulted from MMS for removal of skin cancer. The majority of the procedures were performed under local anaesthetic (LA) using 1% lignocaine with adrenaline (1 : 200 000) and ropivacaine hydrochloride (Naropin , Astra Zeneca, Auckland, New Zealand) intraoral nerve blocks. The vast majority (98%) of reconstructions were undertaken by dermatological surgeons accredited by the American College of Mohs Surgery. All patients who had undergone MMS under LA were contacted by telephone (J.H.; Tauranga, New Zealand) retrospectively, to ascertain the patients’ perception of the tolerability of MMS and subsequent reconstruction under LA. All postoperative clinical images were reviewed independently by another Mohs surgeon working at a different institution (W.H.; Leeds, U.K.) and graded according to a scale (excellent, good, average, poor). This co-author also trained at the same institution in New Zealand and therefore cases that he was directly involved with were excluded from the study. In total, 407 perioral Mohs surgical cases were performed over the 7-year period. Table 1 shows the summarized data in relation to patient demographics, surgical sites, histological subtypes of the tumours and closure methods adopted. Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) comprised the majority of the tumours with a female preponderance in the BCC group. There were only two isolated cases of other tumour types (eccrine carcinoma and malignant fibrous histiocytoma). The majority of the NMSCs were primary, and aggressive histological subtypes accounted for 40% of BCCs and 10% of SCCs. The mean Breslow thickness for SCCs was 1 7 mm with perineural invasion being a feature in 1% of cases. Although upper cutaneous lip carcinomas (CLC) were more prevalent than lower CLC, lower vermillion lip carcinomas (VLC) were more common than upper VLC. Tumours which breached the upper and lower vermillion/ cutaneous junction were comparable in both regions. There were 20 (5%) full-thickness defects with preand postoperative defect sizes being similar between both tumour types. Importantly, histological clearance was achieved in one stage for only half the cases. More than half (58%) of the surgical defects were reconstructed with random pattern flaps, the majority of which were performed under LA; 1% were reconstructed by allied healthcare professionals. Complications included infection (eight cases, five of which occurred in smokers), six cases of troublesome postoperative anaesthesia which resolved without intervention and 15 cases of postoperative pincushioning which responded well to a combination of triamcinolone acetonide injections and massage. Of the 407 cases, the cosmetic results graded according to the clinical images were as follows: excellent, 320 (79%); good, 60 (15%); average, 22 (5%); poor, 5 (1%). On reviewing the postoperative medical records, no significant long-term functional disability was noted, in particular, no microstomia or saliva drooling was evident. Response to the telephone follow-up survey was good: 380 (93%) responded, of whom the majority (360, 95%) felt the procedure was very comfortable and, if required, would be happy to undergo further MMS in the perioral region under LA; there was no correlation with defect size or complexity of reconstruction in the minority who did not. In this study the number of full-thickness defects created post-MMS was proportionately very small. To our knowledge, there is currently no data in the literature to suggest how many tumours in this study would have required full-thickness technique reconstruction. Bearing in mind that 35% of the tumours in this study were SCCs, it is conceivable that up to 50% of defects may have ended up with a full-thickness defect without the MMS technique. In addition, the collated demographic data were in line with previous studies with regard to tumour histology and age range, and the sex distribution revealed a greater proportion of BCCs occurring in females in the perioral region in keeping with previous studies. The retrospective telephone follow-up component of this study, which assessed patients’ tolerability of undergoing MMS in the perioral region, supports our view of performing these procedures under LA. There is wide-ranging practice among allied specialists who perform perioral surgery under general anaesthesia, which may in part be due to these specialists having ready access to anaesthetists. This study has shown that the majority of patients do in fact tolerate MMS in the perioral region under LA, thus obviating the need for general anaesthesia and the attendant risks associated with it. This is particularly important in older patients who may have concomitant co-morbidities that may increase the overall risk of the procedure. NMSCs in the perioral region are managed by a number of specialties including dermatology, plastic surgery and maxillofacial surgery. The approach of fellowship-trained dermatological surgeons towards the management of tumours in the perioral region may well differ from these allied specialties.

Reducing the strain of dermatological surgery.

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Optimizing the transfer of split-thickness skin grafts from the donor to the recipient site using the 'moist gauze pick-up' technique.

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'Skimming the surface': a review of split-thickness skin grafting practices and preferences among U.K. dermatological surgeons.

rs240993, from our GWAS of the TRAF3IP2 gene in psoriasis. It is different from that reported in the western population. Ellinghaus et al. included rs33980500, which causes a missense mutation from aspartic acid to asparagine, in their interaction analysis, rather than rs13210247, the top association SNP in TRAF3IP2, because rs33980500 accounts for the association at the TRAF3IP2 gene locus. It is believed that there is ethnic heterogeneity not only in psoriasis susceptibility genes, but also in the gene–gene interaction networks. In this study, we have confirmed the previous positive interaction between ERAP1 and HLA-C, although different SNPs were genotyped and we got a negative epistasis result between TRAF3IP2 and HLA-C, as in previous results in white patients. Nevertheless, we did not find evidence for interaction between TNFAIP3 and HLA-C in our Chinese Han population, highlighting the ethnic heterogeneity for this pairwise interaction.