Walayat Hussain

The AIRNS flap: An alternative to the bilobed flap for the repair of defects of the distal nose

BACKGROUND Defects of the distal nose and nasal tip are inherently challenging to reconstruct. Although the bilobed flap has a pivotal role for the closure of such defects to achieve a satisfactory outcome, it demands meticulous planning and execution. OBJECTIVE We sought to present our experience of the advancement and inferior rotation of the nasal sidewall (AIRNS) flap as a possible alternative to the bilobed flap for reconstruction of the distal nose. METHODS All patients who underwent AIRNS repair after Mohs tumor extirpation of the nose at 2 regional skin cancer units since April 2011 were reviewed. RESULTS In all, 45 patients underwent the AIRNS flap repair. There were 25 men and 20 women, with a mean age of 70 years (range 41-88). The average defect size was 1.2 × 1.2 cm. The majority of cases involved the nasal tip. A single case of postoperative infection occurred in a smoker, which resolved without any long-term sequelae. No cases of flap necrosis or nasal airflow obstruction were seen. All cases produced good or excellent cosmetic results. LIMITATIONS Because of blunting of the superior alar crease, which may be avoided in a bilobed repair, the AIRNS flap is best avoided in laterally based defects of the nasal alar. CONCLUSIONS The AIRNS flap is a reliable, single-stage closure option that, in our opinion, is simpler in design and execution compared with the bilobed flap and thus adds to the reconstructive surgeons armamentarium when faced with centrally located defects of the distal nose.

Inferiorly Based Crescentic “Sliding” Cheek Flaps for the Reconstruction of Paranasal Surgical Defects

Doctors involved in the surgical management of skin cancer frequently encounter the repair of paranasal surgical defects. Similar to other reconstructions, these defects present surgeons with a variety of options, depending on the site, size, depth, and available tissue laxity. In the paranasal region, mobilizing the cheek skin reservoir for flap repairs allows the reconstructive surgeon to optimize tissue match and often to conceal resultant scar lines at the junction of cosmetic units or within naturally occurring rhytides. Another important consideration in this region is to avoid distortion of free margins such as the lower eyelid, ala, and upper lip caused by flap movement.

Sclerosing Squamous Cell Carcinoma of the Skin, An Underemphasized Locally Aggressive Variant: A 20-Year Experience

BACKGROUND Desmoplastic (sclerosing) responses to a variety of neoplasms have been documented but rarely evaluated in association with primary cutaneous squamous cell carcinoma (SCC). We report a distinctive variant of SCC demonstrating an infiltrative growth pattern and stromal desmoplasia. METHODS Cases were identified through a retrospective review of our dermatopathology and dermatologic surgery databases. After initiation of the study, additional cases were identified prospectively. Neoplasms were scored microscopically for specific histopathologic parameters and reactivity with selected histochemical and immunohistochemical stains. Clinical follow‐up data were obtained through a review of medical records or contact with the patients referring physicians. RESULTS Seventy‐three carcinomas from 72 patients were identified (46 men, 26 women; median age 76, range 45–91). The original pretreatment biopsies were available in 69 of 73 cases. All lesions developed on sun‐damaged skin, with the cheek constituting the most common site. The clinical presentation was typically as a sclerotic plaque. All neoplasms extended into the reticular dermis or subcutaneous fat, and perineural invasion was identified in 53 cases (73%). Patients who underwent standard excisional surgery experienced a recurrence rate of 80%; 9% of those treated with micrographic surgery experienced postoperative recurrences. Metastasis or carcinoma‐related death was not observed in any patient during the follow‐up period (median 36 months). CONCLUSIONS Our results suggest that desmoplasia is uncommonly found in association with cutaneous SCC but helps define a locally aggressive variant of carcinoma. In light of the infiltrative nature of desmoplastic SCC of the skin and the high incidence of perineural invasion, micrographic surgery is the surgical modality of choice. The authors have indicated no significant interest with commercial supporters.

The Nasal Sidewall Rotation Flap: A Workhorse Flap for Small Defects of the Distal Nose

BACKGROUND Skin cancers of the nasal tip present a challenge for the dermatologic surgeon. The bilobed flap has been widely used as the “workhorse” flap for such defects but requires meticulous design and may be complicated by a tendency toward pin‐cushioning. OBJECTIVE To describe the use of the nasal sidewall rotation (NSR) flap for reconstructing defects on the nasal tip. METHODS A retrospective analysis of the Mohs micrographic surgery database over a 4‐year period was performed. All cases in which the NSR flap was used were identified. Defect location and size and any postoperative complications were noted. All patients were reviewed at the time of suture removal and at 6 weeks. RESULTS There were 65 cases (19 men and 46 women). Age ranged from 39 to 86 (mean 60.5, median 59). Defect size varied from 0.4 to 2.0 cm in diameter, with 63% measuring 1.0 to 1.4 cm. Good to excellent results were seen in all patients, and postoperative complications were uncommon and minor. CONCLUSION The NSR flap is a versatile and useful alternative for reconstructing surgical defects of the nasal tip. The authors have indicated no significant interest with commercial supporters.

A low‐risk tumour, at a high‐risk site? Basal cell carcinoma of the nipple–areola complex

1 Veness MJ. Defining patients with high-risk cutaneous squamous cell carcinoma. Australas J Dermatol 2006; 47:28–33. 2 Quaedvlieg PJ, Creytens DH, Epping GG et al. Histopathological characteristics of metastasizing squamous cell carcinoma of the skin and lips. Histopathology 2006; 49:256–64. 3 Brantsch KD, Meisner C, Schönfisch B et al. Analysis of risk factors determining prognosis of cutaneous squamous-cell carcinoma: a prospective study. Lancet Oncol 2008; 9:713–20. 4 Abbas O, Bhawan F. Cutaneous perineural inflammation: a review. J Cutan Pathol 2010; 37:1200–11. 5 Calonje E, Brenn T, Lazar A et al. Foreign body granulomata. Epidermoid cysts. In: McKee’s Pathology of the Skin (Calonje E, Brenn T, Lazar A, McKee PH, eds), 4th edn. Philadelphia, PA: Elsevier Saunders, 2012; 311–13; 1571–4. 6 Leshin B, Prichard EH, White WL. Dermal granulomatous inflammation to cornified cells. Significance near cutaneous squamous cell carcinoma. Arch Dermatol 1992; 128:649–52. 7 Bhatai A, Kumar Y, Kathpalia A. Granulomatous inflammation in lymph nodes draining cancer: a coincidence or a significant association. Int J Med Med Sci 2009; 1:13–16.

Avoiding wrong site surgery: how language and technology can help

MADAM, Avoiding wrong site surgery on patients is a priority for all doctors who perform surgical procedures. The recent articles published in this Journal by Al-Rawi and Varma and Pagliarello et al. should therefore be given their due attention. The authors in both these articles eloquently describe inexpensive, useful and reproducible methods of avoiding wrong site surgery, which I have been employing in my clinical practice for several years. Certainly, the use of a ruler for delineating the precise location of the index lesion from a fixed anatomical landmark is invaluable in patients with generalized actinic damage or where the index lesion or biopsy scar is hard to find. To reduce further the chances of the wrong lesion being removed, especially on the face where significant field change may be present, clinicians should be expected to use as accurate an anatomical description as possible. For example, in the case highlighted by Al-Rawi and Varma, the two lesions in close proximity lie in different cosmetic subunits of the nose. Thus clearly indicating ‘biopsy from nasal sidewall and NOT from mid nasal dorsum’ could have been beneficial. It is important for dermatologists to encourage the correct use of anatomical language among their trainees to instil this at an early part of their training. Take the ear for example, a site commonly biopsied due to the frequency with which actinic change occurs at this site. It is a complex structure of ridges, convexities and concavities (helical rim, antihelix, concha, crura, tragus etc.). Simply stating ‘biopsy from ear’ therefore should not be acceptable to clinicians. Anatomy is the ‘language of medicine’ – a fact we should not ignore. Also in this Journal, the use of technology in the form of dermatology ‘apps’ for smartphones has been highlighted by Hamilton and Brady. It has become commonplace for such smartphones to have a high-resolution camera as part of their function and this is something that may be used for the benefit of the patient in preventing wrong site surgery. I have on several occasions had patients volunteer that they would be agreeable to taking a photograph of the biopsy site with their own phone, to bring with them at their subsequent outpatient clinic or theatre appointment. In this way, another reference point is available for the clinician, who may be meeting the patient for the first time, to confirm the correct site. This has several advantages in that the patient is responsible for their own image, obviating any implications regarding secure storage; the device on which the photograph is taken is readily transportable; the patient may choose to keep or delete their own image once it is no longer required; in the situation where patient notes are unavailable to the clinician, it may enable treatment to proceed with confidence that the right lesion ⁄body site is being treated. I certainly do not advocate this as the sole method of ensuring patients are having the correct site treated, but simply as another supportive measure that may be employed to ensure that wrong site surgery does not occur in our patients.

Superficial acral fibromyxoma presenting as a haemorrhagic pigmented streak on the toenail

Superficial acral fibromyxoma (SAF) is a benign, slowgrowing, soft-tissue tumour that commonly affects the periungual and subungual regions of the fingers or toes. The tumour is painless, and can be dome-shaped, polypoid or verrucous in appearance. We describe a very unusual presentation of SAF. A 57-year old woman, with Fitzpatrick skin type VI, presented with a longstanding and asymptomatic pigmented streak of the right second toenail. She had originally been referred because of a burning sensation of the soles of her feet. She was otherwise well, with no relevant medical history. On physical examination, a pigmented streak, 5 mm in diameter, was seen, involving the lateral surface of the right second toenail (Fig. 1a,b). Hutchinson sign of the proximal nailbed was positive. There was evidence of haemorrhage at the distal end of the nail plate. An assessment of the toenail from the foot of the examination bed also revealed a thickened, verrucous subungual mass. Because of the clinical suspicion of melanoma, an urgent biopsy examination was performed. On histological examination, the nailbed was found to display basal hyperpigmentation and elongation of the rete ridges. A normal melanocytic population without atypia was seen. Unexpectedly, despite the clinical picture, no melanocytic lesion was identified. The underlying dermis contained a bland, spindle-cell lesion that had a poorly formed, mixed fascicular and storiform pattern with collagenous stroma (Fig. 2a). Scattered mast cells were present. Immunohistochemical studies showed the tumour to be positive for CD34 (Fig. 2b) and negative for S100, Melan A, desmin, smooth muscle actin and epithelial membrane antigen (EMA). There was no cytological atypia. The lesion was diagnosed as SAF. SAF was first described in a series of 37 cases by Fetsch et al. in 2001. Since then, < 50 cases have been reported in the literature, including lesions on the palm and sole. SAF is reported to be twice as common in male as in female patients. The mean age at presentation is 43 years, with a wide age range of 14–72 years. The size of the tumour varies from 6 to 50 mm, and typically extends throughout the entire dermis. Occasionally, the lesion may extend to involve the subcutis. Histologically, there is a moderately cellular proliferation of spindled fibroblast-like and stellate-shaped cells, embedded in a myxoid and ⁄ or collagenous matrix in the dermis. The epidermis may be hyperkeratotic. Mitotic figures are rare, and cytological atypia is usually mild. Mast cells are readily identified. Tumour cells stain positive for CD34, CD99 and vimentin. There is variable immunoreactivity to EMA and recently, expression of CD10 was found in three of four cases reported by Tardio et al. The myxoid matrix within SAF is highlighted using Alcian blue (pH 2.5) stain. We highlight the fact that SAF can present as a pigmented lesion, something we believe has not been previously described in the literature. Surgical excision is the treatment of choice in symptomatic patients. Reassuringly, there have been no reports of malignant transformation.

Frontalis‐based island pedicle flaps for the single‐stage repair of large defects of the forehead and frontal scalp

Summary Background  Medium‐ to large‐sized surgical defects of the forehead and frontal scalp provide a challenge for the reconstructive surgeon.

Optimizing adherence of full-thickness skin grafts to the wound bed of the nasal ala with the 'sandwich suture'.

and during laser or cosmetic procedures the patient’s expectation can be aligned with those of the surgeon. Other steps may be undertaken to avoid any uncertainty regarding the lesion in question, e.g. taking a photograph of the lesion at the time of the initial consultation. Additionally, routinely following the steps of the World Health Organization Surgical Checklist (one component of which refers to confirming with the patient the surgical site) should ensure that the correct area is operated on. The hand-held mirror is inexpensive and has innumerable benefits. We recommend that it should be available in every consulting room and theatre. It confirms the lesion in question and almost totally eliminates any potential misunderstanding.

Optimizing Outcomes in Trilobed Flap Reconstruction for Nasal Tip Defects

We have found it most useful for the repair of medium-sized defects involving the very distal nasal tip, where the defect extends onto the soft triangle or infra-tip and columella area. Furthermore, we have, like the authors, found the flap of particular use in men with rhinophymatous change in whom the thick sebaceous nasal skin is particularly immobile and in whom a bilobed flap does not facilitate enough tissue movement to allow tension-free closure of the distal nasal tip.