Surgical tips

A potpourri of practical surgical tips is presented in this article. Included are the clues for diagnosis, ideas for wound management, intraoperative tips, and assorted other items to enhance surgical practice.

Erythrocyanotic discoloration of the toes

A 35-year-old woman from Virginia presented with purplish, tender toes. She was diagnosed with pernio and successfully treated, initially with nifedipine and subsequently with management of the affected area's environment. Clinical presentations and treatment strategies are discussed below.

Pilomatricoma: an alarming presentation

Pilomatricoma is an uncommon, benign growth with origination from the hair matrix that may have several clinical presentations and is frequently misdiagnosed. This case of a rapidly growing pilomatricoma in a 26-year-old was particularly deceptive, generating a differential diagnosis, principally of malignant tumors. The typical features, variants, histogenesis, differential diagnosis, and therapy are reviewed.

Duplicitous growth of infiltrative basal cell carcinoma: Analysis of clinically undetected tumor extent in a paired case-control study

BACKGROUND

Many clinicians believe infiltrative basal cell carcinoma (BCC) is a more difficult tumor to eradicate than nodular BCC because the growth of infiltrative BCC is not easy to detect clinically. However, data supporting this observation are largely anecdotal.

OBJECTIVE

Our purpose was to show that infiltrative BCC have wider and deeper tumor extensions than nodular BCC of similar clinical size.

METHODS

In this retrospective study, 139 cases of infiltrative BCC excised by Mohs micrographic surgery (MMS) were matched to a control group of 139 cases of nodular BCC similarly excised. They were paired by site, size, number of recurrences, age, gender, and previous treatment type. The cases were selected and paired by computer from 1197 consecutive BCC (primary and recurrent) referred for MMS over a 5-year period. MMS technique allowed us to quantitate the extent of tumor spread using three measurements: the number of surgical stages required for complete removal of tumor, the width of tissue required to remove subclinical extension of tumor, and the depth of defect at completion of MMS.

RESULTS

Analysis showed the infiltrative BCC was more difficult to detect and to eradicate than the nodular BCC. The number of surgical stages required for complete removal of tumor, the width of tissue required to remove subclinical extension of tumor, and the depth of defect at completion of MMS were all greater with infiltrative BCC when compared with nodular BCC regardless of whether cases were primary or recurrent. These differences were all statistically significant.

CONCLUSION

Infiltrative BCC can be significantly more destructive than nodular BCC because tumor extension is difficult to detect clinically. Clinicians should treat infiltrative BCC with its potential for convert invasion in mind.

Micronodular basal cell carcinoma. A deceptive histologic subtype with frequent clinically undetected tumor extension

BACKGROUND AND DESIGN

Micronodular basal cell carcinoma (BCC) is thought to have a greater potential for clinically surreptitious tumor spread compared with the majority of BCCs that are nodular. However, most supporting data are anecdotal. This study gives objective evidence that micronodular BCCs have wider and deeper tumor extensions than nodular BCCs of similar clinical size. In this retrospective study, 69 cases of micronodular BCC excised by Mohs' micrographic surgery (MMS) were matched to a control group of 69 cases of nodular BCC that were similarly excised. They were paired by site, size, number of recurrences, age, gender, and previous treatment type. The cases were selected and paired by computer from 1070 consecutive BCCs (primary and recurrent) referred for MMS over a 4-year period. The MMS technique allowed us to quantitate and compare the extent of tumor spread using three measurements: the number of surgical stages required for complete removal of the tumor, the width of tissue required to remove subclinical extension of tumor, and the depth of defect at completion of MMS.

RESULTS

Analysis showed the micronodular BCC to have significantly more covert tumor extension, making it more difficult to detect and to eradicate than the nodular BCC. The number of surgical stages required for complete removal of tumor, the width of tissue required to remove subclinical extension of tumor, and the depth of defect at completion of MMS were all greater with micronodular BCCs when compared with nodular BCCs regardless of whether cases were primary or recurrent. These differences were all statistically significant.

CONCLUSIONS

Micronodular BCCs can be significantly more destructive than nodular BCCs because tumor extension is difficult to detect clinically. When treating micronodular BCC, clinicians should keep in mind its potential for clandestine invasion.

An evaluation of the efficacy and irritability of Sporicidin as a hand dip

Sporicidin, diluted 1:16, used as a disinfectant hand dip, was found to produce substantial percent reductions in the mean number of colony-forming units in comparisons between microbial recoveries of the control and Sporicidin-dipped hands. Sporicidin at this concentration appears to demonstrate efficacy as an antimicrobial agent, but dermal irritation, sensitivity and yellowing of the skin, and its objectionable odor may preclude its routine clinical use.

Cutaneous draining sinus tract: an odontogenic etiology

Although the most common cause of the intermittently suppurating cutaneous sinus tract in the face and neck area is chronic dental infection, chronic draining sinus tracts of the face and neck continue to be a diagnostic challenge. The attending clinician must look carefully for a potential odontogenic infection; chronicity, lasting for weeks, months, and even years and the recognition of the lesion as a sinus tract are keys to making the correct diagnosis. Diagnostic errors can result in multiple surgical excisions and biopsies, long-term antibiotic therapy, and even radiation therapy or electrodesiccation. A review of 137 cases of cutaneous draining sinus tracts from the literature is presented, and four cases are reported. Conservative, nonsurgical root canal therapy is recommended as the first choice of treatment.

Insulin-induced hypertrophic lipodystrophy

Localized asymptomatic soft tissue swellings developed in a 20-year-old woman, Type I juvenile-onset diabetic, at the site of repeated insulin injections. Histopathologic examination of specimens from these lesions in three patients showed chronic inflammatory changes and exogenous foreign material that was thought to be silicon. Lipodystrophic changes associated with insulin therapy are briefly reviewed.