Revisiting the East-West advancement flap: great for multiple anatomic locations

BACKGROUND

The east-west advancement flap is a simple flap traditionally used to repair Mohs surgery defects on the nose. We aim to demonstrate this flap can be used with good cosmetic outcome and minimal complications on a variety of anatomical sites.

METHODS

This study was a case series of four patients taking place between March 2021 and September 2021 with 4- to 6-week postoperative follow-up.

RESULTS

Four male patients were included in the study. Repair sites included the helix, chin, wrist, and scalp. All patients and the Mohs surgeon reported satisfaction with the cosmetic outcome at 4- to 6-week postoperative follow-up with no complications.

CONCLUSION

The east-west advancement flap is a viable repair option for Mohs surgery defects on a variety of anatomical sites.

Intramuscular lipoma of the scapular region

Intramuscular lipomas are rare, benign soft tissue neoplasms characterized by infiltrative growth into muscle tissue or between muscle fibers. These benign tumors can present similarly to malignant soft tissue neoplasms, such as liposarcomas. Unlike subcutaneous lipomas, intramuscular lipomas require diagnostic imaging to better distinguish the tumor and rule out alternative, malignant etiologies. It is imperative that dermatologists are able to identify this rare lipoma variant and have a thorough understanding of the diagnosis, imaging, and treatment options for this uncommon soft tissue tumor. Our case serves as a reminder for dermatologists to be cognizant of this rare tumor and aware of the importance of diagnostic testing in ruling out similarly-presenting, soft tissue malignancies.

Mohs micrographic surgery: a treatment method for many non-melanocytic skin cancers

Mohs micrographic surgery (MMS) is a breakthrough surgical technique that has changed the management of neoplasms in dermatology. Through continued practice and evolution, MMS now can successfully treat a variety of rare non-melanocytic cutaneous malignancies for which achieving remission and the optimal aesthetic result after surgery was previously challenging. Mohs micrographic surgery has utility for conditions besides melanoma. Herein, we discuss this versatility of Mohs micrographic surgery. Specifically, Mohs micrographic surgery can be successfully used for cases such as dermatofibrosarcoma protuberans, atypical fibroxanthomas, extramammary Paget disease, Merkel cell carcinoma, sebaceous carcinoma, and microcystic adnexal carcinoma.

Optimizing patient positioning during dermatologic surgery

Patient positioning is an important technique for tension control during dermatologic surgery. Increasing tension across a surgical site during excision and decreasing tension during closure ultimately reduces the work required to complete procedures and increases efficiency. These techniques should be considered in areas of high tension and repetitive motion such as the back and lower extremities.

Dermatologic manifestations in spaceflight: a review

With manned missions to Mars on the horizon, understanding and preparing for the medical conditions these astronauts might face becomes vital. According to the literature, the most commonly reported medical events in space are dermatological in nature. Dermatologic conditions rarely threaten an astronaut's life or the mission. However, manifestations and management of dermatologic events become an important consideration in anticipation of spaceflights to Mars and beyond. Given the limited number of articles written about dermatological conditions in this specific population, this review summarizes current knowledge related to dermatology in space. Overall, common dermatologic conditions found during spaceflight include viral reactivations, contact dermatitis or eczematous patches, and skin infections. Diagnosis and treatment can be difficult given the lack of resources in space as well as the hazards and side effects of certain treatments. In this review article we aim to summarize common skin changes induced by spaceflight, describe previously reported skin conditions including current treatment options, explore the risk of skin cancer in this unique population, and address the challenge of remote diagnosis.

Infiltrative basal cell carcinoma mimicking tinea corporis

The diagnosis of infiltrative basal cell carcinoma (BCC) can be delayed owing to its often subtle clinical findings. A 90-year-old woman presented with an asymptomatic annular pink plaque on her left shin that was clinically diagnosed as tinea corporis. After years of not responding to topical anti-fungal therapy, biopsies confirmed a diagnosis of infiltrative BCC. We discuss the differential diagnosis of the case, the difficulties in identifying infiltrative BCC, and the pathologic features of infiltrative BCC.

Cutaneous leishmaniasis mimicking squamous cell carcinoma

A 41-year-old man from Cuero, Texas with a nonhealinglesion on his left cheek was referred to ourclinic for removal of a squamous cell carcinoma. Thepatient first noticed a "pimple" on his left cheek 3-4months prior to presentation. When the lesion beganto grow he presented to his primary care physician anda biopsy was taken, showing "atypical squamous cellproliferation." Mohs surgery was performed and thenodule was removed with no evidence of malignancyseen on histopathology. Upon review of the surgicalbiopsies by consulting pathologists, the diagnosis ofleishmaniasis was established and later confirmed bythe Center for Disease Control and Prevention (CDC)as Leishmania mexicana. The patient was referred toinfectious disease specialists for further management.

Needlestick and Sharps Injuries in Dermatologic Surgery: A Review of Preventative Techniques and Post-exposure Protocols

Background: Needlestickand sharps injuries are the leading causes of morbidity in the dermatologicfield. Among medical specialties, surgeons and dermatologists have the highest rates of needlestickand sharps injuries.The high rates of needlestickand sharps injuries in dermatology not only apply to physicians, but also to nurses, physician assistants, and technicians in the demnatologic field. Needlestickand sharps injuries are of great concern due to the monetary, opportunity, social, and emotional costs associated with their occurrence. Objective: A review of preventative techniques and post-exposure protocols for the majortypes of sharps injuries encountered in dermatologic practice. Design: The terms "needle-stick injuryT'sharps injuryTdermatologic surgery? "post-exposure prophylaxis,"and "health-care associated injury" were used in combinations to search the PubMed database. Relevant studies were reviewed for validity and included. Results The authors discuss the major types of sharps injuries that occur in the dermatologic surgery setting and summarize preventative techniques with respect to each type of sharps injury.The authors also summarize and discuss relevant post-exposure protocols in the event of a sharps injury. Conclusion: The adoption of the discussed methods, techniques, practices, and attire can result in the elimination of the vast majority of dermatologic sharps injuries.

Common Adult Skin and Soft Tissue Lesions

A strong foundational knowledge of dermatologic disease is crucial for a successful practice in plastic surgery. A plastic surgeon should be able to identify and appreciate common dermatologic diseases that may require medical and/or surgical evaluation and management. In this article, the authors describe epidermal/dermal, infectious, pigmented, and malignant cutaneous lesions that are commonly encountered in practice. Descriptions include the epidemiology, pathogenesis, clinical course, and management options for each type of lesion.

Eccrine hidrocystomas presenting as multiple papules on the cheeks

Hidrocystomas are common, benign adnexal neoplasms most frequently found on the eyelids, canthi, or periocular areas. Herein, we report a case of multiple hidrocystomas distributed over less common facial areas: cheeks and cutaneous lips.

Pathology of the ear

The external ear is exposed to weathering and trauma; it also has sparse vascularity, making it prone to infection and disease. The external location of the cutaneous ear makes it easily visible for diagnosis and accessible for treatment. In this article, the authors focus on diseases of the ear that are most commonly encountered and may be subject to surgical and medical evaluation and/or treatment. Epidemiology, pathogenesis, clinical course, and treatment for each disease entity are discussed.

The rate of melanoma transection with various biopsy techniques and the influence of tumor transection on patient survival

BACKGROUND

Depth of melanoma invasion is critical because it dictates patient treatment and prognosis. Recent reports indicate melanoma transection with initial biopsy does not impact patient survival; however, tumor transection can lead to misdiagnosis and inaccurate staging.

OBJECTIVE

This study assessed the rate of melanoma transection with various biopsy techniques and the impact of tumor transection on patient survival.

METHODS

We conducted a retrospective review of all melanoma cases at our institution between 2000 and 2008. Of the 490 melanoma cases identified, 479 met inclusion criteria for the study. The transection rates of biopsy techniques were determined. Cases of transected tumors were matched with nontransected cases in a retrospective case-control fashion to evaluate survival.

RESULTS

The rate of melanoma transection was 1.5% for excisional biopsies, 4.1% for punch biopsies, and 9.0% for saucerization biopsies. The means of disease-free survival for the control and transected groups were 911 days and 832.7 days, respectively (P value .67). Overall survival for the control group was 1073.7 days versus 1012.4 days for the transected group (P value .72).

LIMITATIONS

The study used a select population. The sample size of transected biopsies was limited, in turn limiting the power of the study. Residents performed the majority of biopsies.

CONCLUSION

Punch and saucerization biopsies were more likely to transect tumors than excisional biopsies. The transection of melanoma did not affect overall disease-free survival or mortality in the population studied.

Amelanotic subungual melanoma after trauma: An unusual clinical presentation

Amelanotic subungual melanoma (SUM) is difficult to clinically diagnose owing to its rarity and variable presentation. We describe a case of a 63-year-old gentleman with an amelanotic SUM that developed after local trauma and presented as a persistent non-healing ulcer which was initially mistaken for a chronic infection. Because amelanotic SUM can mimic other lesions, the physician should have a high index of suspicion for SUM when managing atypical nail lesions to ensure prompt recognition and treatment. The prior trauma to the nail also suggests that posttraumatic inflammation may play a role in SUM development.

Porokeratosis of Mibelli: Successful treatment with 5 percent topical imiquimod and topical 5 percent 5-fluorouracil

Porokeratosis of Mibelli (PM) is a clonal disorder of keratinization. It clinically presents with one or more annular plaques with central atrophy and elevated keratotic borders. With a 7.5 percent risk of malignancy, PM should be treated to prevent transformation into squamous cell carcinoma, Bowen disease, or basal cell carcinoma. Multiple treatment options are available, however, there is not one universally effective treatment. We describe the successful treatment of porokeratosis of Mibelli of the left calf in an 83-year-old man with topical 5 percent imiquimod and topical 5 percent 5-fluorouracil.

Severe reaction to 5% imiquimod cream with excellent clinical and cosmetic outcomes

Imiquimod, an immune response modifier approved for the treatment of external genital warts, actinic keratoses, and superficial basal cell carcinoma, can induce a severe local inflammatory response. This phenomenon can accompany inappropriately overzealous, as well as entirely conventional, drug utilization. Despite strikingly brisk reactions, the 9 patients reported herein ultimately experienced excellent cosmetic and clinical outcomes. We report this series to alert clinicians of the good prognosis for a satisfactory outcome even when faced with extreme imiquimod cream-induced inflammation.

The age of skin cancers

Cancer affects two major cell types in the human skin: epithelial cells and melanocytes. Aging and a previous history of ultraviolet light exposure are major risk factors for skin cancers, including basal and squamous cell carcinomas and melanomas. However, melanomas, which are the most deadly of the skin tumors, display two intriguing characteristics: The incidence is increased and the prognosis is worse in males over 60 years as compared with females of the same age. This Perspective discusses possible reasons for age and gender as melanoma risk factors, as well as the need for studies aimed at unraveling the molecular mechanism of such puzzling events.

Sudden onset of Multiple nevi after administration of 6-mercaptopurine in an adult with Crohn's disease: a case report

The correlation between combined chemotherapy, including 6-mercaptopurine, and development of excessive number of melanocytic nevi in childhood has been previously reported and studied. As of yet, no such relation has been reported in adults. We recently observed a 27-year-old female patient who developed numerous benign melanocytic nevi during a 20-month period while taking 6-mercaptopurine for Crohn's disease. The appearance of many nevi was worrisome to the patient from a cosmetic and medical perspective (given the higher risk of melanoma associated with large numbers of nevi).

Reticulate Hyperpigmentation secondary to 5-fluorouracil and idarubicin

Although cutaneous reactions from antineoplastic therapy are common, a reticulate pattern of hyperpigmentation has not been frequently reported in the literature. We report 2 cases of reticulate hyperpigmentation associated with cancer chemotherapy with 5-fluorouracil and idarubicin. These 2 cases serve to raise awareness of this particular pattern of hyperpigmentation as a potential side effect of chemotherapeutic regimens.

Advancement flaps: a basic theme with many variations

BACKGROUND

The advancement flap involves the linear advancement of tissue in one direction. Despite its straightforwardness and simple concept, it can be used to close a variety of defects, ranging from small defects on the scalp or extremities to large, complicated defects involving cosmetic units on the face.

OBJECTIVES

To provide a basic and useful review for the indications, advantages, disadvantages, and techniques for the use of advancement flaps in the reconstruction of defects in dermatologic surgery.

MATERIALS AND METHODS

We performed a literature search for articles discussing advancement flaps and compiled a brief review of our findings.

RESULTS

The movement of the advancement flap must be balanced by the blood supply of the flap. The excision of Burow's triangles along various aspects of the advancement flap can increase movement and improve cosmesis of the flap. The types of advancement flaps discussed include the single advancement flap, double advancement flap, A-T flap (O-T flap), Burow's triangle flap (Burow's wedge flap), crescenteric advancement flap, island pedicle flap (V-Y flap), helical rim advancement flap, and facelift flap.

CONCLUSION

Advancement flaps are versatile and useful basic flaps for repairing defects.

Specialty Clinics for the Dermatologic Care of Solid-Organ Transplant Recipients

BACKGROUND

Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity.

OBJECTIVE

The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer.

METHODS

Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings.

RESULTS

All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics.

CONCLUSIONS

Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.

Unusual infectious complications of dermatologic procedures

Because dermatologic procedures disrupt skin integrity, they alter the body's protective barrier and predispose individuals to cutaneous infection. Postoperative wound infections--even with common pathogens such as S. aureus--seldom complicate dermatologic procedures; however, unusual infections have been reported to complicate excisions, biopsies, skin grafts, chemical peels, dermabrasion, laser resurfacing, liposuction, blepharoplasty, and injections (eg, with anesthetic solutions or botulinum toxin). Numerous environmental and patient risk factors increase the rate of postoperative wound infections, but otherwise healthy individuals undergoing relatively simple procedures are sometimes affected. Obtaining a thorough patient, history (including history of prior HSV infection or any immunocompromising factors) is crucial. Patients should be warned of potential complications, particularly when they are undergoing cosmetic procedures. It is important to maintain a high index of suspicion for possible wound infection in all patients that extends several months postoperatively. Manifestations of unusual postoperative infections are highly variable, and they might be secondary to bacterial, fungal, viral, or parasitic pathogens. Bacterial lesions are often polymicrobial, and bacterial superinfection can exacerbate other wound complications such as HSV reactivation. Most wound infections remain localized, but occasionally systemic disease occurs. For example, cutaneous diphtheria or rapidly growing mycobacteria rarely disseminate, whereas TSS results in systemic disease caused by toxin release. Some unusual postsurgical infections are self-limited, but they can still be potentially life threatening or disfiguring. Antimicrobial prophylaxis might reduce the risk of wound infection in some cases. Clinicians can better care for patients by becoming familiar with the causes and clinical manifestations of unusual dermatologic postoperative wound infections (Table 1). Following the recognition of an infectious process, appropriate diagnostic procedures allow for pathogen identification and the prompt institution of indicated therapy.

Treatment of squamous cell carcinoma in situ of the penis with 5% imiquimod cream: A case report

A patient with widespread in situ squamous cell carcinoma of the glans penis was successfully managed with topical application of 5% imiquimod cream. Therapy with topical immune response modifiers may prove beneficial in cases of superficial cutaneous carcinoma and may, if future studies confirm our findings, play a role in settings in which more destructive techniques may result in cosmetic defects or functional impairment. The use of imiquimod for intraepithelial squamous cell carcinoma of the anogenital area seems particularly logical because of the strong correlation between this neoplasm and infection with human papillomavirus.

Ectopic extramammary Paget's disease arising on the cheek

BACKGROUND

Extramammary Paget's disease (EMPD) is a rare neoplasm affecting apocrine gland-bearing skin. Patients usually present with a long-standing unilateral, ill-defined, erythematous or whitish-gray, crusted patch or plaque. This tumor almost never occurs outside of the anogenital or axillary areas.

OBJECTIVE

We report the first case of "ectopic" extramammary Paget's neoplasm afflicting the face.

METHODS

The excisional specimen from a 67-year-old man was reviewed. Histology and immunohistochemistry studies were performed on the specimen.

RESULTS

Histology revealed hyperkeratosis, parakeratosis, acanthosis, and proliferation of cytologically atypical epithelioid cells permeating the epidermis and the cutaneous adnexae. Special stains showed reactivity to cytokeratins (AE1/AE), epithelial membrane antigen, and carcinoembryonic antigen in the atypical cells. There was no evidence of apocrine glands in the area.

CONCLUSION

Herein we present the first case of truly "ectopic" extramammary Paget's disease on the face.

Treatment of a large superficial basal cell carcinoma with 5% imiquimod: a case report and review of the literature

BACKGROUND

Large superficial basal cell carcinomas (BCCs) may be difficult to treat surgically due to the potentially large resulting defect after removal. Imiquimod, an immune response modifier, when applied topically, has been demonstrated to be successful in treating superficial BCCs. There is no published experience on the treatment of larger superficial BCCs (greater than 2 cms2) with imiquimod at this time.

OBJECTIVE

To assess the clinical and histologic regression, as well as the short- and long-term effects of topical imiquimod on large superficial BCC.

METHOD

A 52-year-old white female with a 30 cm2 biopsy proven superficial BCC of 28 years duration on the right dorsal arm was treated with 5% imiquimod three times a week for 12 weeks. Clinical follow-up was conducted 1, 4, 6, and 10 months after treatment, as well as histologic assessment of recurrence at 4 months after treatment.

RESULTS

Apparent clinical and histologic clearance was achieved. The treatment was well-tolerated and the patient completed the treatment schedule without a rest period, despite erosion of the lesion in the last week of treatment.

CONCLUSION

This report describes the first case of a large superficial BCC (30 cm2) successfully treated with topical imiquimod and with a 10 month follow-up.

Techniques in the removal of skin lesions

The skin is one of the most easily accessible organs of the human body. Various skin lesions may be removed safely and easily in the office. This article describes various available methods, with suggestions regarding which method to use under selected circumstances.

Application of local anesthetics in dermatologic surgery

BACKGROUND

Local anesthesia is an integral aspect of cutaneous surgery. Its effects provide a reversible loss of sensation in a limited area of skin, allowing dermatologists to perform diagnostic and therapeutic procedures safely, with minimal discomfort and risk to the patient.

OBJECTIVE

This article discusses the application of local anesthetics in dermatologic surgery through a brief review of the mechanism of local anesthetic activity, classification of local anesthetics, and adverse effects. The discussion will focus on the different methods of administration and techniques that may make the administration less painful to patients.

METHODS

An evaluation of the literature, as well as clinical experience in the administration of local anesthetics provide the basis for this review.

CONCLUSION

Local anesthesia provides a safe and effective means of decreasing patient's sensitivity to pain. Because of its critical importance to the field of dermatology, a working knowledge of local anesthetics is necessary for optimal use of these agents.