Dermal regeneration template: a new option for the repair of a large surgical defect after mohs surgery in epidermolysis bullosa

La epidermólisis ampollar es un raro trastorno hereditario caracterizado por fragilidad cutánea, formación de ampollas mucocutáneas recurrentes luego de un traumatismo mínimo y cicatrización deficiente de heridas. Además, algunas variantes se han asociado con la aparición de carcinomas espinocelulares. Presentamos el caso clínico de un paciente con epidermólisis ampollar, que presentó un extenso carcinoma espinocelular localizado en cara posterior de brazo. Este fue tratado con cirugía micrográfica de Mohs y el defecto quirúrgico resultante fue reparado aplicando una matriz de regeneración dérmica sobre la herida durante un mes. Posteriormente continuamos con curaciones y ungüento antibiótico sobre la herida dos veces al día, completando la cicatrización con un excelente resultado cosmético y funcional. Enfatizamos en el carácter novedoso de esta opción terapéutica y en su utilidad en pacientes con epidermólisis ampollar.

Epidermolysis bullosa is a rare hereditary disorder characterized by skin fragility, recurrent mucocutaneous blisters following minimal trauma, and compromised wound healing. Moreover, some variants have been associated with squamous cell carcinoma. Following, we present the clinical case of a patient with epidermolysis bullosa, who presented a large squamous cell carcinoma of the arm. It was resected using Mohs micrographic surgery, and the final defect was repaired by applying a dermal regeneration template over the wound for a month. After this period, we continued using cures and antibiotic ointment over the wound twice a day, and healing was completed with excellent cosmetic and functional results. We emphasize the novelty of this therapeutic option, and its usefulness in patients with epidermolysis bullosa.

Primary treatment of early fistula of parotid duct with botulinum toxin type A injection

Abstract: Salivary duct injury can be idiopathic, iatrogenic, or post-trauma and may result in sialocele or fistula. Most injuries regress spontaneously and botulinum toxin A is one of several therapeutic possibilities. We report a case of iatrogenic injury to the parotid duct after Mohs' micographic surgery for a squamous cell carcinoma excision in the left jaw region, treated by injection of botulinum toxin type A. Although the fistula by duct injury can be self-limiting, botulinum toxin injection by promoting the inactivity of the salivary gland allows rapid healing of the fistula.

Complications and solutions in Mohs micrographic surgery: a retrospective analysis / Complicaciones y soluciones en cirugía micrográfica de Mohs: un análisis retrospectivo

Introducción: la cirugía micrográfica de Mohs es el gold standard para el tratamiento del cáncer de piel no melanoma. Ocasionalmente puede presentar complicaciones. Nuestro objetivo fue describir las complicaciones que observamos en nuestra Unidad de Cirugía Dermatológica y comparar nuestros resultados con otros estudios. Materiales y métodos: se realizó un estudio retrospectivo de todas las cirugías de Mohs realizadas en nuestro servicio entre noviembre 2013 y abril 2016. Los datos clínicos, tumorales y quirúrgicos representan aquellos disponibles en la historia clínica. Resultados: se realizaron 100 cirugías individuales en 71 pacientes;48 hombres y 23 mujeres. La edad promedio fue de 69.1 ± 1.7 años. El área del defecto promedio fue de 6.2 ± 0.9 cm2. Sólo se observaron 3 complicaciones (3%): necrosis de colgajo, hematoma con abultamiento de colgajo, y hemorragia postoperatoria. Todas se presentaron en pacientes diferentes, todas en fumadores activos y en región de cabeza y cuello. Discusión: las complicaciones son infrecuentes y suelen corresponder a infecciones del sitio quirúrgico, dehiscencia de suturas, hematoma/hemorragia o necrosis. Si bien el número de pacientes es limitado, nuestros resultados y la revisión de la literatura concuerda en su mayor parte. Destacamos que el tabaquismo activo representa un factor de riesgo para complicaciones. Conclusiones: la cirugía de Mohs tiene una incidencia baja de complicaciones, y la mayoría de estas son menores. Un conocimiento de sus modos de prevención y tratamiento es necesario para llevar a cabo este procedimiento.

Introduction: Mohs micrographic surgery is the gold standard for non-melanoma skin cancer treatment. It may occasionally present complications. Our objective was to describe the complications we observed in our Dermatologic Surgery Unit and compare our results with other studies. Materials and methods: we performed a retrospective analysis of all Mohs surgeries done in our service between November 2013 and April 2016. Clinical, tumoral and surgical data was gathered from the patients' medical history. Results: 100 individual surgeries in 71 patients were registered; 48 males and 23 females. Mean age was 69.1 ± 1.7 years. Mean defect area was 6.2 ± 0.9 cm2. Only 3 complications were seen (3%): flap necrosis, hematoma with flap bulging, and postoperative hemorrhage. All of these occurred in different patients, all of them in active smokers and in the head and neck region. Discussion: complications are infrequent and are usually surgical site infections, suture dehiscence, bleeding/hematoma or necrosis. Although our number of patients is limited, our results are mostly compatible with the literature. We highlight that active smoking represents a risk factor for complications. Conclusions: Mohs surgery has a low incidence of complications, and most of these are minor. A knowledge of prevention and treatment modalities is necessary to perform this procedure.

The importance of superficial basal cell carcinoma in a retrospective study of 139 patients who underwent Mohs micrographic surgery in a Brazilian university hospital

OBJECTIVE: Mohs micrographic surgery is a specialized surgical procedure used to treat skin cancer. The purpose of this study was to better understand the profile of the patients who underwent the procedure and to determine how histology might be related to complications and the number of stages required for complete removal. METHODS: The records of patients who underwent Mohs micrographic surgery from October 2008 to November 2013 at the Dermatology Division of the Hospital of the Campinas University were assessed. The variables included were gender, age, anatomical location, histology, number of stages required and complications. RESULTS: Contingency tables were used to compare the number of stages with the histological diagnosis. The analysis showed that patients with superficial basal cell carcinoma were 9.03 times more likely to require more than one stage. A comparison between complications and histological diagnosis showed that patients with superficial basal cell carcinoma were 6.5 times more likely to experience complications. CONCLUSION: Although superficial basal cell carcinoma is typically thought to represent a less-aggressive variant of these tumors, its propensity for demonstrating “skip areas” and clinically indistinct borders make it a challenge to treat. Its particular nature may result in the higher number of surgery stages required, which may, as a consequence, result in more complications, including recurrence. Recurrence likely occurs due to the inadequate excision of the tumors despite their clear margins. Further research on this subtype of basal cell carcinoma is needed to optimize treatments and decrease morbidity.

Reconstrução em cirurgia micrográfica / Reconstruction in Mohs micrographic surgery

Introdução: A cirurgia micrográfica de Mohs é empregada para exérese de neoplasias cutâneas, especialmente carcinomas basocelulares de subtipos histológicos localmente agressivos, tumores recidivados ou localizados em regiões nobres. Apresenta elevados índices de cura e permite preservação tecidual. O objetivo é analisar a eficácia da cirurgia micrografia de Mohs e os métodos de reconstrução utilizados. Método: Foram coletados, retrospectivamente, dados de 50 pacientes submetidos à exérese de tumores cutâneos por meio da cirurgia micrográfica de Mohs e à reconstrução da perda de substância. Todos os pacientes foram operados no período entre janeiro de 2005 a dezembro de 2013 na Clínica de Cirurgia Plástica do Hospital Felício Rocho (Belo Horizonte, MG, Brasil). Os pacientes foram estudados com relação à idade, gênero, localização do tumor, tratamento prévio, tipo histológico, número de fragmentos analisados na cirurgia micrográfica, método de reconstrução empregado e proservação. Resultados: Trinta e um pacientes (62%) foram do gênero feminino e 19 (38%) do masculino. A média de idade foi de 63,8 anos. Todas as lesões encontravam-se na face, com 66% dos casos com acometimento da região nasal. Considerando o diagnóstico pré-operatório, 48 casos (96%) eram carcinoma basocelulares e dois casos (4%) correspondiam ao carcinoma microcístico anexial. Retalhos locais foram o tipo de reconstrução mais utilizado. Os pacientes foram acompanhados por média de 48,4 meses. Nenhum caso de recidiva tumoral foi observado. Conclusão: A cirurgia micrográfica de Mohs se mostrou altamente eficaz no tratamento dos 50 casos de neoplasias cutâneas. Recomenda-se que os defeitos cirúrgicos sejam reparados pelo cirurgião plástico.

Introduction: Mohs micrographic surgery is used for the excision of skin neoplasms, especially in locally aggressive histological subtypes of basal cell carcinoma, tumor recurrences, or tumors located in critical areas . This technique has a high cure rate and allows maximum preservation of tissues. In this study, we aimed to assess the effectiveness of Mohs micrographic surgery and reconstruction methods. Method: Data from 50 patients who underwent Mohs micrographic surgery to excise skin tumors and reconstruct lost tissue were collected retrospectively. All patients were operated on between January 2005 and December 2013 at the Plastic Surgery Clinic of the Felício Rocho Hospital (Belo Horizonte, MG, Brazil). The patients' age, sex, tumor location, previous treatment, histological type, number of segments analyzed by micrographic surgery, reconstruction method used, and preservation were studied. Results: Thirtyone patients (62%) were women and 19 (38%) were men. The mean age was 63.8 years. All lesions were facial, with 66% of cases affecting the nasal area. Pre-surgery, there were 48 cases (96%) of basal cell carcinoma and 2 cases (4%) of microcystic adnexal carcinoma. Local flaps were the most used reconstruction method. The patients were followed-up for a mean of 48.4 months. We did not observe any cases of tumor recurrence. Conclusion: Mohs micrographic surgery was shown to be effective in the treatment of 50 skin neoplasms. We recommend that surgical defects should be repaired by the plastic surgeon.