Using en face ink to guide the conservative sectioning of a Mohs margin.

BACKGROUND: While the epidermal rim of a Mohs layer routinely requires some manipulation, the deep margin seems to conform easily to a smooth surface for sectioning even when tissue textures and contours are prominent. How well these common features of the deep margin flatten during processing has not been well studied. OBJECTIVE: To determine how successfully tissue processing flattens the deep margin of Mohs specimens. METHODS: Using en face inking, this study compared the sectioning required to reach a completed epidermal margin with that of the completed deep margin in 100 routine first-stage Mohs specimens. RESULTS: A mean of 248.8 µm of additional sectioning beyond the completed epidermal margin was required in 74% of specimens to reach the completed deep margin. This deep margin differential was associated with increasing layer size (p = .003) and those specimens that required the least amount of sectioning to reach a completed epidermal margin (p < .001). CONCLUSIONS: The differential between the epidermal and deep margin suggests that tissue texture and contour irregularities can be easily compressed and internalized during embedding. En face inking can be used to delineate the tissue texture and surgical features of a Mohs margin ensuring a complete and conservative section evaluation.

Modifying the Burow's triangles of traditional transposition flaps for the repair of adjacent nasal defects.

BACKGROUND: Adjacent defects are commonly encountered during Mohs micrographic surgery for nasal skin cancers and often present a formidable reconstructive challenge. OBJECTIVE: This article will describe similar modifications of both the bilobed and nasolabial transposition flaps' Burow's triangles that allow for the repair of two adjacent defects of the distal nose using a single flap. METHODS: This is a report of two similar reconstructive cases after Mohs micrographic surgery requiring the repair of adjacent nasal defects. RESULTS: Both cases demonstrate the feasibility of this technique. LIMITATIONS: This technique is based on two case reports. CONCLUSIONS: Traditional transposition flaps' Burow's triangles can be effectively modified for the repair of properly selected adjacent wounds of the distal nose.

The tissue efficiency of common reconstructive design and modification.

BACKGROUND: Facial reconstructive techniques are capable of restoring a normal anatomic appearance despite the tissue loss resulting from skin cancer removal. Because none of these techniques recreate the lost tissue, most of these techniques require the removal of additional normal tissue in the form of Burow's triangles to achieve this goal. OBJECTIVE: To analyze the quantity and potential variability of redundant tissue loss encountered during the use of conventional reconstructive techniques through the calculation of tissue efficiency. METHODS: Conventional reconstructive designs were applied to a standard circular defect using computer-aided design software to determine the surface area of each closure design. Tissue efficiency was defined as the surface area of the defect divided by the total surface area of tissue loss after reconstruction. RESULTS: Island pedicle flaps (78.5%) and rhombic flaps (68.0%) offer the highest degree of tissue conservation among conventional flap designs. CONCLUSIONS: The majority of flap designs offer a significant improvement in tissue efficiency over the standard linear closure; they simply result in less overall tissue loss. A number of design modifications can limit or even reduce additional tissue loss while gaining significant advantages in flap mobility or tissue recruitment.

The density and distribution of melanocytes adjacent to melanoma and nonmelanoma skin cancers.

BACKGROUND: The determination of clear margins during Mohs surgery for melanoma in situ arising on sun-damaged skin is often made difficult by the presence of background atypical melanocytic hyperplasia. OBJECTIVE: To determine the density and distribution patterns of melanocytes adjacent to melanoma and nonmelanoma skin cancers. METHODS: 180 skin specimens obtained during the routine repair of defects resulting from the removal of melanoma and nonmelanoma skin cancers were analyzed using H and E-stained permanent sections to determine the quantity and distribution of epidermal melanocytes. RESULTS: The mean melanocyte density was 7.97 melanocytes per 1 mm of epidermis (SD,+/-6.7). Contiguous melanocytes were found in 30 (16.7%), atypical melanocytes were observed in 8 (4.4%), and follicular extension of melanocytes was observed in 11 (6.1%) of the specimens. These features were significantly associated with higher melanocyte densities (p< .001) and were more commonly observed in specimens from patients with melanoma. CONCLUSIONS: There is a high degree of variability in melanocyte densities seen adjacent to melanoma and nonmelanoma skin cancers. Contiguous melanocytes, atypical melanocytes, and follicular melanocytes can be seen in the sun-damaged skin surrounding both melanoma and nonmelanoma skin cancers, but especially with melanoma. Because some of the features of melanoma in situ can be seen in chronically sun-damaged skin, the Mohs surgeon should be cautious when assessing the margins for melanoma in this setting.

Treatment of basal cell carcinoma with curettage alone.

BACKGROUND: Although curettage and electrodesiccation (C&E) is widely used to treat basal cell carcinoma, whether electrodesiccation improves outcome is unknown. OBJECTIVE: We sought to compare cure rates of curettage alone with those of C&E. METHODS: We conducted a retrospective records review of patients treated with curettage alone at 5-year follow-up or longer that extracted data about tumor location, size, histologic subtype, biopsy specimen margin involvement, and recurrence, as well as data about the medical history of patients treated in a dermatology clinic in a tertiary-care academic medical institution. RESULTS: Biopsy-proven tumors (302) amenable to treatment with C&E and treated by a single investigator with curettage alone had a 5-year cure rate of 96.03%, with minimal complications (hypopigmentation, scarring). Tumors involving more than 50% of the deep edge of the shave biopsy specimen had an increased risk of recurrence. LIMITATIONS: This is a retrospective study based on historic controls. CONCLUSION: For nonaggressive basal cell carcinoma, curettage alone has a cure rate similar to the published rates for C&E.