A 5-year follow-up study of 633 cutaneous SCC excisions: Rates of local recurrence and lymph node metastasis.

BACKGROUND: A 5-year follow-up study of 633 cutaneous squamous cell cancer (SCC) excisions was performed by collecting data on rates of local recurrence (LR) and lymph node (LN) metastasis. METHODS: A retrospective analysis of patients was performed across four regional plastic surgery centres (Stoke Mandeville Hospital, Aylesbury; John Radcliffe Hospital, Oxford; Salisbury District Hospital, Salisbury and Queen Alexandra Hospital, Portsmouth) assessing rates of LR and LN metastasis. RESULTS: We report 5-year outcomes from 598 SCCs (95% follow-up rate). The total recurrence rate (LR and LN metastasis) was 6.7% (n = 40) at 5 years, with 96% of these occurring within 2 years. Median time to LR was 9 months (1-57), with 76.9% (n = 20) undergoing further wide local excision. Median time to LN metastasis was 5.5 months (1-18 months). There were two cases of disease-related death. Only 15% (n = 6) of incomplete excisions recurred. Interestingly, 19.1% (n = 9) of 47 SCCs with perineural invasion on original histopathology recurred versus only 5.6% (n = 31) of the 551 SCCs without perineural invasion (p = 0.005). CONCLUSIONS: This study is one of the largest studies to date following up 598 SCC excisions at 5 years with total recurrence rates comparable to those in current published literature. We report perineural invasion as a significant predictor of recurrence and that 96% of total recurrence occurred within 2 years. This is in contrast to current UK guidelines (75% at 2 years, 95% at 5 years), thus suggesting that shorter length of hospital follow-up may be reasonable.

Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with low morbidity.

AIM: To examine the short-term outcomes of perineal reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap following abdominoperineal excision (APE). METHOD: Retrospective case note review of all patients undergoing APE and primary VRAM reconstruction between July 2001 and February 2012 in a district general hospital tertiary referral centre for APE. Complications were categorized using the Clavien-Dindo classification, which grades complications from I to V in order of increasing severity. RESULTS: Fifty-five consecutive patients (31 men, median age 65, range 38-84 years) underwent APE with VRAM flap reconstruction, 15 for anal cancer and 40 for rectal cancer. Median length of stay was 11 days but was significantly shorter in the laparoscopic group compared with the open group (8 vs 12 days; P < 0.01) and in patients who did not experience any complications (P < 0.05). Four patients (7%) had major complications (Grade 3 and above) directly related to the flap or donor site. CONCLUSION: VRAM reconstruction of the perineum can be safely performed following APE with results that compare favourably with other techniques. Most flap complications are minor, although these are still associated with an increase in the length of hospital stay.

Guidelines for the excision of cutaneous squamous cell cancers in the United Kingdom: the best cut is the deepest.

Surgical excision remains the gold standard for the management of cutaneous squamous cell cancers (SCC) and national guidelines for operative radial margins predict 95% oncological clearance with a margin of 4 mm for low-risk and 6 mm for high-risk tumours. We retrospectively analysed all cutaneous SCC excisions performed across 4 regional Plastic surgical units in England over a consecutive 24-month period and collected data on tumour characteristics, operative and histological margins and completeness of excision. We identified 633 eligible SCC excisions of which 265 (42%) were over 2 cm in diameter with 37 recurrent tumours (5.8%). The mean radial operative margin was 6.5 mm across all tumours and 8.4 mm for tumours greater than 2 cm. The mean histological tumour diameter was 21 mm. The overall incomplete excision rate was 7.6% (7.9% for tumours >2 cm). Ninety-four percent (45/48) of incomplete excisions involved the deep margin and only 3 out of 633 excisions (0.47%) were incomplete at a radial margin only. No differences were observed in tumour size or excision margin between incompletely and completely excised tumours. Incomplete excisions were most common on the ear, nose and cheek. In summary our analysis demonstrates that despite adherence to recommended surgical margins for cutaneous SCCs the incomplete excision rate remains higher than expected. We believe that this is because most incomplete excisions are incomplete at the deep margin and question the utility of performing increasingly wide excisions, and, the generalisability of the evidence upon which recommendations for radial margins are based.

Critical assessment of the anterolateral thigh flap donor site.

BACKGROUND: The free anterolateral thigh flap (ALT) is now used as a 'workhorse flap'. The donor site morbidity is thought to be minimal, although most evidence derives from questionnaire-based studies rather than rigorous objective clinical assessment. In particular, robust quantitative data on thigh sensibility and quadriceps function is lacking. The aim of this study was to provide a comprehensive clinical assessment of donor site morbidity. METHODS: We performed a prospective study of consecutive free ALT perforator flaps performed at Salisbury Foundation Trust between March 2008 and April 2010. The donor site was assessed at six months including a questionnaire (symptoms, function), scar analysis (Vancouver Scar Scale, VSS), and evaluation of quadriceps power and lateral thigh sensibility (compared with the contralateral unoperated thigh). RESULTS: One hundred ALT flaps were performed on 97 patients (mean age 46.8 years). The donor site was closed directly in 88 cases and using a split skin graft in 12 cases. At follow-up (n=68), tingling was the most common reported symptom (59%), whereas pain, itching and muscle herniation were reported infrequently. Donor site scars were mostly flat, pale and soft but widened. Pathological scarring was rare. Sensibility was reduced in donor thighs (p<0.001) and correlated with flap width but peak quadriceps contraction was similar between donor and unoperated thighs. CONCLUSIONS: There was a high throughput and diverse application of ALT flap reconstructions during the study period. Reduced sensibility was common around the scar but rarely troublesome. Quadriceps function was not affected even when dissection of intramuscular perforators was required. The ALT is a versatile flap that can deliver a large skin paddle with minimal impact on thigh function.

Subcutaneous emphysema of a digit through a pre-existing puncture wound.

A case of injection of compressed air into a digit is reported. The air was injected at 50 PSI through a trivial puncture wound sustained some hours previously. The case had a benign course, in comparison to high pressure injection injuries with foreign material.