Recurrence of cutaneous squamous cell carcinoma at remote limb donor site.

Squamous cell skin cancer (SCC) is the second most common skin malignancy. The risk of metastasis is usually low and generally occurs through lymphatic spread. Surgical excision is the gold standard for treatment and subsequent reconstruction often involves a skin graft from a distant donor site. Our case highlights an incident in which metastatic spread of an SCC occurred in a distant skin graft donor site on the limb following free flap harvest.

A study of the personal use of digital photography within plastic surgery.

The advent of digital photography has greatly increased the use of medical illustration within specialties dealing with visible pathologies. It offers improved communication between medical professionals, education and counselling of their patients and forms an important aspect of their medical records. With the increased availability of digital cameras there is an increased tendency for clinicians to take digital photographs of patients themselves. In doing so, clinicians take on the responsibility to act in accordance with the regulations governing this practice issued by the UK Department of Health. This study sought to investigate the prevalence of this practice by way of an anonymous questionnaire distributed to three representative plastic surgery units within the UK. It looked at the awareness of and compliance with the present governing regulations. The results showed that of the 60 distributed questionnaires, 30 of 42 respondents took digital photographs of patients themselves. Photographs were taken for the purposes of inclusion in the medical records, education, development of personal libraries and publication. Consent was usually taken but was often only in a verbal form. Processing, storage and security measures highlighted potential risks for breaches in confidentiality. Knowledge relating to the NHS Confidentiality Code of Practice, the Data Protection Act and the need for registration with the Data Commissioner when acting in a private capacity were often not known. This small study highlights a number of important points surgeons need to be aware of when taking photographs of patients themselves and makes recommendations for its practice within a plastic surgery department.

Prospective survey of factors affecting risk discussion during consent in a surgical specialty.

BACKGROUND: The Department of Health in the UK has developed new consent guidance but without clear recommendations on how the incidence and severity of a given risk should influence its discussion during the process of obtaining informed consent. Plastic surgery is a litigation-prone specialty that offers a paradigm for assessing attitudes to consent. METHODS: A questionnaire was sent to all surgeons at six plastic and reconstructive surgery units within the UK. It enquired what incidence of a relatively frequent minor severity risk such as wound infection, or an extremely rare but major risk such as stroke, would merit its discussion when obtaining informed consent for elective surgery. RESULTS: Sixty of 85 questionnaires were returned. For a minor risk, there was a consensus that an incidence threshold of 5 per cent or greater would necessitate its discussion. For a major risk, the modal threshold was 0.1 per cent, but there was a greater variability of response. CONCLUSION: There was a wide variation of opinion as to how frequently a major risk must occur before it is likely to be conveyed to a patient during the process of consent. The findings suggest that recent change in case law has yet to disseminate fully in one surgical specialty, with the potential for the challenge that consent is not 'informed'.

Fine needle aspiration in plastic surgery outpatients: a retrospective study.

A survey suggested that fine needle aspiration cytology of masses in plastic surgery outpatient clinics was suboptimal. A cytopathologist gave training in the technique and the effectiveness of this intervention was audited. A total of 236 aspirates were taken from 147 patients in the earlier time period and 215 from 149 in the later period. The overall inadequate aspirate rate remained constant at 43%. The most common reasons for poor aspirates were excess blood, unrepresentative adipose tissue and insufficient cellular material. When the specimen was adequate after training, the sensitivity and specificity of the investigation were 96% and 100%, respectively. We present methods for sample optimization. Alternative strategies may be to limit aspiration to one clinician or to refer the patient to a cytopathologist experienced in the technique.

A step-by-step guide to classifying and managing pretibial injuries.

Even in cases of relatively minor trauma, pretibial injuries to older patients can cause significant damage as a result of poor blood supply to the skin. This paper offers a classification of pretibial injuries and an algorithm for their management.

Do plastic surgeons resect basal cell carcinomas too widely? A prospective study comparing surgical and histological margins.

Basal cell carcinoma is a common condition facing the plastic surgeon. When formally excised, a surrounding margin of normal skin is included in an attempt to ensure complete excision. We set out to investigate our excision margins in a prospective study of 100 basal cell carcinomas in 86 patients treated by conventional surgical excision. The edge of each lesion was delineated, an excision margin was drawn, and the closest point was identified and measured. The tumours were excised, and the specimens were examined to determine the closest histological margin. A comparison was made between the marked surgical margins and the margins observed on microscopy. The mean observed surgical margin was 3.0 mm and the mean histological margin was 3.7 mm; 44% of the margins agreed to within 1 mm, 79% to within 2 mm and 92% to within 3 mm. There were four incomplete excisions, all at the lateral margin. There was agreement in the position of the closest margin in 69% of cases. The measured surgical excision margins correlated well with those assessed histologically, as did the position of the closest margin. Given a 3 mm margin, 96% of lesions would have been excised completely. We feel that our current practice represents a satisfactory balance between maintaining a low rate of incomplete excision and minimising the sacrifice of normal skin.

Malignant transformation in congenital sebaceous naevi in childhood.

Sebaceous naevi are uncommon congenital skin lesions with a well-recognised potential for neoplastic change. They should be considered premalignant lesions as malignant degeneration, most commonly basal cell carcinoma and squamous cell carcinoma, occurs with a lifetime risk of between 5% and 22%. This incidence is equal to that of actinic keratosis and exceeds that of oral leukoplakia. Such change, however, is rare before puberty. Basal cell carcinoma may develop in children with naevoid basal cell carcinoma syndrome, xeroderma pigmentosum and rarely de novo but sebaceous naevus is the only solitary lesion in childhood associated with the development of basal cell carcinoma. We present two cases of malignant transformation in a congenital sebaceous naevus occurring in childhood and review the literature and discuss the evidence upon which to base management guidelines.

Metastasising dermatofibroma or dermatofibroma-like dermatofibrosarcoma protuberans?

Dermatofibroma is a relatively common cutaneous fibrohistiocytic tumour with a marked tendency to recur locally. It is almost invariably benign. In a review of the world literature there was one report of two patients with dermatofibroma with histologically documented metastases. In both of these there was local recurrence and subsequent metastasis to lymph nodes and haematogenous spread to the lungs. We present a case of cellular dermatofibroma of the lower limb with local recurrence and metastasis to the abdominal wall, posterior chest wall and both lungs 30 months after excision of the primary lesion. The clinical and pathological features of the case are presented to emphasis the need for follow up of patients with dermatofibroma which present any unusual histological features.