The surgical management of extensive cases of acne keloidalis nuchae.

OBJECTIVE: To determine the efficacy of excision with primary closure in the treatment of extensive and refractory acne keloidalis nuchae (AKN). DESIGN: Intervention before-after trial. Duration of follow-up ranged from 1 to 5 years. SETTING: University-based ambulatory outpatient dermatologic surgery unit. PATIENTS: Referred sample of 25 patients with extensive AKN that was refractory to medical management. All patients were healthy, young black men who had no medical problems and were not taking any medications. No other eligible patients refused to be included in the study. All 25 patients completed the study. INTERVENTIONS: All 25 patients underwent surgical excision of AKN. Twenty of the 25 underwent excision with layered closure in 1 stage. Four patients underwent 2-stage excisions with layered closure. One patient underwent excision with second-intention healing. MAIN OUTCOME MEASURE: A test of the following hypothesis: excision with primary closure is a successful treatment modality with little risk of recurrence for extensive cases of AKN. RESULTS: The author and all 25 patients rated the cosmetic result of surgery as good to excellent. No patients experienced complete recurrence of their acne keloids. Fifteen patients developed tiny pustules and papules within the surgical scar. Five patients developed hypertrophic scars. Papules, pustules, and hypertrophic scars were all successfully treated with high-potency topical and intralesional steroids. CONCLUSIONS: Excision with primary closure is an excellent surgical treatment modality for the management of extensive cases of AKN. Extremely large lesions should be excised in multiple stages. The surgeon should carefully assess each patient to determine whether AKN should be excised in 1 or multiple stages.

The use of full-thickness skin grafts to repair nonperforating nasal defects.

BACKGROUND: Full-thickness skin grafts are traditionally thought of as inferior alternatives to local flaps in nasal reconstruction. OBJECTIVE: Our purpose was to demonstrate that full-thickness skin grafts are viable alternatives to local flaps in the reconstruction of nonperforating defects extending through the dermis of the nose. METHODS: The literature was reviewed to determine the best donor sites for full-thickness skin grafts to repair defects on different regions of the nose. RESULTS: The optimal donor site for the repair of defects on the thin skin of the upper two thirds of the nose (dorsum and sidewall) is the preauricular area. The best donor site for the repair of defects on the thick, sebaceous skin of the lower one third of the nose (tip and ala) is the conchal bowl of the ear. Defects located on the transition zone between the upper two thirds and lower one third of the nose are best repaired with Burow's grafts or nasolabial fold grafts. CONCLUSION: Full-thickness skin grafts are excellent alternatives to local flaps in the reconstruction of nonperforating nasal defects provided that the surgeon selects the appropriate donor site based on whether the surgical defect is located on the thin, pliable skin of the upper nose or the thick, sebaceous skin of the lower nose.

The use of perichondrial cutaneous grafts to repair defects of the lower third of the nose.

The reconstruction of surgical defects on the nasal tip and nasal ala which require both skin coverage and underlying support is often a complex surgical problem. The perichondrial cutaneous graft (PCCG) is a composite graft of skin and perichondrium harvested from the conchal bowl of the car. It is an excellent alternative to full-thickness skin grafts and local flaps for reconstructing defects of the lower third of the nose. This composite graft, which is composed of epidermis, dermis, a small amount of subcutaneous tissue, and the underlying perichondrium, yields excellent cosmetic and functional results in a simple, single-stage, out-patient procedure. This article describes and illustrates the repair of surgical defects on the nasal tip and nasal ala using the PCCG.

Dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans is a tumor of intermediate malignancy characterized by its aggressive local growth and marked propensity to recur after surgical excision. This article reviews the incidence, clinical presentation, histologic features, immunocytochemical studies, histogenesis, prognosis, management, and follow-up recommendations for this unusual neoplasm.

A comparison between Mohs micrographic surgery and wide surgical excision for the treatment of dermatofibrosarcoma protuberans.

BACKGROUND: There is growing evidence that Mohs micrographic surgery (MMS) is the treatment of choice for dermatofibrosarcoma protuberans (DFSP). OBJECTIVE: This study retrospectively compared the recurrence rates of DFSP after MMS with those after wide surgical excision; results at the Mayo Clinic and in the world literature were evaluated. In addition, preoperative tumor sizes and postoperative defect sizes after MMS were compared to determine whether MMS conserved more normal tissue than wide surgical excision. METHODS: The medical records of 84 patients with DFSP who had been treated at the Mayo Clinic were reviewed. They were categorized into two treatment groups: MMS and surgical excision. RESULTS: Fifteen patients with DFSP who underwent MMS had follow-up data available; one of these patients had local recurrence (recurrence rate, 6.6%; average duration of follow-up, 40 months). Thirty-nine patients had wide excision; four of these patients had local recurrences and one had pulmonary metastases (recurrence rate, 10%; average duration of follow-up, 36 months). A review of the world literature revealed neither local recurrences nor metastases in the 11 studies in which DFSP was treated with MMS. Overall, including our results, the average recurrence rate of DFSP after MMS was 0.6% (range, 0% to 6.6%) and the total recurrence rate was 1.6% (1 of 64). Including our series, DFSP was treated with wide excision in 15 studies; the average recurrence rate was 18% (range, 0% to 60%) and the total recurrence rate was 20% (100 of 489). In eight published studies, DFSP was surgically resected with undefined or conservative excisional margins; the average recurrence rate was 43% (range, 26% to 60%) and the total recurrence rate was 44% (140 of 317). A surgical margin of 2.5 cm to deep fascia was required for complete clearance of all tumors treated with MMS. Twenty-two percent of tumors were removed with a 0.5 cm margin, 50% with a 1.0 cm margin, 67% with a 1.5 cm margin, and 89% with a 2.0 cm margin. CONCLUSION: On the basis of our results and data compiled from the literature, MMS may be the treatment of choice for DFSP because of its high cure rate and maximal conservation of tissue.

The epidemiology of skin cancer.

BACKGROUND: The incidence of skin cancer is increasing at an alarming rate. OBJECTIVE: To discuss current epidemiologic data concerning the incidence, morbidity, environmental influences, predisposing, host conditions, precursor lesions, and prevention of melanoma and nonmelanoma (basal and squamous cell) skin cancer. METHODS: The current literature was reviewed in order to provide current epidemiologic data for melanoma, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). RESULTS: Skin cancer is exceedingly common and the incidence is rising rapidly. Although the mortality rate for nonmelanoma skin cancer (NMSC) is decreasing, that of melanoma is increasing. Both NMSC and melanoma are associated with significant morbidity. Whereas chronic sun exposure is the main cause of NMSC, the development of melanoma appears to be related to intense, intermittent sun exposure. Ozone depletion has contributed to rising incidence rates of both NMSC and melanoma. In contrast to NMSC, there is not a direct relationship between ultraviolet radiation and melanoma. Genetic susceptibility significantly increases the lifetime risk of acquiring melanoma. There is no precursor lesion for BCC. Precursor lesions for invasive SCC include actinic keratoses and SCC in situ. Melanoma may arise from benign nevi and dysplastic nevi. Prevention of melanoma and NMSC is extremely important since prognosis improves with early detection. Prevention may be achieved by educating patients and physicians how to detect skin cancers early and by decreasing or eliminating exposure to ultraviolet light. CONCLUSION: The incidence of skin cancer has reached epidemic proportions. Only through heroic efforts by health care professionals and the general public to prevent the development or progression of skin cancer will this epidemic be abated.

The use of full-thickness skin grafts for the repair of defects on the dorsal hand and digits.

BACKGROUND: The hand is a complex part of the human body and plays an important role in our everyday lives. It is critical to preserve manual function when repairing surgical defects on the dorsum of the hand and digits. OBJECTIVE: To demonstrate the effectiveness of the full-thickness skin graft (FTSG) in the repair of surgical defects on the dorsum of the hand and digits. METHODS: Through a retrospective review of photographic and written records and person-to-person interviews, the authors evaluated 19 patients who underwent FTSG repair of 21 defects on the dorsum of the hand and digits after Mohs micrographic surgery. RESULTS: In all cases, the FTSG was durable, yielded good cosmetic results, and maintained normal function of the hand. CONCLUSION: The FTSG is a good option for repairing surgical defects on the dorsum of the hand and digits.

Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts.

BACKGROUND: The documented presence of human papillomavirus DNA in the plume after carbon dioxide laser treatment of warts has raised questions about the risk of transmission of human papillomavirus to laser surgeons. OBJECTIVE: We sought to define more clearly the risks to surgeons of acquiring warts from the CO2 laser plume. METHODS: A comparative study was conducted between CO2 laser surgeons and two large groups of population-based control subjects (patients with warts in Olmsted County and at the Mayo Clinic from 1988 to 1992). Conclusions were drawn about the risks to surgeons of acquiring warts from the CO2 laser plume. RESULTS: There was no significant difference (p = 0.569) between the incidence of CO2 laser surgeons with warts (5.4%) and patients with warts in Olmsted County from 1988 to 1992 (4.9%). There was a significant difference between the incidence of plantar (p = 0.004), nasopharyngeal (p = 0.001), and genital and perianal warts (p = 0.004) in the study group and in patients with warts treated at the Mayo Clinic from 1988 to 1992. No significant difference was found between physicians who had acquired warts and those who were wart free, on the basis of the failure to use gloves (p = 0.418), standard surgical masks (p = 0.748), laser masks (p = 0.418), smoke evacuators (p = 0.564), eye protection (p = 0.196), or full surgical gowns (p = 0.216). Finally, the incidence rates of surgeons with warts per 1000 person-years did not increase significantly (p = 0.951) as the length of time that the CO2 laser was used to treat warts increased. CONCLUSION: When warts are grouped together without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than a person in the general population. However, human papillomavirus types that cause genital warts seem to have a predilection for infecting the upper airway mucosa, and laser plume containing these viruses may represent more of a hazard to the surgeon.