Analysis of vector alignment with the Zitelli bilobed flap for nasal defect repair: a comparison of flap dynamics in human cadavers.

OBJECTIVE: To determine whether differences of angles between the alar rim and the long axis of the secondary defect in a Zitelli bilobed flap affect alar displacement in a fresh cadaver model. METHODS: In fresh cadaver heads, identical, unilateral 1-cm circular defects were created at the superior alar margin. Three different laterally based bilobed flap templates for reconstruction were used. One template, used on 3 cadavers, had an angle of 60 degrees between the alar rim and the long axis of the secondary defect. Another template, used on 3 cadavers, had an angle of 90 degrees . The last template had an angle of 135 degrees and was used on 2 cadavers. Photographs were taken before the repair and after with the camera and cadaver heads in the same spatial relationship to each other. RESULTS: In the 3 cadavers that had repair using an angle of 60 degrees , all cadavers experienced alar retraction, with a mean displacement of 1.3 mm. This was not a statistically significant change (P = .07). In the defects that had repair using an angle of 90 degrees , there was also no significant alar displacement (P = .72). In the 2 cadavers that underwent repair using an angle of 135 degrees , both ala underwent depression by 1.0 mm. When the differences achieved between the different angles were compared, there was a significant difference in measured distortion between the cadavers that had 90 degrees and 60 degrees vector placement (P = .02). There were no measurable changes to the contralateral maximal nostril distance. CONCLUSIONS: Vector alignment can have an impact on nostril displacement. In bilobed flaps, the axis of the secondary defect may play an important role. This study suggests that secondary defects aligned perpendicular to the nostril have the least amount of alar distortion.

Staged excision for lentigo maligna and lentigo maligna melanoma: A retrospective analysis of 117 cases.

BACKGROUND: Complete surgical excision for lentigo maligna (LM) and LM melanoma (LMM) in the head and neck region may be challenging because of potential significant subclinical extension. OBJECTIVE: We sought to review clinical and histologic features of LM and LMM and determine surgical margin necessary for complete excision. METHODS: We conducted a retrospective study of 117 LM and LMM cases treated with a staged margin-controlled excision technique with rush paraffin-embedded sections. RESULTS: The mean total surgical margin required for excision of LM was 7.1 mm and was 10.3 mm for LMM. Of the tumors diagnosed as LM on initial biopsy specimen, 16% were found to have unsuspected invasion. Total surgical margin was associated with initial clinical lesion diameter. LIMITATIONS: Retrospective and single-institution experience are limitations. CONCLUSION: This study corroborates that the standard excision margins for LM and LMM are often inadequate and occult invasive melanoma occurs in LM. An excision technique with permanent sections using a team of dermatopathology and surgery that carefully examines the central tumor and the surgical margins is reliable for the treatment of LM and LMM.

Skin cancer coverage in a national newspaper: a teachable moment.

BACKGROUND: The objectives of this study were to (1) identify the number of published articles related to skin cancer in The New York Times newspaper from 1980-2004; (2) assess the content of the articles related to skin cancer, and (3) examine the trends in media coverage of skin cancer over time. METHODS: We performed a content analysis on articles related to skin cancer appearing in The New York Times during January 1, 1980, through December 31, 2004, using the ProQuest online content repository database and key words skin cancer. We conducted an advanced focus search of all "skin cancer" articles using key words "melanoma," "squamous cell carcinoma," "basal cell carcinoma," "sunscreen," "tanning," "sunbathing," and "tanning salon". RESULTS: We identified 874 published articles relating to skin cancer. Melanoma was the primary subject of the 874 articles, with 29% of the articles focusing on some aspect of melanoma. Coverage of other major subjects included sunscreen (11%), tanning (9%), basal cell carcinoma (7%), squamous cell carcinoma (3%), sunbathing (2%), and tanning salon (2%). The remaining 37% of articles contained some mention of skin cancer, but skin cancer was not the main topic nor were any of the focus terms. Over the 25-year period we examined, there was a slight upward trend in the number of skin-cancer-related articles, although we observed year-to-year variation. CONCLUSIONS: Understanding how the print media portrays skin cancer issues provides valuable feedback for federal agencies and cancer organizations and may ultimately help promote skin cancer prevention and education.

Multiple cutaneous granular-cell tumors.

A 54-year-old woman presented with subcutaneous nodules and a prior diagnosis of multiple, cutaneous granular-cell tumors. The first case of granular cell tumor was reported in 1854. It remains a rare tumor, which is most commonly seen in women. One-half are usually located in the head and neck region, mostly on the tongue. Approximately one third are cutaneous and 25 percent of the cases occur as multiple lesions.

Therapeutic decision making in the therapy of actinic keratoses.

Actinic keratoses (AKs) represent the second most common reason to visit a dermatologist in the United States and their therapy has become a major portion of most dermatologists' practice. An ever-increasing array of therapeutic options exist for the therapy of actinic keratoses, offering physicians and patients a greater number of choices than ever before. Patient expectations and needs seem to be changing at the same time, thus effecting therapeutic decision-making. While destructive therapies with resultant wounds, time for wound healing, and possible hypopigmentation or scarring were acceptable in the past, many patients from the baby-boom generation are now developing AKs and have little tolerance for any time for wound healing or any cosmetic changes. This paper will raise some fundamental questions regarding AKs and their management.

X-linked recessive ichthyosis.

A 13-year-old boy presented with a lifelong history of tightly-adherent, brown, polygonal scales that covered the extensor surfaces of the extremities, lateral aspects of the trunk, and neck. The clinical presentation and the history of a similar skin condition in the patient's male maternal relatives helped establish the diagnosis of X-linked recessive ichthyosis (XLI). Systemic manifestations of the steroid sulfatase (STS) deficiency underlying XLI include cryptorchidism, asymptomatic corneal opacities, and maternal failure to progress during labor. Most cases of XLI are caused by deletions of the STS gene, and contiguous gene syndromes may occur when the deletions extend to neighboring genes on the distal short arm of the X chromosome.

Piebaldism.

A 46-year-old man presented with a history of a congenital pigment disorder. On physical examination hypopigmented and depigmented patches were present on the mid-forehead, anterior chest, and extremities. He also had loss of pigment of the medial eyebrows and a white forelock. The patient has a family history of a similar congenital pigment disorder, the pattern of which is indicative of the autosomal dominant disorder piebaldism.

Papulonodular mucinosis with subacute cutaneous lupus erythematosus.

A 30-year-old woman with subacute cutaneous lupus erythematosus presented with a facial eruption, painful and swollen ulcers of her digits, and asymptomatic lesions on her abdomen. The laboratory findings were consistent with subacute cutaneous lupus erythematosus with an anticardiolipin antibody. A biopsy specimen of the asymptomatic lesions on her abdomen showed mucin within the upper reticular dermis. Papulonodular mucinosis is a rare but well-documented finding associated with systemic and cutaneous forms of lupus erythematosus. The etiology and pathogenesis of this finding remain to be elucidated.

HDM2 protein overexpression and prognosis in primary malignant melanoma.

Overexpression of the oncogene HDM2 is observed in a substantial proportion of melanomas, including noninvasive and thin lesions, suggesting that HDM2 overexpression may be an early event in melanocyte transformation. To determine the role of HDM2 in the clinical progression of melanoma, we examined whether its expression was associated with patient survival. From November 1972 through November 1982, 134 patients with melanoma who participated in the New York University Melanoma Cooperative Group were studied, if representative tissues and follow-up were available. HDM2 protein expression was assessed immunohistochemically. Unexpectedly, we observed that HDM2 overexpression was statistically significantly associated with improved disease-free survival (relative risk [RR] = 0.47, 95% confidence interval [CI] = 0.24 to 0.89; two-sided chi(2) P =.021) and overall survival (RR = 0.55, 95% CI = 0.33 to 0.94; two-sided chi(2) P =.027) in multivariable analysis. HDM2 overexpression appears to be an independent predictor of survival for patients with primary melanoma; however, larger prospective studies are required for validation.

Evaluation of the proliferation marker MIB-1 in the prognosis of cutaneous malignant melanoma.

BACKGROUND: The proliferation marker MIB-1, which recognizes the Ki-67 antigen, provides independent prognostic information in several tumor types. Its utility in melanoma has been evaluated mostly in studies of thick primary tumors. Its usefulness in thinner lesions has not been assessed adequately. METHODS: A well characterized cohort of 137 patients diagnosed with primary cutaneous melanoma at the New York University School of Medicine between 1972 and 1982 was studied based on the availability of representative tissues and adequate clinical follow-up. Twenty-one tumors were less than or equal to 1.0 mm thick, 94 were between 1.01 and 4.0 mm thick, and 22 were thicker than 4.0 mm. Tumor cell proliferation was assessed by immunohistochemistry using the monoclonal antibody MIB-1. MIB-1 expression was correlated with baseline clinicopathologic parameters, as well as recurrence (RR), disease-free (DFS), and overall survival (OS) rates. Median follow-up among survivors was 6.5 years (range, 5.6-17.5). RESULTS: High proliferative index, defined as 20% or more of tumor cells showing nuclear immunoreactivity, was observed in 65 of 137 (47.4%) cases. High proliferative index was significantly correlated with increased tumor thickness (P < 0.001) and higher stage (P = 0.03). Trends approaching statistical significance were observed with ulceration of the primary tumor (P = 0.09), male gender (P = 0.06), and shorter DFS (P = 0.12). No significant associations were seen between high proliferative index and RR or OS. In multivariate analyses, tumor thickness was the strongest predictor of clinical outcome. CONCLUSIONS: In primary cutaneous melanoma, a high proliferative index is associated with clinicopathologic parameters predictive of worse clinical outcomes. However, it was not an independent predictor of clinical outcome.