The dog-ear rotation flap for the repair of large surgical defects on the head and neck.

BACKGROUND: The Mohs micrographic surgeon is often faced with the daunting challenge of having to repair very large surgical defects on the head and neck where cosmesis and maintenance of normal function are of paramount importance. OBJECTIVE: We describe a novel flap, the dog-ear rotation flap, for the repair of such defects. We will demonstrate that this flap offers superior cosmetic and functional results to many other closure options, particularly for extensive defects of the cheek, temple, forehead and scalp. METHODS: The dog-ear rotation flap is a combination repair. It is executed by first closing one end of the surgical defect in a primary side-to-side-fashion, to a point at which tension across the wound precludes any further closure. A rotation flap is then developed to close the remaining defect, using tissue from the large dog-ear created at the distal end of the wound. RESULTS: In our experience, the dog-ear rotation flap is able to close substantial head and neck defects with less tension across the wound edges when compared to other closure types, resulting in diminished scarring and little to no distortion of surrounding anatomic structures. It also provides an excellent tissue match, is relatively quick and easy to perform, and has an extremely low incidence of flap necrosis. CONCLUSIONS: The dog-ear rotation flap is an excellent choice for the repair of very large surgical defects on the head and neck, particularly the cheek, temple, forehead and scalp, and, in our experience, provides a superior cosmetic and functional result to other closure options.

Applications of the double O to Z flap repair for facial reconstruction.

Multiple defects are often encountered in the treatment of malignant skin tumors. Nearby defects can present a reconstructive challenge since the closure of one defect may impact the closure of the other defect. The double O to Z flap design is ideally suited to combine the closure of adjacent defects into one technique. This flap technique and design is illustrated and described. Examples include defects on the forehead, temple, cheek, and nose following Mohs micrographic surgery.

Techniques for reconstruction of perialar and perialar-nasal ala combined defects.

BACKGROUND: The nasal ala and perialar areas involve junctions with the nose, cheeks, and lips. Following Mohs surgery, defects in this area often extend across one or more creases or folds, thus requiring repair of more than one reconstructive subunit. OBJECTIVE: Our goal is to present various reconstructive techniques required to obtain aesthetic results. METHODS: Defects and reconstructions will be illustrated to demonstrate techniques and results. Emphasis will be on selection of techniques and documentation of results. RESULTS: Examples include various flap procedures (advancement, rotation, pedicle, interpolation, transposition), full-thickness and composite grafting, second intention healing, and combinations thereof. CONCLUSIONS: Thoughtful application of the various techniques will help to maximally camouflage scars and avoid maneuvers which would result in bridging and/or blunting of creases and folds.

The use of hyaluronidase as an adjunct to surgical procedures.

BACKGROUND: Although the use of hyaluronidase as an adjunct to anesthesia is frequently described for plastic surgery and ophthalmologic procedures, its use in dermatologic surgery has not been well investigated. OBJECTIVE: In this report we review the advantages and disadvantages of using hyaluronidase in dermatologic procedures. METHODS: The effect of adding hyaluronidase to local anesthesia was evaluated in 72 operations performed over a 1-year period. RESULTS: Although the duration of anesthesia is slightly decreased, the addition of hyaluronidase to local anesthesia offers the benefits of minimizing loss of surface contour and enhanced ease in undermining and dissection through subcutaneous tissue planes. The onset of anesthesia using hyaluronidase is immediate and the area of anesthesia appears increased over anesthesia without hyaluronidase. CONCLUSION: We therefore recommend the adjunct of hyaluronidase to local anesthesia as a useful advancement in surgical technique.

Primary cutaneous adenoid cystic carcinoma treated with Mohs micrographic surgery toluidine blue technique.

A patient with primary cutaneous adenoid cystic carcinoma treated with Mohs surgery is presented. This tumor is characterized clinically by frequent local recurrences and infrequent metastases. Histologically it demonstrates cribiform islands of tumor cells with an abundance of mucin. Because toluidine blue stains this mucin metachromatically, it may be superior to hematoxylin and eosin for identifying the presence of this tumor. We recommend Mohs micrographic surgery with toluidine blue staining technique for the treatment of adenoid cystic carcinoma.

Long-term therapy with low-dose isotretinoin for prevention of basal cell carcinoma: a multicenter clinical trial. Isotretinoin-Basal Cell Carcinoma Study Group.

BACKGROUND: High-dose isotretinoin has been reported to have a prophylactic effect on nonmelanoma skin cancer, although it is associated with significant toxicity. PURPOSE: To test the effectiveness of the long-term administration of low-dose isotretinoin in reducing the occurrence of basal cell carcinoma at a new site in patients with previously treated basal cell carcinomas and to measure the toxicity associated with this regimen, we conducted a clinical trial at eight cancer centers. METHODS: Nine hundred and eighty-one patients with two or more previously confirmed basal cell carcinomas were randomly assigned to receive either 10 mg of isotretinoin or a placebo daily. Patients were followed for 36 months and monitored at 6-month intervals for skin cancer and toxic effects. RESULTS: After 36 months of treatment, no statistically significant difference in either the cumulative percent of patients with an occurrence of basal cell carcinoma at a new site or the annual rate of basal cell carcinoma formation existed between patients receiving isotretinoin and those receiving the placebo. Elevated serum triglycerides, hyperostotic axial skeletal changes, and mucocutaneous reactions were more frequent in the group receiving isotretinoin than in the control group, and these differences were all statistically significant (P less than .001). CONCLUSION: This low-dose regimen of isotretinoin not only is ineffective in reducing the occurrence of basal cell carcinoma at new sites in patients with two or more previously treated basal cell carcinomas but also is associated with significant adverse systemic effects. IMPLICATION: The toxicity associated with the long-term administration of isotretinoin, even at the low dose used in this trial, must be weighted in planning future prevention trials.

Applications of the crescentic advancement flap.

Repair of defects of the lateral nose, perialar, and nasolabial region are often challenging. Maintaining the normal anatomic boundary lines and if possible placing the sutures within these lines are important considerations when designing a closure. The crescentic advancement flap has proved to be a versatile closure for skin cancer defects in these regions. A brief historic perspective on this flap along with important concepts in its utilization for defects of the lateral nose, perialar region, and nasolabial fold are discussed.

Ear reconstruction with local flaps.

Functional and aesthetic reconstruction of the external ear can be simplified by a regional approach utilizing commonly known principles and techniques of surgical repair. Reconstructive options are herein offered in a step-by-step fashion.

Cartilage removal prior to skin grafting in the triangular fossa, antihelix, and concha of the ear.

Skin grafting onto a large area of exposed ear cartilage with irregular contours poses an increased risk of inadequate re-establishment of circulation. Removal of cartilage not needed for structural support before grafting following Mohs surgery on the triangular fossa, antihelix, and concha of the ear decreases the risk of recurrence of the carcinoma, and increases the chances for survival of the graft.

Cutaneous angiolipoleiomyoma.

We describe eight cases of cutaneous angiolipoleiomyoma, a rare tumor previously reported only once under the term cutaneous angiomyolipoma. Clinically, the tumors were acquired, solitary, asymptomatic nodules that were always acral in location. Patients' ages ranged from 33 to 77 years (median 52.6 years); the male/female ratio was 7:1. Signs of tuberous sclerosis or renal angiomyolipoma were absent in all cases. Histologically, the tumors were subcutaneous, well circumscribed, and composed of smooth muscle, vascular spaces, connective tissue, and mature fat. In some tumors the fat was the predominant component, and in others smooth muscle predominated. Elastic tissue stains revealed that some blood vessels had developed an elastic lamina whereas other blood vessels lacked it. Additional histologic features occasionally observed included vascular thrombi, glomus bodies, and focal mucin deposition.

Familial cervical hypertrichosis with underlying kyphoscoliosis.

A family with congenital localized hypertrichosis transmitted in an autosomal dominant pattern is presented. The excessive hair growth was localized to the cervical region and was associated with underlying kyphoscoliosis. No additional cutaneous or skeletal abnormalities were identified. To our knowledge these are the first cases of familial congenital cervical hypertrichosis associated with underlying kyphoscoliosis reported in the literature.

Cutaneous lentiginosis with atrial myxomas.

This report describes a 25-year-old white woman with lentigines, cutaneous myxomas, bilateral atrial myxomas, and cerebral artery aneurysms. We believe this case to be the fifth reported case of this unusual association in the medical literature, with the additional finding of a central nervous system aneurysm. In the past this association has been described under the mnemonics NAME syndrome and LAMB syndrome. We propose that these mnemonics be dropped because the particular features encompassed within this syndrome are unclear. We suggest that "cutaneous lentiginosis with atrial myxomas" is an adequate description of this syndrome.

Treatment of mycosis fungoides with isotretinoin.

A 56-year-old man with a 7-year history of well-documented mycosis fungoides is reported. Because the patient was a treatment failure with topical nitrogen mustard due to severe allergic contact dermatitis, and because of recent reports of the efficacy of retinoid compounds, he was treated with a 6-month course of isotretinoin with total clearing of his skin lesions. Previous case reports and possible mechanisms of action are reviewed.

Transplantation of human basal cell carcinomas to athymic mice.

Basal cell carcinomas (BCCs) obtained from 22 subjects undergoing microscopically controlled surgery were transplanted to 40 athymic (nude) mice. With no further immunosuppression of the mice, no tumor growth was noted in the first 14 attempts. When mice were further immunosuppressed with anti-lymphocyte serum (ALS) injections and by splenectomy, successful tumor growth was achieved in 15 of 22 mice by a subcutaneous implantation technique and in 1 of 4 by a superficial grafting technique. Transplanted BCC retained the morphology and basement membrane proteins typical of human BCC. As determined by autoradiography, 3H-thymidine was incorporated primarily in the peripheral palisaded cells of the transplanted tumor. Successful use of the athymic mouse model for study of human BCC requires use of mice further immunosuppressed by splenectomy and ALS, and the use of a subcutaneous implantation technique. With the use of this model, studies of the biology of human BCC may be possible.

Cutaneous meningioma.

A case of a subcutaneous meningioma is presented. It is uncommonly encountered but, because of its superficial location, is apt to present to a dermatologist. Meningioma should be included in the differential diagnosis of lesions of the scalp, especially the midline, face, and paraspinal areas. Biopsy, especially of type III, can be potentially complicated by infection or leakage of cerebrospinal fluid. Suspicion of the nature of the lesion and appropriate additional studies may avoid these complications.

Carcinoma of sebaceous glands on the head and neck. A report of four cases.

Carcinoma of sebaceous glands most commonly occurs on the eyelids and caruncles of the elderly. Local recurrences after would-be adequate treatment and distant metastases are common in this malignancy in this site. Carcinomas of sebaceous glands arising elsewhere in the skin also have a strong tendency to recur locally, but are said to be much less likely to metastasize. Our experience with four such carcinomas on the head and neck have led us to believe that the malignancy is biologically aggressive anywhere if not adequately treated at the onset.