A retrospective cohort study of cutaneous squamous cell carcinoma of the scalp: features of disease and influence of sociodemographic factors on outcomes.

BACKGROUND: Cutaneous squamous cell carcinoma (SCC) is an increasingly prevalent and potentially fatal disease with considerable implications if not recognized early and treated promptly. Several disease features contribute to a higher risk profile and adverse outcomes in affected patients. AIMS: Given the clinical observation that elderly males from rural communities often present with large SCCs of the scalp, we sought to investigate and describe features of disease and sociodemographic factors from a cohort of patients with scalp SCCs. METHODS: Histology reports of scalp primary SCCs were retrospectively assessed. Disease and demographic features were recorded. Descriptive statistics were generated, and statistical analyses (Fisher's exact, Mann-Whitney U and Spearman's rank test) were utilized to examine relationships between high-risk disease features and sociodemographic features. RESULTS: Ninety-three occurrences of scalp SCC in 61 patients were assessed. The average age at presentation was 78.81 years. Males were predominantly affected at a 14:1 ratio. Half of all tumours were greater than 2 cm (47/93 (50.54%)). The geographical distance from treatment was significantly associated with larger tumours at presentation. (rs = .34 P = 0.002). Recurrence and metastasis rates were determined amongst 188 patients with a primary scalp SCC, and low rates were observed (2.66% and 2.13%, respectively). CONCLUSIONS: Elderly males are inordinately affected by scalp SCC compared to females. Those living further from care exhibited larger tumours at presentation. Data from this study characterize features of SCC of the scalp and provide evidence to suggest that rural isolation may act as a mediator of high-risk presentation and larger tumour size.

Levels of Evidence in Plastic and Reconstructive Surgery Research: Have We Improved Over the Past 10 Years?

Levels of evidence (LOE) aid in the critical appraisal of evidence by ranking studies based on limitation of its design. Analyzing LOE provides insight into application of evidence-based medicine. The aim of this study is to determine if the quality of evidence in plastic surgery research has improved over the past 10 years. Systematic review of research published in Plastics and Reconstructive Surgery journal over the years, 10-year period (2008, 2013, 2018), was performed. LOE for each article was determined using the American Society of Plastic Surgeons (ASPS) guidelines. Each level was calculated as percentage of publications per year and compared yearly and between different topics. Eight hundred eighty-four studies were included in the final analysis. The LOE of the research improved over the study period. Level 4 evidence was the most frequent published (50.6%, 447/884), with a decline from 63.2% in 2008 to 41.3% in 2018. Level 1 evidence improved each year and accounted for 2.1% of all research in 2018. Aesthetic surgery was the most frequent published topic with upper limb research demonstrating an 18.5% increase in high-quality evidence over the study period. Increased awareness of evidence-based medicine has improved the quality of plastic surgery research over the past decade. It is vital this continues to provide gold standard patient care.

Botulinum Toxin Treatment for Mild to Moderate Platysma Bands: A Systematic Review of Efficacy, Safety, and Injection Technique.

Background: Platysma bands are characteristic of an aging neck. Resection and plication of the platysma muscle is the basis of treatment. However, unfavorable surgical outcomes and improved understanding of platysma band etiology have shifted treatment towards nonsurgical rejuvenation. Objectives: The aim of this paper was to assess the efficacy, injection techniques, and complications associated with botulinum toxin injection for the treatment of platysma bands. Methods: A systematic literature search was performed to identify articles reporting botulinum toxin injections for platysma bands in neck rejuvenation. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and the Cochrane Library-between January 1985 and December 2017. Results: Three studies met the inclusion criteria, with a total of 78 patients undergoing botulinum toxin injection for platysma bands. Incobotulinumtoxin A was used in 62.3% (n = 45/78) of patients, with 38.4% (n = 30/78) receiving abobotulinumtoxin A. Efficacy was assessed using the Merz platysma score scale. A mean score improvement of 2.0 points, with a response rate of 93.7%, was observed after 14 ± 2 days. At 3 months, the mean score improvement was 1.2 points with a response rate of 86%. Patient-reported metrics demonstrated an improvement in 91% (n = 71/78) of subjects. The three studies used a standard injection technique, with a maximum 20 IU of incobotulinumtoxin A and 5 U abobotulinumtoxin A administered per band. Complications were reported in 15.4% (n = 12/78) of patients, with none requiring further intervention. Conclusions: Botulinum toxin is a highly effective treatment for isolated platysma bands. A safe injection technique is described and recommended for clinical practice.

Trapezius flaps for reconstruction of head and neck defects following oncological resection - A systematic review.

OBJECTIVE: Head and neck (H&N) reconstruction after cancer resection is challenging. Myocutaneous trapezius flaps provide an alternative reconstruction for patients not suitable for microvascular free tissue transfer. METHODS: A systematic review was performed on studies involving trapezius flaps for H&N reconstruction post oncological resection between the years 1985-2015. Data extracted included patient numbers and demographics, operative technique and complications. Complication rates, for the study cohort, were calculated and a univariate analysis was preformed evaluating patient and flap-related risk factors. RESULTS: Seventeen studies met the inclusion criteria, with a total of 157 trapezius flaps. Intraoral defects were the most frequent recipient site (74.5%). The mean skin paddle width was 6.84 cm (range 3-15 cm) and length was 11.1 cm (range 4-25 cm). Type 2 (superficial branch of transverse cervical artery) accounted for 77.1% (118/153) of all trapezius flaps performed. The complication rate was 15.9%, with 15 reported flap related and 7 donor site complications. Skin paddle size, pedicle selection, primary versus salvage reconstruction and radiotherapy were not identified risk factors for complications. CONCLUSION: Trapezius flaps are a reliable and versatile myocutaneous flap for both primary and salvage surgery reconstruction of H&N defects following oncological resection.

Tumor Margin Assessment With Loupe Magnification Enables Greater Histological Clearance of Facial Basal Cell Carcinomas Compared With Clinical Examination Alone.

BACKGROUND: Surgical excision of facial basal cell carcinomas (BCCs) is a balance between oncological clearance and conservation of cosmetic and functionally sensitive tissues. OBJECTIVE: To assess if loupe magnification (LM) can enhance the visual assessment of BCC tumor margins resulting in a greater histological clearance. MATERIALS AND METHODS: This prospective study randomized patients with primary facial BCCs into preoperative tumor margin assessment with LM (study group) or clinical examination alone (control group). Basal cell carcinomas were excised with a predetermined surgical margin of either 2, 3,, or 4 mm. Mean histological margin, incomplete excision rate, and method of closure were recorded and compared between LM and control groups, across a range of surgical margins. RESULTS: Ninety-four BCCs were excised from 93 patients, 47 BCCs in each group. The mean histological margin was larger in the study versus control group for each group (2-mm margin, 1.8 vs 1.4, 3-mm margin, 2.4 vs 2.3, 4-mm margin, and 3.1 vs 2.7), but only statistically significant in the 4-mm group (p = .032). There was no difference in method of closure between LM and control groups. CONCLUSION: Loupe magnification improved tumor margin assessment for facial BCC enabling a greater diameter of histological clearance. The use of LM should become a standard practice for facial BCC excision.

Trends in the Level of Evidence in Clinical Hand Surgery Research.

BACKGROUND: The application of evidence-based medicine (EBM) to the practice of hand surgery has been limited. Production of high-quality research is an integral component of EBM. With considerable improvements in the quality evidence in both orthopedic and plastic and reconstructive surgery, it is imperative that hand surgery research emulates this trend. METHODS: A systematic review was performed on all hand surgery articles published in 6 journals over a 20-year period. The journals included Plastic and Reconstruction Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, Journal of Hand Surgery-European Volume, Journal of Hand Surgery-American Volume, Journal of Bone & Joint Surgery, and the Bone & Joint Journal. The level of evidence of each article was determined using the Oxford level of evidence. The quality of methodology of randomized controlled trials (RCTs) was assessed using Jadad scale. Statistical analysis involved chi-squares and Student t test (P < .05). RESULTS: A total of 972 original hand surgery research articles were reviewed. There was a significant increase in the average level of evidence of articles published between1993 and 2013. High-quality evidence only accounted for 11.2% of evidence published, with a significant increase over the study period (P = 0.001). Quantitative evaluation of the 26 published RCTs, using Jadad scale, revealed a progressive improvement in study design from 0.3 in 1993 to 3.33 in 2013. CONCLUSIONS: Hand surgery research has mirrored trends seen in other surgical specialties, with a significant increase in quality of evidence over time. Yet, high-quality evidence still remains infrequent.

Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain.

INTRODUCTION: Bilateral breast reduction (BBR) is one of the most frequently performed female breast operations. Despite no evidence supporting efficacy of drain usage in BBRs, postoperative insertion is common. Recent high quality evidence demonstrating potential harm from drain use has subsequently challenged this traditional practice. The aim of this study is to assess the current practice patterns of drains usage by Plastic & Reconstructive and Breast Surgeons in UK and Ireland performing BBRs. METHOD: An 18 question survey was created evaluating various aspects of BBR practice. UK and Irish Plastic & Reconstructive and Breast Surgeons were invited to participate by an email containing a link to a web-based survey. Statistical analysis was performed with student t-test and chi-square test. RESULTS: Two hundred and eleven responding surgeons were analysed, including 80.1% (171/211) Plastic Surgeons and 18.9% (40/211) Breast Surgeons. Of the responding surgeons, 71.6% (151/211) routinely inserted postoperative drains, for a mean of 1.32 days. Drains were used significantly less by surgeons performing ≥20 BBRs (p = 0.02). With the majority of BBRs performed as an inpatient procedure, there was a trend towards less drain usage in surgeons performing this procedure as an outpatient; however, this was not statistically significant (p = 0.07). CONCLUSION: Even with the high level of evidence demonstrating the safety of BBR without drains, they are still routinely utilised. In an era of evidence- based medicine, surgeons performing breast reductions must adopt the results from scientific research into their clinical practice.

The oncologic safety and practicality of breast conservation surgery in large breast tumors 5 centimeters or more.

BACKGROUND: Surgery remains a therapeutic strategy for women with breast cancer, and long-term outcomes for breast conservation surgery (BCS) and radiotherapy are equivalent to those for mastectomy. To date, there are few published data assessing the oncologic safety and practicality of BCS in women with large breast cancers ≥ 5 cm. The current study compares survival outcomes for women with breast cancer ≥ 5 cm undergoing BCS or mastectomy. METHODS: All women undergoing surgery for breast cancer ≥ 5 cm between January 2004 and December 2011 were included in this study. Kaplan-Meier survival curves statistically compared the overall survival (OS), disease-free survival (DFS), and local recurrence-free survival (LRFS) in the BCS and mastectomy groups. Statistical analysis involved chi-square analysis and t test. The mean length of follow-up was 55.25 months (range, 6-115 months). RESULTS: A total of 217 women had surgery for tumors ≥ 5 cm (BCS in 51, mastectomy in 166). There was no statistical difference in the OS, DFS, and LRFS between groups (P = .439; 95% confidence interval, 0.114-0.347). The re-excision rate of women undergoing BCS was 45.1%, with 65.2% of women undergoing a completion mastectomy. Extensive ductal carcinoma in situ represented the only significant risk factor associated with inadequate margins (P = .021). Larger tumor size was associated with a greater risk of local recurrence (P = .039). CONCLUSIONS: This study is one of the largest studies to date to report BCS + radiotherapy as a safe oncologic treatment option for women with large breast cancers. However, the higher re-excision rate advocates a need to investigate ways to improve patient selection.

Plastic surgery and the breast: a citation analysis of the literature.

BACKGROUND: A large proportion of the plastic surgery literature is dedicated to the breast. It is one of the most common topics in our specialty, yet it is unclear which articles have been the most influential. The purpose of this study was to identify the top 100 most-cited articles on breast in the plastic surgery literature and examine the characteristics of each individual article. METHODS: Using an electronic database through the Web of Science, we were able to determine the 6 journals that contributed to the 100 most-cited articles on breast in the plastic surgery literature. RESULTS: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. Plastic and Reconstructive Surgery contributed the most articles to the top 100 with 81 articles including the most-cited article which has been referenced 673 times to date. The United States produced 73% of the top 100 articles, and the most prolific institution was the University of Texas M. D. Anderson Cancer Center with 15 articles. CONCLUSIONS: This study has identified the most influential articles on breast in the plastic surgery literature over the past 68 years and highlighted many important scientific breakthroughs and landmarks that have occurred during this time.

100 citation classics in the melanoma literature: a bibliometric analysis.

BACKGROUND: Modern immunologic therapies targeting genetic mutations have created a renewed interest in melanoma research, and this is reflected in the increasing number of published works. OBJECTIVE: The purpose of this study was to identify the top 100 most cited articles in melanoma and to examine the characteristics of each individual article. METHODS: Using an electronic database through the Web of Science, we were able to determine the 22 journals that contributed to the 100 most cited articles in melanoma. RESULTS: Each article was examined individually looking at characteristics such as subject matter, article type, country of origin, institution, authorship, and year of publication. The New England Journal of Medicine contributed the most articles to the top 100 with 20 articles, whereas the most cited article originated from the Archives of Surgery and has been cited 2,384 times. The United States produced 74% of the top 100 articles, and the most prolific institution was the National Cancer Institute in Maryland with 18 articles. CONCLUSION: This study has identified the most significant contributions to melanoma research over the past 63 years and identifies many important scientific breakthroughs and landmarks that have occurred during this time.

Rapidly enlarging cutaneous nodules on a full-thickness skin graft following an excision of a squamous cell carcinoma - a diagnostic clue for multiple myeloma.

Cutaneous extramedullary plasmacytomas (EMPs) are rare plasma cell neoplasms of the skin occurring in 2-4% of patients with multiple myeloma (MM). We describe a man diagnosed with IgA lambda MM (Stage III) after rapidly enlarging cutaneous nodules developed in the surgical site of recently excised skin malignancies. Cutaneous EMP must be considered for expanding cutaneous nodules at sites of surgery or trauma.