Excision Margins for Melanoma In Situ on the Head and Neck.

BACKGROUND: Complete surgical excision of melanoma in situ (MIS) is curative. A 5-mm margin is often taken as the standard primary excision margin despite increasing evidence that this is frequently inadequate for tumor clearance. OBJECTIVE: To calculate the proportion of patients requiring >5 mm margin for clearance and to investigate any patient/lesion characteristics necessitating larger margins. MATERIALS AND METHODS: Three hundred forty-three primary MIS cases on the head and neck treated in the authors' department by Mohs micrographic surgery (MMS) over a 65-month period were retrospectively analyzed. Records were made of patient and lesion characteristics, and the total surgical margin for clearance calculated. RESULTS: Sixty-five percent were cleared by a 5-mm margin; for a 97% clearance rate, 15 mm was necessary. The increased clearance with additional margin was significant (p < .0001). Patient age, lesion site, and preoperative size did not predict margin. CONCLUSION: These results verify that MIS on the head and neck can spread significantly beyond the clinical margin and demonstrate the importance of confirming clearance histologically before closure procedures. Mohs micrographic surgery has the advantage of total margin evaluation and where available it may be reasonable to start with a 5-mm margin. Where MMS is not a treatment option, the authors would advocate larger excision margins of ≥10 mm.

Mohs micrographic surgery of the eyelid: an overview of anatomy, pathophysiology, and reconstruction options.

BACKGROUND: Mohs micrographic surgery (MMS) is the ideal treatment for skin cancer removal. The advantages of MMS in the eyelid area include its high cure rate, tissue-sparing effects, and overall cost effectiveness. OBJECTIVE: To review eyelid anatomy, detail ocular tumors that are amenable to MMS, and examine the surgical repair options commonly used in this area. MATERIALS AND METHODS: A review of the literature on MMS of the eyelid was performed with specific reference to ocular anatomy, eyelid malignancy types, and surgical reconstruction. CONCLUSION: Eyelid function is critical for the maintenance of ocular health and vision. MMS is an ideal skin cancer treatment for the delicate structure of the eyelid, where maximal tissue preservation is critical. There are a plethora of reconstruction options to consider after MMS has been performed in this area. The choice of repair and surgical outcome depend, in part, on the surgeon's knowledge of eyelid anatomy and his or her ability to assess the repair requirements of the post-MMS defect. Dermatologic surgeons can effectively work with other specialists to help ensure that their patients receive a cure with restored ocular function and optimal cosmesis.

Solid organ transplant recipients presenting for Mohs micrographic surgery: a retrospective case-control study.

BACKGROUND: Solid organ transplant recipients (SOTR) have a high risk of cutaneous malignancy. Mohs micrographic surgery (MMS) is recommended for the treatment of skin cancers in this group. The characteristics of the tumors in SOTR presenting for MMS are not well documented. OBJECTIVE: To describe the characteristics of tumors in SOTR presenting to a single institution over an 11-year period and compare them with tumors of non-SOTR who have also undergone MMS. METHODS: A database query captured patients with a current organ transplant who underwent MMS. These patients (cases) were matched to controls who also underwent MMS. Statistical models were used to identify tumor and operative characteristics significantly associated with SOTR compared with matching controls. RESULTS: Ninety-two SOTR underwent MMS for 432 skin cancers; 163 controls had 269 skin cancers. Squamous cell carcinoma (SCC) was the most common tumor in SOTR, with a reversal of the usual ratio of basal cell carcinoma to SCC. Mean tumor and defect sizes were similar in SOTR and controls. Cardiac transplants were the predominant transplant. CONCLUSIONS: SOTR referred for MMS have disproportionately more and different types of skin cancers than controls.

Mohs micrographic surgery for penoscrotal malignancy.

Mohs micrographic surgery (MMS) has been shown to reduce recurrence rates when used to excise many different mucocutaneous neoplasms, especially of the head and neck. The low recurrence rates are due to careful microscopic evaluation of the horizontal and vertical surgical margins. This article discusses the utility and limitations of MMS in controlling neoplasia of the male genitalia. Specific penoscrotal neoplasias discussed in this article include invasive and in situ squamous cell carcinoma, basal cell carcinoma, extramammary Paget disease, and granular cell tumor.

A novel 2-hour method for rapid preparation of permanent paraffin sections when treating melanoma in situ with mohs micrographic surgery.

BACKGROUND: Distinguishing sun-induced melanocyte atypia from residual melanoma in situ (MIS) can be challenging, particularly when working with frozen sections. Immunostains such as melanoma-associated antigen recognized by T cells (MART-1) can assist, but paraffin sections provide an optimal means of analyzing melanocyte morphology. OBJECTIVE: To verify the effectiveness of a 2-hour paraffin processing technique that uses microwave technology in the preparation of MIS sections. METHODS: Twelve MIS debulk specimens were divided into 4 pieces with each piece processed 1 of 4 ways: our 2-hour paraffin technique with hematoxylin and eosin (H&E), conventional 24-hour paraffin processing with H&E, frozen sections with H&E, and frozen sections with MART-1 immunostaining. A Mohs surgeon and a dermatopathologist compared all specimens in a blinded fashion using a 3-point ranking scale to assess ease of visualizing normal melanocytes, ease of visualizing abnormal melanocytes, and overall ability to adequately visualize epidermal and dermal structures. RESULTS: A nonparametric signed rank test indicated no significant differences between our microwave technique and conventional paraffin processing in all 3 criteria (p=.29, .63, .75, respectively). Our microwave technique was significantly better than frozen H&E sections for all 3 criteria (p=.046, .004, .005, respectively). CONCLUSION: This rapid microwave tissue processing technique is comparable with conventional paraffin section processing.

Longitudinal diminution of tumor size for basal cell carcinoma suggests shifting referral patterns for Mohs surgery.

BACKGROUND: The Mohs technique for removal of cutaneous malignancies offers tissue-sparing benefits compared with other treatment methods. With wider acceptance and availability of Mohs surgery, referral patterns may be shifting toward the treatment of smaller, lower-risk tumors. OBJECTIVE: The objective was to examine whether referral patterns for basal cell carcinoma (BCC) at an academic Mohs surgery practice have shifted over recent years toward referral for smaller, lower risk tumors. METHODS: A retrospective longitudinal comparison of tumor characteristics was performed for BCCs treated at our institution from a recent year (2004) and a past year (1996). Statistical analyses were used to identify differences in tumor size, distribution by anatomic site, and primary versus recurrent status. RESULTS: Complete data were available for 603 BCCs treated in 1996 and 1,514 BCCs treated in 2004. A 24% decrease in preoperative tumor surface area was observed from 1996 (1.25 cm2) to 2004 (0.95 cm2). Tumors were twice as likely to be recurrent in 1996 (15.1%) than in 2004 (7.4%). There were no significant differences in the anatomic distribution of lesions in the years compared. CONCLUSIONS: Findings at our institution suggest that in recent years, referral patterns have shifted toward a preference for Mohs surgery for the treatment of smaller, primary BCCs. This may be a result of increased awareness by the dermatologic and medical community of the numerous advantages of Mohs surgery and a greater appreciation of its tissue-sparing properties, which may result in less complex and more successful aesthetic reconstructions.

Chondrocutaneous advancement flap for reconstruction of helical rim defects in dermatologic surgery.

The helical rim is often affected with cutaneous malignancies and requires special attention in the repair, owing to the complex cartilaginous contour, preservation of the aesthetic contour and restoration of its supportive function for eyeglasses and hearing aids. We review the surgical technique of chondrocutaneous advancement flap described by Antia and Buch as one of the most cosmetically appealing and versatile approaches for the repair of small defects of the ear helix.

Running combined simple and vertical mattress suture: a rapid skin-everting stitch.

BACKGROUND: Vertical mattress sutures are used in skin surgery to produce eversion of the wound edges, which produces a better, cosmetically acceptable scar. The disadvantages of this closure include the risk of wound hypereversion if tied too tightly, longer time to perform the stitch, and difficulties with grasping the externalized loops during suture removal. OBJECTIVE: To examine and discuss the new modification of running vertical mattress sutures, which can overcome the disadvantages. METHODS: Running combined simple and vertical mattress suture techniques are presented in a series of schematic diagrams that follow. RESULTS: The running combined simple and vertical mattress is easier and quicker to close the wound than the classic interrupted or running vertical mattress suture. Whereas the mattress suture everts the wound edges, the simple suture coapts the sides, preventing undue inversion or hypereversion of the wound. Suture removal is less uncomfortable for the patient and is performed faster by the medical staff owing to a reduction in the number of externalized loops by half compared with the classic vertical mattress stitch. CONCLUSION: Alternation of the vertical mattress and simple running suture saves the surgeon's time without lessening the advantages of good wound eversion and hence the formation of a less apparent, cosmetically more appealing scar after wound contraction.

Advanced reconstructive techniques for the lip and perioral area.

Defects of the lip and perioral area present a significant challenge for reconstructive surgeons. It is important to obtain results that are a success from the functional and aesthetic standpoint. In planning the reconstruction, the surgeon should consider the age and general state of health of the patient and dental status. The surgeon should be well acquainted with the essential principles in planning reconstructive procedures. By becoming familiar with advantages and shortcomings of different cheiloplasty procedures, the surgeon will be able to implement the functionally and cosmetically appropriate technique in each specific case.

Digital anesthesia with epinephrine: an old myth revisited.

BACKGROUND: The prohibition against the use epinephrine with local anesthetics for digital blocks or infiltrative anesthesia is an established dogma in dermatologic surgery. Major textbooks reinforce this teaching suggesting that there is substantial risk of digital gangrene caused by local anesthesia containing epinephrine. OBJECTIVE: To provide a comprehensive literature review of the cases of digital necrosis associated with the use of local anesthesia containing epinephrine. METHODS: A PubMed search of the National Library of Medicine database using the terms "lidocaine" and "epinephrine" and "finger" with no specified limits was performed. RESULTS: A total of 16 papers were referenced and only 6 papers dealt with digital anesthesia. A total of 50 cases of digital gangrene were reported, mostly in the early part of the 20th century. In 21 cases digital gangrene was associated with anesthetic mixed with epinephrine. Actual concentration of epinephrine was known in only 4 cases. Careful analysis of all cases of necrosis did not support epinephrine itself as a cause. Other contributing factors including older compounds (cocaine, eukaine, and procaine), non-standardized inaccurate methods of mixing epinephrine with lidocaine, inappropriate use of a tourniquet, postoperative hot soaks, infection, or large anesthetic volume were also present. None of the reported cases were associated with the use of a commercial lidocaine-epinephrine mixture. CONCLUSION: A literature review failed to provide evidence to support the dogma that block or infiltrative anesthesia with lidocaine and epinephrine produces digital necrosis. Proper injection technique and adequate selection of patients (absence of thrombotic, vasospastic conditions, or uncontrolled hypertension) are mandatory to minimize complications. The addition of epinephrine, in fact, reduces the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during digital procedures.

Presentation, histopathologic findings, and clinical outcomes in 7 cases of melanoma in situ of the nail unit.

OBJECTIVE: To report on the presentation, histopathologic findings, and clinical outcomes for a case series of MIS of the nail apparatus because melanoma in situ (MIS) of the nail unit has not been well characterized in the literature. SETTING: A division of a tertiary academic center specializing in micrographic excision of cutaneous neoplasms. DESIGN: Surgical records were searched for cases of MIS of the nail unit for the period of January 1, 1997, to December 31, 2002. The patient demographics and disease presentation, treatment, and clinical course were reviewed. RESULTS: Seven cases of MIS of the nail unit in white patients were identified. Longitudinal melanonychia was present in all cases, but dyspigmentation of the proximal nail fold and onychodystrophy were uncommon. Histopathologic analysis revealed poorly circumscribed proliferations of single cells over nests with variable pagetoid spread. Atypia was variable. Mitotic activity was low. All cases were treated with micrographic surgery. Amputation was avoided in 3 cases and was limited to partial distal interphalangeal amputation in the remainder. Six cases did not recur locally after initial surgical intervention. With an average of 24 months of follow-up, all patients were free of disease. CONCLUSIONS: Longitudinal melanonychia in a white patient mandates consideration of MIS of the nail unit. Given the nondescript clinical presentation, the threshold for biopsy should be low. The histopathologic findings appear similar to those of MIS in other areas, with asymmetry and poor circumscription predominating. With additional study and further acceptance, micrographically controlled excision has the potential to minimize morbidity. Further investigation is warranted.

Monitoring vital signs during outpatient Mohs and post-Mohs reconstructive surgery performed under local anesthesia.

BACKGROUND: Although dermatologic surgery carries a low risk of serious adverse events, concern over the safety of outpatient surgical procedures in general has led some to question whether intraoperative patient monitoring should be performed during all procedures performed in the clinic setting. OBJECTIVE: To characterize the intraoperative monitoring practices of Mohs surgeons and examine the relationship between changes in vital signs during skin surgery and the incidence of serious adverse events. METHODS: We surveyed a group of Mohs surgeons and prospectively measured blood pressure, pulse, and pulse oximetry of 100 patients undergoing repair of Mohs surgery defects under local anesthesia in the outpatient clinic setting. RESULTS: The majority of survey respondents utilize no intraoperative monitoring, and serious adverse events are rare (0.2 per 1000 procedures performed). Moderate fluctuations in our patients' vital signs occurred (<10% deviation from baseline); however, all measured variables returned to near baseline by procedure end and were not associated with any serious adverse events. CONCLUSIONS: Surgical repair of Mohs defects performed under local anesthesia in the outpatient clinic setting continues to be very safe. Intraoperative vital sign measurements did not appear to be useful in detecting or avoiding potential adverse events in our patient population.

Traumatic pseudoaneurysm of the superficial temporal artery: two cases and review of the literature.

Aneurysms of the facial vasculature have been reported since the mid-seventeenth century from a variety of accidental, violent, and surgical injuries. Of the 386 cases of facial aneurysm reported in the world literature, 327 involve the superficial temporal artery. The nomenclature is somewhat confusing, because pseudoaneurysms are often referred to as simply "aneurysms" in the literature. Given that superficial temporal artery pseudoaneurysms might be seen in the guise of a cyst or lipoma, it is imperative that the dermatologist be aware of their presentation. To date, there have been 7 cases reported in the dermatologic literature. We report 2 additional cases of traumatic superficial temporal artery pseudoaneurysm and review the dermatologic literature.

Rapidly enlarging growth of the proximal nail fold.

BACKGROUND: Squamous cell carcinoma (SCC) of the nail unit is a rare but often underappreciated neoplasm. Treatment can be delayed due to confusion with paronychia and verruca. Infection with human papilloma virus (HPV) has been associated with this malignancy. OBJECTIVE: To describe the development of a superficially invasive SCC of the proximal nail fold in a patient infected with HIV, to report the association of a previously unrecognized HPV genotype, and to review key etiologic, diagnostic, and therapeutic points as related to SCC of the proximal nail fold. RESULTS: This is the first report of HPV 26 coinfection in monogamous sexual partners, both of whom are HIV infected and have demonstrated lesions of malignant degeneration consistent with SCC. CONCLUSION: SCC must be considered in the differential diagnosis of nail fold neoplasm. An immunocompromised condition such as HIV/AIDS may predispose to malignant degeneration of lesions caused by infection with HPV.