Surgical Treatment of Pyoderma Gangrenosum with Negative Pressure Wound Therapy and Skin Grafting, Including Xenografts: Personal Experience and Comprehensive Review on 161 Cases.

Significance: Pyoderma gangrenosum (PG) is a rare debilitating autoinflammatory ulcerative skin disease. No gold standard has been established for the treatment of PG. The role of surgical interventions and negative pressure wound therapy (NPWT) was discussed controversially until recently as these procedures might pose a trigger to further aggravate the condition. Recent Advances: Recent advances confirm the paradigm change that a surgical approach of PG with split thickness skin grafting (STSG) secured by NPWT is a safe and valuable treatment if performed under adequate immunosuppression. We elaborate this on the hand of a broad literature search retrieving 101 relevant articles describing 138 patients complemented with our personal experience on 23 patients, including 2 patients treated with a porcine xenodressing. Critical Issues: A wide range of surgical approaches have been reported, including xenografts. Treatment was finally successful in 86%, including the xenotransplant cases. Ten percent improved and failures were mainly reported without immunosuppression. Despite halting the inflammatory process, NPWT alone, without skin grafting, does not much accelerate healing time. The best surgical approach appears to be STSG fixed with NPWT as this leads to higher skin graft take. There remains the problem of the chronic nature of PG and the recurrence after tapering of immunosuppression or trauma; therefore, a sustained immunosuppressive treatment is suggested. Future Directions: While surgical treatment is supported by the published data, the exact immunosuppression is still evolving. Due to deeper insights into pathogenesis and growing clinical reports, a broader utilization of biologic treatments and a shift from tumor necrosis factor (TNF)-alpha to interleukin (IL)-12/23 or IL-23 antibodies alone are predictable, as IL-12/23 antibodies show good clinical responses with fewer side effects. The positive results with porcine xenodressings might be due to immunological effects of the xenomaterial; they appear promising, but are preliminary and should be confirmed in a larger patient collective.

Spalthauttransplantation zur Defektdeckung am Ohr: eine statistische Analyse.

HINTERGRUND UND ZIELE: Die Rekonstruktion nach Entfernung ausgedehnter maligner Hauttumoren am Ohr ist eine Herausforderung. Verschiedene Methoden der Defektdeckung wurden beschrieben. Lappenplastiken, längere Anästhesiezeiten, geringe Compliance und Antikoagulation stellen bei den oft älteren Patienten zusätzliche Risiken dar. Eine rasch, effizient und unkompliziert durchführbare Methode der Defektdeckung ist daher wünschenswert. Ziel der Studie war die Beurteilung des ästhetischen Resultats, des Heilungsprozesses, der Komplikations- und Rezidivrate nach Transplantation ungenetzter Spalthaut (SPHT) zur Defektdeckung nach knorpelerhaltender Resektion maligner Tumoren am Ohr. PATIENTEN UND METHODIK: 32 Patienten wurden nach Entfernung von Hauttumoren am Ohr einer Defektdeckung mittels SPHT unterzogen. ERGEBNISSE: Die durchschnittliche Defektgröße betrug 8,0 cm2 . Eine vollständige Einheilung des Transplantates erfolgte in allen Fällen innerhalb von zwei Wochen. Wesentliche Komplikationen traten nicht auf. Das ästhetische Resultat wurde sowohl von den Patienten als auch von einem Dermatochirurgen und zwei plastischen Chirurgen als gut bewertet. SCHLUSSFOLGERUNGEN: Die SPHT am Ohr ist eine zuverlässige Methode zur Deckung ausgedehnter Hautdefekte. Selbst bei großen Tumoren des äußeren Ohres ist der Ohrknorpel nicht immer infiltriert. Eine knorpelschonende Tumorresektion mit anschließender Defektdeckung mittels SPHT ist eine ausgezeichnete und rasch durchführbare Technik mit hoher Patientenzufriedenheit.

Split-thickness skin grafting for reconstruction of auricular skin defects: a statistical analysis.

BACKGROUND AND OBJECTIVES: Surgical reconstruction following the removal of large malignant auricular lesions is challenging. While many options for defect closure have been described, in the elderly population usually affected flap surgery, long anesthesia times, patient compliance, and anticoagulant therapy pose additional risks. An alternative quick, simple, and effective method of defect closure is therefore highly desirable. The objective of the present study was to assess the aesthetic outcome, healing process, complications, and recurrence rates associated with unmeshed split-thickness skin grafts (STSGs) used for covering large auricular skin defects following cartilage-sparing skin cancer removal. PATIENTS AND METHODS: Under local tumescent anesthesia, 32 patients received STSGs for defect closure following the removal of malignant cutaneous neoplasms of the ear. RESULTS: The average defect size was 8.0 cm². In all cases, complete healing of the recipient site occurred within two weeks. There were no major complications. The aesthetic outcome was rated highly by patients as well as by the dermatosurgeon involved and two independent plastic surgeons. CONCLUSIONS: STSGs are a valid option for closing large auricular skin defects. Even large cutaneous tumors of the external ear do not necessarily infiltrate the cartilage. Thus, cartilage-sparing tumor resection with subsequent defect closure using a STSG is an excellent and quick method associated with high patient satisfaction.

Misdiagnosed microcystic adnexal carcinoma on the lateral forehead and challenges in reconstruction of a large and bone-deep defect.

BACKGROUND: Microcystic adnexal carcinoma (MAC) is a rare cutaneous malignancy characterized by aggressive local infiltration, including a high propensity for perineural invasion. Histologically it can be easily confused with benign adnexal tumors, which often leads to inappropriate initial treatment. As a consequence delayed surgical excision often requires removal of large cutaneous masses which can be followed by challenges in reconstruction. METHODS: We report the case of a challenging reconstruction of a large forehead defect by a modified AT flap with central Burow's triangle grafting and previous wound conditioning using hyaluronic acid after complete micrographic removal of MAC. RESULTS: A 80-year-old healthy female presented with an almost six year history of an asymptomatic slowly progressing skin mass previously biopsied and diagnosed as benign syringoma five years in advance. Deep biopsies confirmed MAC. She underwent staged surgical excision with Tübingen torte technique with removal of the frontal periostium. A skin substitute of esterified hyaluronic acid was applied for three weeks to the bone-deep 6 × 7 cm defect leading to good granulation tissue above the bone. Final reconstruction was achieved by an AT flap combined with full thickness skin transplantation of the central dog ear. The cosmetic outcome was satisfactory, no recurrence was observed within 18 months follow-up. CONCLUSIONS: We confirm the histological difficulties in the diagnosis of this tumor entity and the large extension of MAC due to delay in diagnosis and treatment. Deep tumor removal including the periostium might be necessary to achieve tumor free margins. Fast granulation tissue above the frontal bone might be achieved by applying hyaluronic acid products. The combination an AT flap with transplantation of the adjacent Burow's triangles gives optimal skin texture and color matching and seems to be a good option to close even large defects of the front especially for supra brow defects.

Reconstruction of large rectangular infraorbital and malar skin defects in elderly patients with a modified "reading man flap" using local tumescent anesthesia.

BACKGROUND: The classical "reading man flap" is a recently described flap named after its appearance and mainly used for reconstruction of circular malar or infraorbital skin defects. It avoids surgical complications such as lower lid retraction and ectropion but is limited to circular skin defects. Local tumescent anesthesia uses a diluted local anesthetic together with diluted epinephrine to anesthetize large skin areas without the need for general anesthesia. OBJECTIVES: To assess the esthetic outcome, pain control, and complications of a modified "reading man flap" under local tumescent anesthesia in elderly patients with rectangular malar or periorbital skin defects. METHODS: Two flaps are used to close the surgical defect, the first rectangular flap is transposed to the defect area, then approximately half to two-thirds of the flap's donor site are closed directly as done with transposition flaps, whereas a second smaller triangular flap is advanced for the closure of the last third of the remaining now triangular donor site, where the greatest tension would occur if closed directly. RESULTS: The median age of patients was 83 years (range 64-92 years) of the total 12 patients, 10 (83%) were women, and two were men. The mean defect size was 9.2 cm(2) (5.5-22.1 cm(2) ). The defect closure was possible in all patients, no lasting postoperative complications occurred, and cosmetic results were satisfactory. Twenty to 70 ml of local tumescent anesthesia were used, and a larger volume (≥ 40 ml) was associated with better pain control (P = 0.03). CONCLUSIONS: The modified "reading man flap" is a good option for the closure of larger rectangular facial skin defects especially in elderly patients, and the use of at least 40 ml of tumescent solution is suggested to achieve optimal pain control.

Using the Peng flap for a wide dorsal nasal defect.

Reconstructions of large surgical defects of the central part of the nose pose a challenge for the surgeon due to its cosmetically prominent location. Treatment options include second intention healing, full-thickness skin grafts and various local flaps. In the present case the "Peng flap" was used for the reconstruction of a 3.1 × 7 cm sized deep defect of the convex curve of the central nasal area in a 66-year-old woman. The Peng flap was performed as single-stage procedure without complications. Good cosmetic outcome was provided by the use of adjacent skin from the lax perinasal area, the placement of the scar lines between facial cosmetic units, and the excellent tissue match for the sebaceous nasal skin. Considering the few complications of a single-stage procedure associated with an excellent aesthetic outcome, the Peng flap should be considered not only as an effective choice for reconstruction of the cosmetically complex midline nasal tip but also the convex curve of the central nose.

Extraordinary giant basal cell carcinoma with full-thickness infiltration of the abdominal wall: single-staged resection and simultaneous reconstruction.

BACKGROUND: Basal cell carcinoma (BCC) is the most frequent form of invasive skin cancer. BCCs usually show a slow progression and rarely metastasize; however, around 1% achieve a "giant" size, larger than 5 cm in diameter. Rarely, BCCs larger than 20 cm are reported in the literature. OBJECTIVE: We report a case of a giant BCC, measuring 25 × 13 × 5 cm, involving the abdominal wall. The article describes the curative surgical procedure, which resulted in an excellent aesthetic result.

Occurrence of squamous cell carcinoma in an area of lichen simplex chronicus: case report and pathogenetic hypothesis.

BACKGROUND: Lichen simplex chronicus is a common skin disorder characterized by circumscribed, lichenified, pruritic plaque secondary to local repetitive trauma, notably rubbing and scratching. OBJECTIVE: We describe a case of a squamous cell carcinoma arising in a patient with a long-lasting history of lichen simplex chronicus and discuss the potential role of the microenvironment in predisposing the malignant transformation. CONCLUSION: Here we propose a hypothesis in which rubbing and scratching contribute to an excess of inflammatory mediators, which in turn may lead to alterations in the processes of keratinocyte proliferation and differentiation.