The surgical treatment of traumatic hematoma of the auricle.

BACKGROUND: The auricular hematoma occurs secondary to trauma and can present a therapeutic dilemma for clinicians. Early intervention can be limited to simple incision and drainage. Delay in treatment may allow the growth of ectopic fibroneocartilage derived from the damaged perichondrium. Removal of this abnormal tissue is imperative to avoid permanent ear deformity. OBJECTIVE: Surgical intervention was utilized to treat auricular hematomas in two teenage boys. METHODS: The auricular hematomas were treated by raising a cutaneous flap over the injury site. The clot and serosanguinous fluid were drained and, because the injuries were 1 month old, the developing plate of fibroneocartilage and associated perichondrium was extirpated. The exposed cartilage was fenestrated prior to repairing the cutaneous flap. RESULTS: Both auricles healed without evidence of fibrosis or distortion. CONCLUSION: Appropriate surgical intervention can avoid the cosmetic deformity associated with an auricular hematoma (ie, cauliflower ear).

A case report of laser resurfacing as a skin cancer prophylaxis.

BACKGROUND: Many patients suffer from multiple nonmelanoma skin cancers. We recently encountered two such patients who requested some form of prophylaxis against future skin cancers. OBJECTIVE: To highlight the potential utility of laser resurfacing as a skin cancer prophylaxis. METHODS: Two patients with histories of multiple facial skin cancers were treated with CO2 laser resurfacing for the purpose of skin cancer prophylaxis. RESULTS: During a follow-up period of 33 and 52 months, both patients have remained free of skin cancers in the main treatment field while developing new tumors outside of this area. CONCLUSION: Laser resurfacing should be considered as a potential method of achieving skin cancer prophylaxis in selected patients.

The use of the SMAS to close Mohs defects invading the parotid gland.

BACKGROUND: Plastic surgery literature reports the use of the superficial musculoaponeurotic system (SMAS) in reconstruction after parotidectomies to prevent the complications of Frey's Syndrome and fistula formation. However, there is scant information in the dermatologic literature regarding the use of the SMAS when closing Mohs defects overlying the parotid gland. OBJECTIVE: Our purpose is to introduce to the dermatologic surgery literature the need for plication of the SMAS prior to closure of the overlying tissues when repairing surgical defects which invade the integrity of the parotid gland. METHODS: We describe a patient with a large basal cell carcinoma located in the right preauricular region. Using text and photographs, we detail our closure of this large defect which invaded the parotid gland. RESULTS: Closure of the SMAS over the parotid gland before suturing the overlying tissues provided our patient with an excellent functional and cosmetic result, without the formation of a fistula, sialocele, or Frey's Syndrome. CONCLUSION: We propose that the essential first step in the ideal closure of surgical wounds which penetrate the parotid gland involves the isolation and plication of the SMAS. This will create a barrier to the accumulation of parotid secretions which, in turn, may lead to the development of a sialocele and fistula formation. Such a barrier will also prevent the formation of Frey's Syndrome. Furthermore, plication of the SMAS serves to improve cosmesis by contributing soft tissue bulk to the wound and avoiding a concave deformity.

A comparison of frozen and paraffin sections in dermatofibrosarcoma protuberans.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a tumor with a high local reoccurrence rate. Mohs micrographic surgery offers the highest cure rate. However, differentiating minimal residual tumor from normal skin can be difficult during Mohs surgery. OBJECTIVE: To clarify the problem of determining when a tumor-free plane had been achieved during Mohs surgery for a DFSP. METHODS: In two patients with DFSPs, we compared frozen and paraffin-embedded sections extending from tumor to normal skin, using both H&E and CD34 stains. RESULTS: On frozen, but not paraffin-embedded, sections scattered dermal spindle cells were seen in normal skin. CONCLUSIONS: Scattered dermal spindle cells in the dermis of normal skin make it difficult to differentiate minimal residual tumor from normal dermis during Mohs surgery. A biopsy of normal skin can be useful as a control in this setting.

Pulsed alexandrite laser technology for noninvasive hair removal.

OBJECTIVE: Determination of the efficacy of pulsed Alexandrite Laser technology for rapid noninvasive hair removal. SUMMARY BACKGROUND DATA: Although previous studies have already shown that Ruby lasers are capable of noninvasive hair removal, a technology for the substantial increase of treatment speed is of great interest. METHODS: We have used a 2 msec free running pulsed Alexandrite (lambda = 755 nm) laser operated at a repetition rate of up to 5 pps at energy fluences of 25-40 J/cm2 to treat a wide range of body sites on 126 patients in conjunction with a fiber delivery system and a transparent target ruler. A transparent gel was used as epidermal heat sink. The study lasted 15 months. Pretreatment as well as follow-up hair count per cm2 was performed to determine the level of success. Treatments were repeated when 1-2 mm growth was observed. RESULTS: The average hair count before the second treatment was found to be close to 65% of the pretreatment count. The average hair count 3 months after the last treatment, was found to be lower than 12%. The interval between treatments ranged from 4 weeks to 3 1/2 months. CONCLUSIONS: The 2 msec pulsed Alexandrite laser technology is effective for the removal of unwanted hairs, ranging from fair to dark, except when hairs are absent in the shaft depending on the stage of their growth cycle. This results in the necessity of a few treatments or touchups. Adverse effects are minimal and transient.

Athlete's nodules: sports-related connective tissue nevi of the collagen type (collagenomas).

Sports-related connective tissue nevi of the collagen type (collagenomas) have been referred to as athlete's nodules. Surfers, boxers, marbles players, and football players are some of the athletes in whom these lesions have been observed. The nodules can be found on the dorsal aspect of the feet, knees, or knuckles and can readily be differentiated from other conditions by either clinical history or microscopic features or both. Treatment options include conservative measures or surgical intervention. Recurrent trauma and friction to the involved location are likely causative factors. Although the ultrastructural pathogenesis remains to be established, changes in the molecular metabolism of collagen resulting in enhanced synthesis and/or accumulation of collagen may have a contributory role.

Subungual osteochondroma. Diagnosis and management.

Osteochondroma, a benign tumor of bone that may penetrate the skin is rarely recognized by the dermatologist. We report two cases of osteochondroma of the distal phalanges with cutaneous penetration, and discuss the clinical, histologic, and radiographic features that allow rapid identification of this lesion. Furthermore, we emphasize the importance of total tumor excision, including adequate treatment of the underlying bone, to prevent recurrence of the lesion.

Cancer recurrence following Mohs micrographic surgery: a mechanism of tumor persistence.

Recurrence of basal cell carcinomas after Mohs micrographic surgery is rare but known to occur. This report describes the recurrence of a basal cell carcinoma of the forehead after Mohs surgery in order to illustrate a previously undescribed mechanism of tumor persistence and recurrence despite thorough microscopic evaluation of all surgical margins. The value of the surgeon's reviewing all prior histologic sections before performing micrographic surgery, the importance of resecting all scar tissue from a previous surgical site prior to determination of tumor-free margins, and the potential usefulness of a three-tiered closure after excision of a cutaneous malignancy that involves the muscular layer are discussed.

Mohs histographic surgery and ophthalmic plastic reconstruction.

A retrospective analysis of 43 consecutive cases of primary and recurrent basal cell carcinomas is presented. Each patient's tumor was first managed by Mohs histographic surgery followed by opthalmic plastic reconstruction within 24 h. A review of the age distribution and gender of patients included in this study reveals a sizeably younger population and a increased incidence of females as compared to previous studies. The success rate was high and approached the experience of other authors. Invariably the Mohs failures were among those patients that required six to eight sequential layers but failures do occur in primary cases outside the medial canthus.

Human papillomavirus segregation patterns in genital and nongenital warts in prepubertal children and adults.

This study compared the segregation patterns of human papillomavirus (HPV) in genital and nongenital warts in prepubertal children and adults. HPV 2 was detected in most nongenital warts in children and adults, whereas neither HPV 6 or 11 was detected at nongenital sites in either group with the use of in situ or Southern blot hybridization analyses. Of nine genital tract lesions in children. HPV 2 was detected in two and HPV 6 or 11 in six. More than 90% of cases of regional tract condylomata in adults contained HPV 6 or 11. HPV 2 was not detected in any of 99 genital tract lesions in adults. It is concluded that HPV 6/11 cannot proliferate at nongenital cutaneous sites and HPV 2 can proliferate in the genital tract of children but not adults. Thus, the detection of HPV 6 or 11 in a genital wart in a child implies, assuming cutaneous transmission, infection from a genital site, whereas the detection of HPV 2 presumes nongenital transmission.

Occurrence of human papillomavirus type 16 DNA in cutaneous squamous and basal cell neoplasms.

Sixty-eight cutaneous squamous cell neoplasms (in situ and invasive) and 26 basal cell carcinomas from 89 patients were analyzed for DNA sequences homologous to the human papillomavirus (HPV) types found predominantly in the genital tract. Thirty-six (53%) of the squamous cell neoplasms contained HPV DNA as detected by filter or in situ hybridization analysis. The frequency of detection of HPV DNA was dependent on the site of the lesion. Of 40 genital squamous cell neoplasms (penile, vulvar, and perianal), 27 (68%) had detectable HPV DNA. In 25 of these, the HPV type was 16 or HPV-16-related, which was similar to the results for the squamous cell neoplasms of the finger (HPV DNA in 9 of 11 tumors with HPV-16 in seven). None of 16 squamous cell neoplasms from sites other than the genital tract or the finger had detectable HPV DNA. HPV DNA was detected in one of the 26 basal cell carcinomas (4%). We conclude that, for cutaneous epithelial malignancies, HPV-16 is restricted to squamous cell neoplasms of the genital tract and finger. These data are consistent with venereal transmission of HPV-16 to the periungual region and suggests a role for this virus in the evolution of squamous cell carcinoma at this site.

Athlete's nodules. Treatment by surgical excision.

Athlete's nodules are connective tissue nevi of the collagen type (collagenomas) which appear as thick dermal masses at sites of chronic trauma. They have been described as occurring on the dorsum of the feet, knees, and knuckles of surfers, boxers and marble players. Recurrent minor blunt trauma and pressure are aetiological factors in this condition. We report a 54-year-old man with dermal nodules on the dorsal surface of his feet. These lesions initially appeared during his participation as a player on a high school football team. They were attributed to the chronic pressure of his high-laced athletic sneakers and frequent minor injuries to the involved areas. We describe the successful treatment of our patient's lesions by surgical excision. We also discuss the differential diagnosis and other therapeutic options for athlete's nodules.

Detection of human papillomavirus DNA in penile lesions histologically negative for condylomata. Analysis by in situ hybridization and the polymerase chain reaction.

The purpose of this study was to analyze penile lesions that lacked the histological features of condylomata for human papillomavirus (HPV) DNA. Most of these lesions were detected in men whose partners had an HPV-related lesion. Sequences homologous to HPV DNA were detected in 12 of 84 (14%) lesions using in situ hybridization analysis; nine of these lesions contained HPV 6 or 11. HPV DNA was found in 25 of 26 (96%) penile condylomata, all but two of which contained HPV 6 or 11. Using the highly sensitive polymerase chain reaction (PCR), we also detected HPV DNA in four of 20 (20%) of the penile lesions that lacked the histological features of condylomata negative for HPV by in situ analysis. Most of the lesions that were identifiable only after the application of an acetic acid solution were HPV negative when tested with either technique. We conclude that HPV DNA can be found in penile biopsy specimens that do not demonstrate the unequivocal histological features of condylomata but that the detection rate is much lower than for condylomata even when analyzing tissues in men at high risk for HPV-related lesions by PCR. This study underscores the need for caution when interpreting such tissues and the usefulness of in situ analysis for detecting assumed viral proliferation in noncondylomatous lesions.

Cutaneous odontogenic sinus simulating a basal cell carcinoma: case report and literature review.

A woman was referred for Mohs' microscopically controlled surgical excision of a presumptive basal cell carcinoma located on her nasolabial fold. During examination, pus was expressed from the nodulocystic lesion and an intraoral palpation revealed a fibrous sinus tract extending from the skin lesion to the gingiva of a severely carious tooth. There was roentgenographic evidence of a periapical abscess. The diagnosis was revised to that of a cutaneous odontogenic sinus. The possibility of a draining dental sinus to the skin should be seriously considered when evaluating a suspected basal cell carcinoma in the perioral region--especially in an individual with a history of extensive dental treatments, antecedent oral trauma, or markedly carious teeth.

Human papillomavirus type 16 DNA in periungual squamous cell carcinomas.

Ten squamous cell carcinomas (in situ or invasive) of the fingernail region were analyzed for the presence of DNA sequences homologous to human papillomavirus (HPV) by dot blot hybridization. In most patients, the lesions were verrucae of long-term duration that were refractory to conventional treatment methods. Eight of the lesions contained HPV DNA sequences, and in six of these the sequences were related to HPV 16 as deduced from low-stringency nucleic acid hybridization followed by low- and high-stringency washes. Furthermore, the restriction endonuclease digestion pattern of DNA isolated from four of these lesions was diagnostic of episomal HPV 16. The high-frequency association of HPV 16 with periungual squamous cell carcinoma is similar to that reported for HPV 16 with squamous cell carcinomas on mucous membranes at other sites, notably the genital tract. Our findings suggest that HPV 16 may play an important role in the development of squamous cell carcinomas of the finger, most notably those lesions that are chronic and located in the periungual area.