The forehead flap for nasal reconstruction.

CONTEXT: Reconstruction of extensive nasal defects often represents a significant challenge owing to several unique qualities of the nose, such as complex topography, mobile free margins, and multiple nasal subunits. Furthermore, loss of internal nasal lining and/or structural skeletal support may be present following removal of extensive skin cancers. OBJECTIVE: To describe our experience with the use of forehead flap reconstruction for extensive nasal defects. DESIGN: Retrospective case series. SETTING: Academic health care hospital system. PATIENTS/INTERVENTION: One hundred forty-seven patients with extensive nasal defects repaired with a forehead flap. MAIN OUTCOME MEASURES: The functional and aesthetic results were assessed. The characteristics of defects repaired with the forehead flap and the need for lining and/or cartilage were examined. RESULTS: The forehead flap was used to repair 147 nasal defects after Mohs excision of nonmelanoma skin cancer. Full-thickness skin was lost in all cases, structural skeletal support in 68 cases (46%), and internal mucosal lining in 45 cases (31%). Our experience and surgical technique using the forehead flap are described. CONCLUSIONS: The forehead flap represents one of the best methods for repair of extensive nasal defects. Near-normal functional and cosmetic results can be achieved.

Nasal reconstruction utilizing a muscle hinge flap with overlying full-thickness skin graft.

BACKGROUND: Deep nasal defects of the dorsum, sidewall, and ala can be challenging to repair. OBJECTIVE: The article describes our experience with a muscle hinge transposition flap with overlying local full-thickness skin grafting for repair of deep nasal defects in a single-stage procedure. METHODS: A muscle hinge transposition flap with overlying local full-thickness skin grafting was used immediately after Mohs micrographic surgery to repair 12 deep nasal defects of the dorsum, sidewall, alar lobule, and supratip. RESULTS: No cases of infection, flap, or graft necrosis occurred in our series. Cosmetic and functional outcomes were judged from good to excellent by patient and surgeon. To enhance the cosmetic outcome, 5 patients underwent spot dermabrasion within 2 months of repair. CONCLUSION: For properly selected small to medium-sized deep nasal defects (1-2 cm) that lack a sufficiently loose adjacent tissue reservoir for a single-stage local flap, a muscle hinge transposition flap with local full-thickness skin grafting can provide consistently satisfying aesthetic and functional results.

Principles of CO2/erbium laser safety.

BACKGROUND: There are a variety of potential hazards with laser technology. METHODS: A review of the literature. OBJECTIVE: To summarize the potential hazards of CO2 and erbium laser technologies and the safety guidelines and equipment developed to minimize them. RESULTS: Laser hazards can be divided into the following categories: mechanical, environmental, macrobiologic, microbiologic, and iatrogenic. CONCLUSION: At the conclusion of this learning activity, the reader should be able to discuss the mechanical, environmental, macrobiologic, microbiologic, and iatrogenic hazards of resurfacing laser technology, the literature cited to support current safety guidelines, and the equipment developed to promote laser safety.

Perineural spread of basal cell carcinomas treated with Mohs micrographic surgery.

BACKGROUND: Perineural spread is a well-documented feature of cutaneous tumors and may portend a more aggressive course. The incidence of perineural invasion in basal cell carcinoma (BCC) is reportedly 1%. The authors sought to determine whether perineural spread occurs more commonly than previously thought. METHODS: The authors prospectively evaluated 434 patients with BCC treated with Mohs surgery, assessing the presence or absence of perineural inflammation and invasion in tumors requiring more than one stage of surgery. They also documented the demographic features, clinical characteristics, histologic subtype, and operative data in each case. RESULTS: Seventy-eight BCCs required more than one stage of Mohs surgery. Perineural inflammation, perineural tumor invasion, or both were present in 29 of the 78 tumors (37%), or 6.7% of all 434 prospectively evaluated cases. Twenty-one of the 78 tumors (26.9%) exhibited perineural inflammation, 3 (3.8%) demonstrated perineural invasion, and 5 (6.4%) exhibited both. Tumors with perineural invasion required 5.3 surgical stages on average for clearance, in contrast to tumors without perineural invasion, which required 2.2 stages. Tumors with perineural inflammation, inflammation plus tumor invasion, and invasion alone were, respectively, 138%, 149%, and 194% greater in area preoperatively than tumors without perineural involvement, and their mean defect areas after Mohs surgery were, respectively, 151%, 121%, and 605% larger than those of tumors without perineural involvement. CONCLUSIONS: The incidence of perineural invasion among cases of BCC appears higher than previously recognized. Tumor aggressiveness appears to correlate with the presence of perineural invasion. Surgery with horizontal frozen-section margin control enables easy detection of perineural involvement and should therefore be strongly considered for the treatment of high risk BCC patients.

Collagenolytic and gelatinolytic matrix metalloproteinases and their inhibitors in basal cell carcinoma of skin: comparison with normal skin.

Tissue from 54 histologically-identified basal cell carcinomas of the skin was obtained at surgery and assayed using a combination of functional and immunochemical procedures for matrix metalloproteinases (MMPs) with collagenolytic activity and for MMPs with gelatinolytic activity. Collagenolytic enzymes included MMP-1 (interstitial collagenase), MMP-8 (neutrophil collagenase) and MMP-13 (collagenase-3). Gelatinolytic enzymes included MMP-2 (72-kDa gelatinase A/type IV collagenase) and MMP-9 (92-kDa gelatinase B/type IV collagenase). Inhibitors of MMP activity including tissue inhibitor of metalloproteinases-1 and -2 (TIMP-1 and TIMP-2) were also assessed. All three collagenases and both gelatinases were detected immunochemically. MMP-1 appeared to be responsible for most of the functional collagenolytic activity while gelatinolytic activity reflected both MMP-2 and MMP-9. MMP inhibitor activity was also present, and appeared, based on immunochemical procedures, to reflect the presence of TIMP-1 but not TIMP-2. As a group, tumours identified as having aggressive-growth histologic patterns were not distinguishable from basal cell carcinomas with less aggressive-growth histologic patterns. In normal skin, the same MMPs were detected by immunochemical means. However, only low to undetectable levels of collagenolytic and gelatinolytic activities were present. In contrast, MMP inhibitor activity was comparable to that seen in tumour tissue. In previous studies we have shown that exposure of normal skin to epidermal growth factor in organ culture induces MMP up-regulation and activation. This treatment concomitantly induces stromal invasion by the epithelium (Varani et al (1995) Am J Pathol 146: 210-217; Zeigler et al (1996b) Invasion Metastasis 16: 11-18). Taken together with these previous data, the present findings allow us to conclude that the same profile of MMP/MMP inhibitors that is associated with stromal invasion in the organ culture model is expressed endogenously in basal cell carcinomas of skin.

Cutaneous laser resurfacing.

UNLABELLED: Cutaneous resurfacing with the new generation of carbon dioxide and erbium lasers has recently come into favor for the treatment of facial rhytides, photodamage, and scarring. The precise control of these resurfacing lasers over the extent of tissue vaporization minimizes thermal damage to the skin while maximizing therapeutic efficacy. Proper use of resurfacing lasers is contingent upon a complete understanding of their clinical, histologic, and ultrastructural effects, as well as an appreciation of the principles of laser safety. An organized approach to the preoperative, intraoperative, and postoperative management of the patient undergoing laser resurfacing will be provided, including a discussion of prevention and treatment of postoperative side effects and complications. (J Am Acad Dermatol 1999;41:365-89.) LEARNING OBJECTIVE: At the conclusion of this learning activity, participants should be familiar with the clinical, histologic, and ultrastructural effects of resurfacing lasers and be able to discuss the preoperative, intraoperative, and postoperative management of patients undergoing laser resurfacing.

The birhombic transposition flap for soft tissue reconstruction.

BACKGROUND: Soft tissue reconstruction requires a thorough understanding of both anatomy and tissue movement. Flaps and grafts should be considered when simpler closure methods result in excessive tension or distortion of surrounding structures. OBJECTIVE: We describe our experience with the birhombic transposition flap. METHODS: The birhombic flap was used to repair 19 surgical defects after excision of skin cancer. RESULTS: The average defect size was 3.0 x 2.4 cm with the 19 wounds located on the nose (6), forearm (5), hand (4), forehead/temple (3), and preauricular cheek (1). No cases of excessive tension, infection, or flap necrosis occurred. CONCLUSION: Conceptualization of a larger defect into multiple smaller defects may be useful to facilitate closure of each smaller defect in an easier fashion. Our series demonstrates the usefulness of this concept with the birhombic transposition flap repair.

Advances in melanoma therapy.

This review discusses several advances in melanoma therapy that have recently occurred or are presently in a developmental stage. We discuss the history and present dogma regarding assessment of the regional lymph nodes and adjuvant therapy for melanoma. Of special interest is radiolymphatic sentinel node mapping of the lymph nodes and adjuvant interferon alfa-2b for thick primary lesions and stage III disease. We also discuss several evolving novel and innovative genetic immunotherapy approaches for patients with stage IV disease.

The multidisciplinary melanoma clinic: a cost outcomes analysis of specialty care.

The traditional process of melanoma care delivery can differ substantially among providers regarding screening laboratories, staging work-ups, surgical margins, and outpatient versus inpatient surgical management. It has been suggested that multidisciplinary care may provide a more cost-effective management approach. We sought to evaluate whether coordinated multidisciplinary melanoma care that follows evidence-based, consensus-approved clinical practice guidelines at a large academic medical center can provide a more efficient alternative to traditional community-based strategies with clinical outcomes that are at least equivalent. The University of Michigan Multidisciplinary Melanoma Clinic (MDMC) possesses a database of demographic, clinical, and treatment information for all patients seen since its inception. A consecutive sample of 104 patients with local disease who were treated in the Michigan community were compared with 104 blindly selected subjects treated at the MDMC during an identical time period, matched for Breslow depth and melanoma body site. Patients treated in the MDMC would save a third party payer roughly $1600 per patient when compared with a similar group treated in the Michigan community. Surgical morbidity, length of hospitalization, and long-term survival of MDMC patients were similar to those reported in the literature. The cost discrepancy is explained by the fundamental differences in the usage pattern of health care resources exhibited by the MDMC compared with the community setting.

The staged cheek-to-nose interpolation flap for reconstruction of the nasal alar rim/lobule.

BACKGROUND: A deep defect of the nasal alar rim or lobule may represent a unique and difficult challenge because of the lax free margin and structural support supplied by the alar rim and lobule. Traditional closure strategies, including granulation, full thickness skin grafting, or nasolabial transposition flaps may result in unsatisfactory cosmetic and functional outcomes. OBJECTIVE: This article describes our experience with the staged cheek-to-nose interpolation flap for repairing deep skin cancer excision defects of the nasal alar rim and lobule. METHODS: The staged cheek-to-nose interpolation flap was used immediately after Mohs micrographic surgery to repair 18 deep nasal alar rim/lobule defects. In 13 patients, a free cartilage graft was used to restore structural support. RESULTS: The cosmetic and functional outcomes of each repair were judged from good to excellent by patient and surgeon. No cases of infection or flap necrosis occurred. To enhance the cosmetic outcome, three patients underwent spot dermabrasion within 2 months after flap detachment. CONCLUSION: The staged cheek-to-nose interpolation flap, with or without free cartilage grafts, consistently provides good to excellent cosmetic and functional outcomes when performed on properly selected deep nasal alar rim/lobule defects.

Computed tomography in staging of patients with melanoma metastatic to the regional nodes.

BACKGROUND: This study addresses the yield and clinical impact of computed tomography (CT) imaging in otherwise asymptomatic patients with stage III melanoma metastatic to the regional nodes. METHODS: The database from the University of Michigan Mutlidisciplinary Melanoma Clinic was reviewed and identified 127 asymptomatic patients with stage III melanoma (regional nodal disease) who received CT scans of the head, chest, abdomen, and/or pelvis. Scans were confirmed as true positive, false positive, and normal. RESULTS: Four hundred twenty-six head and body CT scans were performed at the time of presentation of stage III disease. Twenty patients had a true-positive CT scan revealing unsuspected metastases. Fifteen patients had abnormal CT scans subsequently shown to be a benign process or second malignancy. The incidence of true-positive CT scans was not different between the groups of patients who had clinically apparent versus occult nodal disease. There was a significantly higher incidence of abdominal and pelvic metastatic sites identified by CT scan in patients with inguinal nodal disease compared with axillary or head and neck node-positive patients. CONCLUSIONS: The yield of detection of unsuspected metastases by CT scans in asymptomatic patients with stage III melanoma was not insignificant. Because patients with resected stage III disease are recommended to have adjuvant interferon-alpha for 1 year, CT staging plays an important role in identifying appropriate candidates for treatment. The toxicity of interferon-alpha therapy is not insignificant. The value of routine CT in asymptomatic patients with nodal metastasis deserves further prospective study.

The utility of fine needle aspiration in the diagnosis of melanoma metastatic to lymph nodes.

BACKGROUND: Prompt and accurate diagnosis of melanoma metastatic to the lymph nodes is important with respect to prognosis and treatment. OBJECTIVE: The purpose of this study was to determine the utility and diagnostic reliability of fine needle aspiration (FNA) of enlarged nodules in lymph node basins in patients with melanoma. METHODS: We retrospectively reviewed the charts of 46 patients with melanoma who underwent a total of 56 FNAs of palpable nodules in lymph node basins. RESULTS: Of the 56 FNAs, 24 showed melanoma, 26 did not demonstrate melanoma, five were inadequate, and one gave inconclusive but suspect results. Findings were confirmed by open biopsy (n = 35) or clinical follow-up (n = 21). Fifty of 56 FNAs (89%) yielded a definitive diagnosis (sensitivity/specificity = 100% in these 50). CONCLUSION: FNA biopsy of enlarged palpable nodules in nodal basins in patients with melanoma is accurate, rapid, and cost-efficient. An algorithm for management of patients with melanoma who have palpable nodes is provided.

Medical issues and emergencies in the dermatology office.

We review the medical issues and emergencies potentially encountered in the practice of general or surgical dermatology. Traditional guidelines have largely consisted of dated extrapolations from the nondermatologic literature concerning procedures that are primarily irrelevant to dermatology. This article outlines a rational approach to organizing an office emergency plan for anaphylaxis, stroke, status epilepticus, myocardial infarction, and hypertensive crisis. We discuss the literature that has influenced current office behavior regarding endocarditis prophylaxis, the use of electrosurgery with pacemakers, arrhythmogenic drug interactions, vasovagal syncope, lidocaine "allergy," and bleeding complications from oral anticoagulants. Recommendations for managing these issues in a dermatologic context are provided.

The staged retroauricular to auricular direct pedicle (interpolation) flap for helical ear reconstruction.

BACKGROUND: A significant soft-tissue defect involving the helix of the external ear may present a difficult challenge to repair. OBJECTIVE: We describe our experience with the staged retroauricular to auricular pedicle flap for repair of soft-tissue defects with exposed cartilage of the helix of the ear. METHODS: The staged pedicle flap was used to repair 26 helical ear defects after excision of basal cell carcinoma (n = 16), squamous cell carcinoma (n = 3), and melanoma (n = 7). RESULTS: Defect size ranged from 1 x 2 cm to 4 x 6 cm (average 2.4 x 3.3 cm). Defects involved the superior helix in 12 patients, mid helix in 11, and inferior helix in three. No cases of infection or flap necrosis occurred. CONCLUSION: The staged retroauricular to auricular pedicle flap consistently provides a good to excellent functional and cosmetic outcome when performed on properly selected helical ear defects.

The role of dermabrasion and chemical peels in the treatment of patients with xeroderma pigmentosum.

We describe our experience with two patients with xeroderma pigmentosum who underwent periodic trichloroacetic acid chemical peels. One also received a full-face dermabrasion. The effect of chemical peeling was more transient than dermabrasion but was associated with less morbidity. Both chemical peeling and dermabrasion provided a prophylactic effect against the development of skin malignancies; the latter had a more pronounced effect.

Pilot histologic and ultrastructural study of the effects of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin.

BACKGROUND: Chemical peels are employed for a variety of benign and premalignant skin disorders. OBJECTIVE: We compared clinical and histologic features with ultrastructural changes that occur after medium-depth chemical facial peel. METHODS: Three men with actinically damaged facial skin underwent a single 35% trichloroacetic acid peel. Biopsy specimens were taken before the peel, and 2 weeks and 3 months after the peel, for histologic examination, electron microscopy, and gel electrophoresis to assess total collagen type I content. RESULTS: Clinical resolution of actinic damage corresponded with restoration of epidermal polarity. Collagen type I was markedly increased after the peel. Characteristic ultrastructural features of skin after peeling include markedly decreased epidermal intracytoplasmic vacuoles, decreased elastic fibers, and increased activated fibroblasts. CONCLUSION: Electron microscopic studies after a medium-depth chemical peel of photodamaged skin reveal more profound changes than those seen histologically.