Use of the "spiral" flap for closure of small defects of the nasal ala.

BACKGROUND: Multiple wound closure options exist for cutaneous defects of the nasal ala. The best option depends on the depth, size, and location of the defect. OBJECTIVE: To demonstrate a modification of the traditional rotation flap for closure of small alar defects. METHODS: The design and execution of the "spiral" flap for closure of a representative defect are described. RESULTS: Immediate and delayed postoperative views demonstrate expected outcome. CONCLUSION: The spiral flap modification of the rotation flap is a simple and elegant closure option for small nasal alar defects.

Skin cancer: recognition and management.

Skin cancer is the most common malignancy in humans and accounts for one third of newly diagnosed cancers--it will be diagnosed in approximately 1 in 5 Americans in their lifetime and > 1 million cases are diagnosed each year. Skin cancer can cause local tissue destruction, disfigurement, and even death if left untreated; therefore, timely recognition, treatment, and appropriate referral are critical to reducing morbidity. As the incidence of skin cancer rises each year, the primary care physician needs to be familiar with the clinical presentation, treatment options, and means of prevention of the most common skin cancers: basal cell carcinoma, squamous cell carcinoma, and malignant melanoma.

Mast cells and dendritic cells in basal cell carcinoma stroma.

BACKGROUND: The interaction of tumors with the surrounding stroma has become an important topic in tumor biology. Basal cell carcinoma (BCC) stroma has been characterized as hypervascular and rich in mast cells. The presence of dermal dendrocytes thought to have both antigen presenting and wound healing functions has recently been reported in BCC stroma. GP1b-alpha is a newly described vascular adhesion molecule with potential significance in tumor biology. OBJECTIVE: To further characterize the cellular phenotype of BCC stroma. METHODS: Eleven BCCs (8 nodular, 2 sclerosing, 1 adenoid-cystic) were examined using immunohistochemical techniques for the presence of antigens specific to vascular endothelium, mast cells, and dermal dendrocytes. RESULTS: The stroma of all BCCs demonstrated increased vascularity, increased numbers of mast cells, and increased numbers of dermal dendrocytes expressing both CD34 and GP1b-alpha adjacent to tumor nests. No differences in antigen expression were observed between histologic subtypes of BCC. CONCLUSION: The close proximity of stromal mast cells and dermal dendrocytes surrounding BCC nests suggests a biologically significant interaction. The pattern observed is similar to that observed in healing wounds.

Cutaneous metastasis of chordoma.

BACKGROUND: Chordomas are rare neoplasms that arise from the notochord remnant. They develop in the sacrococcygeal (50%) or cervical (15%) region and are generally regarded as a locally aggressive tumor with a slow progressive growth rate and a metastatic incidence ranging from 3 to 48%. Skin involvement by chordoma is rare, but can occur by direct extension, by local recurrence and by metastases. OBJECTIVE: To illustrate by a case report the clinical presentation and management of this disease. METHODS: We present a case of sacral chordoma with metastases over a 10-year period to the lungs, the soft tissue of the chest wall, the triceps tendon, and distant cutaneous metastases to the back and the nose. RESULTS: The cutaneous metastases were treated by excision. CONCLUSION: Chordoma is a slow growing tumor of the notochord remnant that may metastasize to the skin. Physicians and pathologists should be aware of this entity.

Treatment of superficial basal cell carcinoma and squamous cell carcinoma in situ with a high-energy pulsed carbon dioxide laser.

BACKGROUND: High-energy pulsed carbon dioxide (CO2) lasers have been used extensively to resurface wrinkled and photodamaged skin with a low risk of scarring. Results of histological studies demonstrate precise ablation depths in treated skin with minimal thermal damage to underlying tissue. Our objective was to determine if a pulsed CO2 laser could effectively ablate superficial malignant cutaneous neoplasms (superficial multifocal basal cell carcinoma [BCC] and squamous cell carcinoma [SCC] in situ). OBSERVATIONS: Thirty superficial neoplasms (17 BCCs and 13 SCCs) and their surrounding 3-mm margins were treated with either 2 or 3 passes of a pulsed CO2 laser (500 mJ, 2-4 W) using a 3-mm collimated handpiece. The treated areas were subsequently excised and evaluated histologically by serial sectioning at 5-micron intervals for residual tumor at the deep and lateral margins. Average patient age was greater for those with SCCs than for those with BCCs (76.5 vs 56.7 years; P = .001). The average tumor thickness of SCC in situ was significantly greater than that of superficial BCC (0.57 vs 0.34 mm; P = .01). All (9 of 9 patients) BCCs were completely ablated with 3 passes, and residual tumor in the deep margins was seen in 5 of 8 patients treated with 2 passes of the pulsed CO2 laser (P = .005). Incomplete vaporization of the SCC depth was seen in 3 of 7 patients treated with 3 passes and in 2 of 6 patients treated with 2 passes. Those SCCs incompletely treated were significantly thicker than those completely ablated (0.65 vs 0.41 mm; P = .01). Positive lateral margins were seen in 1 BCC and 3 SCC specimens. CONCLUSIONS: Pulsed CO2 laser treatment can be effective in ablating superficial BCC. Treatment of the neoplasm and a minimum of 4-mm margins with 3 passes (500 mJ, 2-4 W) is recommended for complete vaporization using this laser system. Because 3 passes did not completely ablate all SCC in situ, use of this modality alone is not recommended for treatment of thick or keratotic lesions. No direct comparison of efficacy can be made with other destructive modalities that have not been evaluated with comparably sensitive histological techniques. Further study is needed to establish any cosmetic advantage of pulsed CO2 lasers over other destructive modalities for treatment of superficial malignant neoplasms and long-term cure rates.

Repair of defects of the nasal ala.

BACKGROUND: Alar defects present a reconstructive challenge. OBJECTIVE: To define closure options for alar defects of variable thickness and location. METHODS: The repair options for closure of alar defects are reviewed and discussed with regard to depth of defect and complexity of reconstruction. CONCLUSION: Surgeons repairing defects of the nose should develop a variety of reconstructive approaches for the ala including but not limited to those presented here.

A pilot study comparing toluidine blue and hematoxylin and eosin staining of basal cell and squamous cell carcinoma during Mohs surgery.

BACKGROUND: Hematoxylin and Eosin (H&E) is the most common stain used for Mohs frozen sections. Toluidine blue (T-blue) is a metachromatic stain that has been frequently utilized for this purpose. OBJECTIVE: To compare the cytologic and stromal staining patterns of each stain for Mohs frozen sections of squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), and to identify the advantages and disadvantages of each technique. RESULTS: T-blue revealed stromal change associated with the presence of BCC and SCC. H&E provided more prominent visibility of individual cell keratinization and necrosis, which are common features seen in SCC. CONCLUSION: We found T-blue to be fast and effective in identifying mucopolysaccharides in stroma associated with basal cell carcinoma. For this reason, T-blue is our preferred stain for BCCs, while H&E can provide greater ease of identification of histologic features of SCCs.

Treatment of photodamaged skin with trichloroacetic acid and topical tretinoin.

BACKGROUND: Photodamaged skin typically displays lentigines, actinic keratoses, wrinkles, and textural alteration. Chemical peeling has been used to treat these, but few controlled studies have been performed to determine its efficacy. OBJECTIVE: Our purpose was to compare the efficacy of a medium-depth chemical peel with and without tretinoin before and after treatment. METHODS: Sixteen men with actinic damage including actinic keratoses were treated with a 40% trichloroacetic acid(TCA) chemical peel. Half were pretreated for 6 weeks with topical tretinoin; they also used tretinoin after the peel. Photographs were obtained at baseline and at 6 weeks and 6 months after treatment. Changes in specific features were rated by a panel of three examiners. RESULTS: Some improvement was noted in all patients. More rapid and even frosting was observed in the patients pretreated with tretinoin. Solar lentigines, actinic keratoses, and skin texture were the features of photoaging most affected; wrinkles were least affected. No statistically significant difference was found between patients treated with TCA and tretinoin (before and after peel) and those with TCA alone. CONCLUSION: A medium-depth chemical peel with 40% TCA alone produced moderate improvement in some manifestations of actinic damage but had little effect on wrinkles. Treatment with tretinoin before and after TCA did not significantly enhance the efficacy of the peel.

The postauricular (revolving door) island pedicle flap revisited.

BACKGROUND: Few satisfactory closure options exist for large anterior auricular defects. OBJECTIVE: To describe the use of the postauricular (revolving door) island pedicle flap for closure of large defects on the scapha, antihelix, and helix. METHODS: Mohs micrographic surgery for excision of basal cell carcinoma was performed on the anterior auricular surface of two patients. Both defects were closed using a posterior auricular island flap that was advanced through cartilage with excellent cosmetic results. Other closure options are discussed for this region. CONCLUSION: The postauricular (revolving door) island pedicle flap is a good closure option for large anterior auricular defects lacking perichondrium and not easily repaired by other methods.

The postauricular cutaneous advancement flap for repairing ear rim defects.

BACKGROUND: Due to the ear's complicated anatomy and closely adherent anterior skin, repairing ear rim defects is often difficult. OBJECTIVE: We describe a simple postauricular cutaneous advancement flap for correcting ear rim defects of varying sizes. METHODS: Skin tumors involving the ear rims of 12 patients were excised. A postauricular cutaneous advancement flap was designed to correct the resulting defects. RESULTS: The postauricular cutaneous advancement flap provided excellent cosmetic results in our 12 patients. Minimal superficial necrosis of the flap was observed in one patient. CONCLUSION: Utilizing relatively loose postauricular skin, this postauricular advancement flap can cover helical rim defects of varying sizes with excellent cosmetic results and low complication rates.

Familial occurrence of multiple cutaneous chondromas.

True cutaneous chondromas are rare lesions with an uncertain pathogenesis. We report an unusual case of a patient with multiple cutaneous chondromas of the face. One of the patient's siblings, a brother, and that brother's son had similar facial lesions. We conclude that this familial pattern suggests an autosomal dominant mode of transmission.

Massive bilateral diaphragmatic rupture after an apparently minor automobile accident.

A case of massive bilateral diaphragmatic rupture following a low impact motor vehicle accident is described. The patient experienced herniation of intraabdominal contents into the thoracic cavity, but suffered no additional injuries. Few cases of bilateral diaphragmatic rupture have been reported and no cases of acute bilateral rupture have been described as an isolated injury. Diaphragmatic rupture in general may be a difficult injury to recognize. Based on our review of recent cases of diaphragmatic rupture (1979-1990), most patients presenting acutely have additional trauma (89.9%) but only vague symptoms related to their diaphragmatic insult. A chest roentgenogram may be a useful diagnostic tool, although many patients with diaphragmatic rupture have only nonspecific findings. A nasogastric tube placed prior to chest roentgenogram may enable the physician to recognize the injury more readily. A high index of suspicion is required to recognize diaphragmatic rupture and should be maintained for all victims of motor vehicle accidents with abnormal but nondiagnostic chest roentgenograms.