Nonmelanoma skin cancer: today's epidemic.

The practicing physician encounters many benign and malignant skin neoplasms daily. Basal cell carcinoma and squamous cell carcinoma represent the vast majority of the malignant tumors. Identification of predisposing factors, intrinsic and extrinsic, can decrease future tumor development. Early recognition, biopsy confirmation, and treatment selection can reduce patient morbidity.

Unilateral transient forehead paralysis following injury to the temporal branch of the facial nerve.

BACKGROUND: Cutaneous surgery in the temporal region of the forehead can lead to injury to the superficial temporal branch of the facial nerve. A flattened forehead and with ipsilateral forehead paralysis can occur with damage to this nerve. METHODS: A case is presented of transient forehead paralysis resulting from Mohs' micrographic surgery with reconstruction of the defect. The paralysis resolved over a period of fifteen months. RESULTS: The anatomy of the nerve makes it susceptible to injury during cutaneous surgery. The area of danger is the area superior to the zygomatic arch and lateral to the lateral eyebrow where the nerve is closest to the skin. CONCLUSIONS: Restoration of motor function usually occurs without intervention, but may take several months. Should motor function not recur, nerve grafting of a repair of the ptotic brow may be needed. The anatomy of the nerve is reviewed and brow lifting options are discussed.

A comparison of graft implantation techniques for hair transplantation.

Modern hair restoration surgery involves moving hair-bearing grafts from the posterior scalp into areas of hair loss for correction of androgenic alopecia. Over the past decade, this procedure has been refined in multiple ways for the creation of increasingly natural results. The following is a comparison of commonly used graft harvesting, sectioning, and implantation techniques currently in use for hair restoration today. This comparison includes data on total procedure time, graft cutting time, graft insertion time, labor requirements, and cost.

Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. The American Society for Dermatologic Surgery, Inc.

Previous attempts at classifying small graft transplants have focused mainly upon graft size and have not taken into consideration other technical factors involved in graft production that may influence the outcome of the surgery. The proposed classification attempts to consider these factors by including various technical aspects of harvesting, dissection, and placement, all of which impact the quality and quantity of the small grafts used in the procedure. By standardizing the nomenclature, as well as the description of the other factors involved in the surgery, communication between physicians and patients may be facilitated. In addition, different procedures may be more accurately studied and compared.

The density issue in hair transplantation.

BACKGROUND: Modern hair restoration procedures may involve, individually or in combinations, flaps, grafts consisting of plugs, slits, strips, minigrafts, or micrografts, with or without alopecia reduction. OBJECTIVE: To review the density achieved using mini-micrografting technique compared with that accomplished by plug methodology. METHODS: Hair counts per square centimeter were done on both mini-micrografted and plug cases from the author's practice. RESULTS: Comparable density (terminal hair per square centimeter) was noted to occur with either technique but accomplished with fewer sessions using mini-micrografting methodology and relatively dense packing of grafts. CONCLUSION: The density issue is a nonissue if comparable numbers of hair are transplanted per square centimeter.

Cutaneous micrographic surgery for atypical fibroxanthoma.

BACKGROUND: Atypical fibroxanthoma is a locally aggressive cutaneous tumor of the head and neck. Reported treatments include simple excision, cryosurgery, radiation, and cutaneous micrographic surgery. OBJECTIVE: We wish to further document the use of cutaneous micrographic surgery for local control of atypical fibroxanthoma. METHODS: A retrospective study of six cases from the University of Missouri-Columbia and a review of the literature. RESULTS: Five (84%) of our cases were on the heads of elderly patients with strong evidence of photodamage. Subclinical extension of atypical fibroxanthoma required surgical margins averaging 9 mm. Cutaneous micrographic surgery has been associated with no recurrences. CONCLUSION: The results of our data demonstrate cutaneous micrographic surgery to be an excellent modality to address this locally aggressive tumor. Cutaneous micrographic surgery is an advantageous therapy for this tumor because of its meticulous tissue removal, tissue mapping, and tissue sparing qualities.

Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation.

BACKGROUND: Multiple surgical methods are currently used for hair transplantation. Each method has a specific technique, morbidity, and relatively predictable cosmetic result. OBJECTIVE: To describe a methodology that combines elliptical excision of donor tissue and dissection under stereoscopic magnification into small grafts to obtain an improved final cosmetic result. For the purposes of this paper, any graft small enough to be easily inserted into a 16-, 18-, or 20-gauge needle tunnel will be referred to as a micrograft. METHOD: Three hundred thirty patients underwent transplantation by this method over a 6-year period. All patients were photographed before, during, and upon completion to monitor results. RESULTS: Cosmetic results as documented by examination and photography represent a further refinement due to the large number and small size of grafts placed. CONCLUSION: The author considers the method described as a viable alternative technique in hair transplantation for both limited and extensive androgenetic alopecia.

Nonsurgical management of primary skin malignancies.

Cryosurgery, electrosurgery, radiotherapy, chemotherapy, and interferon therapy achieve high cure rates for primary skin malignancies. These techniques are readily mastered. They combine cost-effective use of time, space, and equipment. Proper patient selection maximizes safety, comesis, and cure rates.

Quantitative in vitro drug potency and drug susceptibility evaluation of Leishmania ssp. from patients unresponsive to pentavalent antimony therapy.

Quantitative in vitro drug sensitivity of 32 Leishmania isolates (16 from patients failing pentavalent antimony [SbV] therapy) was determined using a radiorespirometric microtechnique (RAM). Of 30 isolates with histories, 22 (73%) RAM tests agreed with patient history; the remaining 8 (27%) did not. There was no difference in RAM drug sensitivity: clinical correlation between 15 isolates tested blindly and 15 with known clinical history (4 did not agree with clinical history in both). Test sensitivity appeared to be limited only by the sensitivity of the Leishmania to SbV and could be detected at 2 micrograms/ml Sb (about 10% of serum drug level). An isolate from a patient with untreated self-healing cutaneous disease was drug resistant. Using RAM, parasite drug sensitivity can be quantified apart from patient physiologic and immunologic variables intrinsic to clinical data. Potency differed a maximum of 100% (weight% Sb:weight% Sb) among drug lots and also between Glucantime and Pentostam. Potency changes between drug lots were not explainable based on Sb content or test-to-test variability. This microtest offers a rapid method for evaluating the drug sensitivity of patient isolates and for determining of the activity of pentavalent antimonials and other candidate anti-leishmanials prior to the initiation of therapy.

Plasmid library for the transcription of RNA probes complementary to the entire genome of the human immunodeficiency virus type 1 (HIV-1).

A plasmid (pBH10R3) containing a 9-kb Sst I fragment of HIV-1 (clone BH-10) inserted in pSP64, an in vitro expression vector, has been used for the transcription of anti-sense HIV-1 RNA. With this system, the transcripts obtained in vitro were not usually full length (1 to 2 kb long) and they predominantly span the 3' end ORF and ENV regions of the viral genome. We have rearranged the HIV-1 genomic sequences with respect to the SP6 promoter in the pSP64 vector and have obtained a series of new constructs allowing the expression in vitro of RNA transcripts complementary to other regions in the HIV-1 genome, including the 5' end of the ENV region as well as the TAT, POL, and GAG regions. In fact, the combined use of these constructs as templates for in vitro transcription allows the production of RNA probes spanning the entire viral genome. Compared with the 1- to 2-kb probes mentioned above, the combined use of such probes results in a several-fold increase in the sensitivity of molecular hybridization for the detection of HIV-1 nucleic acid sequences. Also, these constructs enable the preparation of RNA probes that have the potential to detect restriction polymorphisms throughout the HIV-1 genome.

Results of cryotherapy for eyelid malignancies.

A total of 164 nodular and infiltrative eyelid basal cell carcinomas were treated with liquid nitrogen spray cryotherapy and followed up for a minimum of five years. For lesions less than 10 mm in diameter, nodular basal cell carcinomas had a 97% cure rate with cryotherapy and infiltrative basal cell carcinomas had a 94% cure rate. However, nodular of infiltrative basal cell carcinoma lesions larger than 10 mm in diameter had 85% and 82% cure rates with cryotherapy, respectively. After a minimum four-year follow-up period, 25 recurrent basal cell carcinomas previously treated by various methods had a 93% cure rate when re-treated with cryotherapy. Data for other malignant eyelid lesions treated with cryotherapy were insufficient for statistical analysis.

Cryosurgery for malignancies of the eyelid.

The results of liquid nitrogen spray technique for 310 biopsy-proven eyelid malignancies are reviewed. The raw recurrence rate for basal cell carcinomas of the eyelids with a mean follow-up of almost three years is 4.2%, while the recurrence rate is 6% in 49 cases followed for five years. For all lid malignancies 10 mm or less in diameter, a 2.0% raw recurrence rate was obtained; however, in those lesions larger than 10 mm, this rose to 9.5%. With this form of therapy, basal cell carcinomas with infiltrative, nonelevated, indistinct borders had twice the recurrence rate than those tumors with elevated distinct borders. Twenty-one squamous cell carcinomas treated with cryosurgery with an average follow-up 21.6 months have yet to show a recurrence. Complications with cryosurgery include permanent loss of eyelashes and depigmentation lasting from six months to over six years. Depending on the extent and location of the tumor, eyelid defects occurred. To date, five plastic reconstructive procedures have been required for ectropion or lid defects; however, no lacrimal outflow surgery has as yet been required.

Cryosurgery of porokeratosis plantaris discreta.

Porokeratosis plantaris discreta is a distinct clinical and pathological entity often resistant to conservative management. Twenty-one lesions of porokeratosis plantaris discreta were treated cyrosurgically in 11 patients. Removal of the blister roof two weeks after cryosurgery with retreatment of any residual lesion proved an effective method for removal of such lesions without scarring. A cure rate of 90.5% was achieved using this technique.

General purpose cryosurgical units. The WSL Nitrosprays I and II.

Lightweight, hand-held, inexpensive cryosurgical instruments are described that combine the desirable features of most available units into a single instrument. As these units are capable of treating the entire spectrum of cryoresponsive lesions, they are believed to be general purpose instruments.

The role of cryosurgery in external ocular and periocular disease.

This preliminary report suggests that cryosurgery has a definite place in the management of certain external periocular and ocular problems. Cryosurgery for basal or squamous cell carcinoma of the lid is easily performed, gives excellent cosmetic results, and has a low recurrence rate. It is not recommended for lesions involving the fornices, or sclerotic and morphea-type basal cell carcinomas. Tumor recurrences following radiation, surgery, or cryosurgery can still be retreated with cryosurgery. To date, there is no evidence that cryosurgery at temperatures above -40 C causes damage to the lacrimal outflow system. Cryosurgery is of value in the management of trichiasis, reactive lymphoid hyperplasia, spider hemangioma, molluscum contagiosum, and conjunctival dysplasia. Cryotherapy for management of intraepithelial epithelioma and squamous cell carcinoma of the conjunctiva and cornea is still under investigation. Cryosurgery will, in our opinion, become the treatment of choice for basal and squamous cell carcinomas of the eyelids. The 96% cure rate with one treatment for these lesions reported here is artificially high since the follow-up period is too short. However, retreatment with cryosurgery is a simple ten-minute outpatient procedure which is certainly not the case with recurrences after other forms of therapy.