Modified rhombic flap for closure of circular or irregular defects.

BACKGROUND: Rhombic flaps include the Limberg and the Quaba/Sommerlad flaps. The latter was described as successful placement of "a square peg in a round hole" but reported a 22% incidence of dog-ear formation complicating the postoperative course of surgery. OBJECTIVE: To demonstrate the clinical use and compare and contrast the rationale of a modified rhombic flap for closure of wounds of circular or irregular shape that aims to minimize dog-ear formation. METHODS: This closure is essentially a 60 degrees transposition flap applied to a round or irregularly shaped defect. The flap is made slightly smaller than the defect. A modification of the Quaba/Sommerlad flap was made whereby a standing-cone was removed from the hinge-point of the base of the flap during the procedure and a greater flap size was used. A series of 104 cases was assessed by photographic and clinical record perioperatively and at 6 months of postoperative follow-up. RESULTS: No dog-ear formation was found in any of the cases. Other complications were minimal. This flap has been found to be simple to design, and also practical with a wide variety of wound shapes and anatomic sites successfully closed. CONCLUSION: This modification successfully eliminates the most common complication of the Quaba/Sommerlad flap. The modified rhombic flap is a very versatile, safe method, of wound repair and is particularly well suited to Mohs' excision surgery.

Rapid cytokeratin stains enhance the sensitivity of Mohs micrographic surgery for squamous cell carcinoma.

BACKGROUND: Recurrence of squamous cell carcinoma (SCC) following Mohs micrographic surgery is uncommon. However, such cases do exist, presumably because of incomplete excision. Identification of single cells or small clumps of SCC tumor may be extremely difficult and can be compromised by inflammatory reaction. OBJECTIVE: The purpose of this study was to evaluate the benefits of incorporating rapid cytokeratin (CK) stains into Mohs technique. METHODS: Simple modification of standard immunoenzyme techniques allows keratin-specific staining to be achieved in less than 90 minutes on Mohs cryostat sections. We used the rapid labeled streptavidin biotin anticytokeratin method at the stage when no tumor was apparent by hematoxylin and eosin staining in 20 patients with large, aggressive, or recurrent invasive SCCs. RESULTS: In eight cases, single cells or small clumps of SCC tumor were identified utilizing AE-1 monoclonal antibody. These patients subsequently underwent further surgery, including wider tumor resection, superficial parotidectomy, or postoperative radiation therapy. CONCLUSION: The rapid CK antibody staining technique enhances the sensitivity of tumor identification in Mohs micrographic surgery, and should reduce tumor recurrence rates.