Modified Mohs micrographic surgery for periocular melanoma and melanoma in situ: long-term experience at Scripps Clinic.

BACKGROUND: Excision of invasive melanoma and melanoma in situ (MIS) using variations of the Mohs micrographic surgery (MMS) technique is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible, and clinical margins are poorly defined. However, little long-term data evaluating the treatment of periocular melanoma are available in the literature. OBJECTIVE: To present our long-term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique with rush permanent, paraffin-embedded tissue sections. MATERIALS AND METHODS: A total of 35 patients with periocular melanoma and MIS were treated using modified MMS during a 15-year period. Twenty-nine patients were available with adequate follow-up of greater than 5 years duration. The mean follow-up duration was 94 months. RESULTS: There were a total of five recurrences (17.2%) detected an average of 85 months after excision. Four of the five recurrent tumors had been previously excised. The recurrence rate for primary tumors was 5% (1/20). The recurrence rate for previously excised tumors was 44.4% (4/9). CONCLUSION: Margin-control surgery is favored in the treatment of periocular melanoma to maximize the cure rate and minimize postoperative morbidity by sparing normal tissue. Ample follow-up intervals are required to adequately assess recurrence rates. The best opportunity for cure is associated with the first tumor excision.

Calcium hydroxylapatite tissue filler discovered 6 years after implantation into the nasolabial fold: case report and review.

BACKGROUND: Injectable calcium hydroxylapatite is becoming increasingly popular as a facial soft tissue filler, due in part to its purported longevity of esthetic correction compared with other materials, but little is known about its long-term histologic appearance and persistence in facial skin. We recently encountered calcium hydroxylapatite microspheres incidentally during Mohs surgery of the nasolabial fold 6 years after implantation. OBJECTIVE: To describe the long-term histologic appearance of calcium hydroxylapatite microspheres in human facial skin and review the relevant literature with a consideration of clinical implications. METHOD: Routine hematoxylin and eosin staining was performed on frozen and fixed excised tissue containing calcium hydroxylapatite microspheres. Additional fixed sections were stained using Movat's pentachrome method. RESULTS: Numerous 4- to 20-mum round vacuoles were present throughout the reticular dermis associated with focal fibrosis, interstitial mucin, and little surrounding inflammation. CONCLUSION: Calcium hydroxylapatite microspheres and associated fibrosis may persist in facial dermis at least 6 years after implantation, long after its clinical effects are thought to subside. Dermatologists and dermatopathologists must be mindful of dermal implants because it is likely that incidental encounters will be an increasingly common occurrence.

Practical cryotherapy for skin disease.

Cutaneous cryotherapy effects cellular destruction by physically destroying cell membranes after exposure to subzero temperatures. Cryosurgery is predominantly used to treat benign and pre-malignant skin tumors. Advanced techniques are occasionally performed for more aggressive palliation of pain, bleeding, infection and cure. Outcomes are improved by following proper technique, discussing postoperative expectations, and avoiding treatment of undefined entities. This review will primarily discuss practical applications of the open spray technique, performed using the handheld spray device known casually as the "cryo gun".

Heterogeneous regional endocardial repolarization is associated with increased risk for ischemia-dependent ventricular fibrillation after myocardial infarction.

UNLABELLED: Repolarization Heterogeneity and Sudden Death Risk. INTRODUCTION: The aim of this study was to investigate whether the characteristics of endocardial ventricular repolarization are associated with differential risk for sudden death. Prolonged surface QT interval is associated with increased arrhythmic risk after myocardial infarction (MI), but the underlying mechanism of QT prolongation and its relation to lethal arrhythmias are unclear. METHODS AND RESULTS: Ventricular fibrillation (VF) risk was assessed in 12 dogs 1 month after anterior MI during an exercise test coupled with brief circumflex coronary occlusion. Susceptible dogs (n = 5) developed VF during the brief ischemic episode, whereas resistant dogs did not (n = 7). Surface QT interval was measured at rest. Endocardial electroanatomic catheter maps of left ventricular repolarization were obtained in four unique regions identified by echocardiography and compared between groups. Compared to resistant dogs, susceptible dogs were characterized by prolonged surface QT intervals (240 +/- 10 msec vs 222 +/- 7 msec, P = 0.04). In addition, they had lower baroreflex sensitivity (9.7 +/- 1.5 msec/mmHg vs 28 +/- 9.8 msec/mmHg, P < 0.01) and a tachycardic response to acute ischemia suggesting higher propensity for stronger sympathetic reflexes. Surface QT interval prolongation in susceptible dogs was due to a marked heterogeneity of endocardial left ventricular repolarization (239 +/- 42 msec, basal anterior wall vs 197 +/- 35, lateral wall; P < 0.001). Resistant animals had no regional differences in endocardial repolarization. CONCLUSION: Sympathetic activation following MI not only produces adverse structural remodeling but also contributes to adverse electrophysiologic remodeling resulting in heterogeneous ventricular repolarization and in a myocardial substrate conducive to lethal reentrant arrhythmias.

Localized epidermolytic hyperkeratosis of the female external genitalia.

BACKGROUND: Epidermolytic hyperkeratosis (EH) is most commonly associated with the diffuse involvement of congenital ichthyosiform erythroderma, but can also be found in a localized pattern. Localized EH is rare, but mucocutaneous lesions have been been identified, most commonly in the mouth. METHODS: We observed a 58-year-old African-American female who noted spots on her genitalia for approximately 2 years. The lesions were increasing in size, darkening, and had become pruritic and sore over the past 6 months. RESULTS: Physical examination revealed seven scattered, tan to brown, verrucoid papules on the labia and mons pubis, resembling condylomata acuminata or Bowenoid papulosis. Biopsy of a single labial papule revealed epidermal acanthosis, compact hyperkeratotic papillomatosis, perinuclear clear zones, granular keratohyalin clumping, hypergranulosis, and dyskeratosis resulting in intracellular eosinophilic globules, all characteristic of EH. CONCLUSIONS: Because of the rarity of localized genital EH and similar appearance to common diagnoses, clinical confusion may occur without biopsy.