Clonal origin of dermatofibrosarcoma protuberans.

Dermatofibrosarcoma protuberans (DFSP) is a malignant tumor originating in the dermis. Although it is known to be locally aggressive, it only rarely metastasizes and will recur unless completely excised. The exact cell responsible for the development of a DFSP has been a matter of controversy for several decades; however, most histochemical and electron microscopic studies support a fibroblastic origin, with the tumor cells staining uniformly for vimentin and containing active endoplasmic reticulum synthesizing collagen. Cytogenetic analysis of some of these tumors has demonstrated at least two specific chromosomal abnormalities in DFSP and suggested that this tumor may be polyclonal in origin. To further address the clonal origin of this locally invasive, mesenchymal tumor, we analyzed DNA from two female patients by restriction fragment length polymorphisms and methylation analysis. Our data strongly support the concept that DFSP is monoclonal in origin and that this tumor mass reflects the clonal expansion of a single cell.

Subcutaneous island pedicle flaps.

The subcutaneous island pedicle flap is a useful and reliably successful means of closing small- to medium-sized cutaneous excisional defects. It is especially useful in areas where primary closure could result in distortion of critical features. The technique is conceptually straightforward and offers advantages over skin grafting and transposition flaps. We describe our experience with 60 consecutive, successful subcutaneous island pedicle flaps.

Surgical treatment of rhinophyma with the Shaw scalpel.

We present our experience with the Shaw scalpel in the treatment of a patient with extensive rhinophyma. The heated blade of the scalpel provides rapid maintenance of hemostasis with minimal tissue damage and thus allows for rapid and accurate removal of tissue. After removing the bulk of tissue with the Shaw scalpel, the carbon dioxide laser and dermabrader are used to refine nasal contours.

Mohs' micrographic surgery: an overview.

Microscopic control of surgical margins has made Mohs' micrographic surgery an increasingly appealing option for patients with large, recurrent, or difficult-to-treat basal cell and squamous cell carcinomas who require precise and effective surgical management. Understanding the pre-, peri-, and postoperative considerations in Mohs' surgery will help dermatology nurses better prepare and educate patients who undergo this procedure.

Pseudoepitheliomatous hyperplasia vs. squamous cell carcinoma arising from chronic osteomyelitis of the humerus.

The differential diagnosis of pseudoepitheliomatous hyperplasia, atypical pseudoepitheliomatous, and well-differentiated squamous cell carcinoma is discussed. A patient is presented who illustrates the occasional difficulty of this diagnostic question.

The use of Mohs surgery in facial tumors in a patient with Darier's disease.

A case illustrating the need for the Mohs technique for removing basal cell carcinomas (BCC) in skin involved with Darier's disease is presented. Because of the erythema and scaling secondary to Darier's disease, defining the margins of the tumor clinically is impossible. Therefore, we recommend Mohs micrographic surgery for BCCs that occur in Darier's-involved skin.

Basal cell carcinoma recurring after radiotherapy: a unique, difficult treatment subclass of recurrent basal cell carcinoma.

Twenty-seven basal cell carcinomas (BCCs) recurring following radiation therapy alone or in addition to other treatment modalities were treated with Mohs micrographic surgery (MMS) from 1983 to 1989. Mean tumor size was 2.1 cm. Of the tumors, 70.4% arose in the mid-face region, 55.6% had undergone multiple previous treatment modalities. The present recurrence rate is 7.4% (mean follow-up: 25 months). Basal cell carcinoma recurring following radiotherapy deserves special subclassification among recurrent BCC. It is very difficult to eradicate, with high recurrence rates following standard surgical excision or further radiotherapy. Tumors are usually large, aggressive, and invasive. Most arise in the cosmetically crucial mid-face region, where extension into subcutaneous tissue planes is common. Mohs surgery, with its inherent abilities to examine all margins, map tumor extension, and conserve tissue, is uniquely suited to treatment of these difficult tumors.

Solitary pigmented Bowen's disease of the scrotum.

An elderly Chinese man with solitary pigmented Bowen's disease of the scrotum is described. This disease must be distinguished from seborrheic keratoses, pigmented basal cell carcinoma, melanocytic nevus, malignant melanoma, and bowenoid papulosis.

Cheek-neck advancement-rotation flaps following Mohs excision of skin malignancies.

The cheek-neck advancement-rotation flap has proved extremely useful for delayed reconstruction of the face following the microscopically controlled surgical excision (MCSE) of skin malignancies. We have recently used these flaps successfully to repair combined defects of the cheek and nose in eight patients, isolated cheek defects in six patients, combined defects of the cheek and lips in two patients, and isolated defects of the nose, temple, and an antral cutaneous fistula in each of three patients. Defects as large as 6.0 X 10.0 cm have been closed in one stage with this flap. This flap is extremely hearty and its scars can be well concealed. It is especially valuable in the elderly patient and should always be considered as one of the options for reconstruction of the face following MCSE of skin malignancies.

Instrumentation for the dermatologic surgeon.

Because dermatologic surgery continues to enjoy widespread popularity as a leading treatment modality for skin disease, the skill and training of the surgeon are critical to patient care. Equally important, however, are the tools the surgeon uses to perform each particular procedure. Surgical instrumentation has often been a confusing subject for the novice surgeon, one in which personal preference often outweighs technical considerations. This article will present the advantages and short-comings of several instruments that constitute the basic armamentarium of the dermatologic surgeon.

Subclinical syringoma coexisting with basal cell carcinoma.

We report three cases of clinically unapparent syringoma found incidentally on horizontal frozen tissue sections from patients undergoing Mohs micrographic excision of basal cell carcinoma (BCC). In the first case, the syringoma and BCC were admixed; in the other two cases, they were seen in close approximation to one another. In all cases, the tumors were detected on the faces of elderly women. The potential existence of a benign syringoma in association with BCC should be borne in mind, particularly in connection with Mohs micrographic excision. These tumors must be distinguished from one another in order to avoid excessive surgery beyond adequate resection of the basal cell carcinoma.

Wound infection rate in dermatologic surgery.

Most dermatologic surgery is performed in clinical settings and not in the rigorous sterile environment of a hospital operating room. This prospective study measures the wound infection rate over a 2 1/2 year period for cutaneous surgery performed in a clinical environment. This percent infection rate compares very favorably with that of formal operating room settings.

Use of computed tomography in the preoperative evaluation of patients with head and neck tumors.

Computed tomography (CT) is a sensitive, noninvasive radiographic technique which can produce detailed cross-sectional images of any anatomic region. The amount and accuracy of the information it provides far exceeds that produced by conventional radiographic techniques. The chemosurgeon can find CT scanning invaluable in his preoperative evaluation of patients with large, invasive head and neck tumors of cutaneous origin.

Use of Mohs micrographic surgery to establish quantitative proof of heightened tumor spread in basal cell carcinoma recurrent following radiotherapy.

We compared 27 basal-cell carcinomas (BCCs) recurrent following radiotherapy and subsequently excised by Mohs micrographic surgery to a control group of BCCs recurrent following other treatment modalities and similarly excised. Mohs technique permitted precise, quantitative tumor assessment, obtained via a novel method utilizing three parameters: the number of surgical stages required for complete excision, the percentage increase between clinical preoperative tumor area and final postoperative defect area, and the presence of deep subcutaneous tissue invasion. Figures for the postradiation group were larger in all three categories, with the latter two revealing statistically significant differences versus the nonradiation group. This study gives strong, direct quantitative support to the clinical impression that BCC recurrent following radiotherapy is a uniquely aggressive, invasive subset of recurrent BCC.

The purse-string suture in facial reconstruction.

Mohs surgical defects in 26 patients were reconstructed utilizing a purse-string suture and a full-thickness graft. The placement of the purse-string suture decreased the surface area of the wound an average of 53%. A full-thickness graft was then placed in the remaining defect. This technique enabled us to repair large wounds of the facial region with a relatively small full-thickness graft. There were no complications in our series. The resultant areas were cosmetically acceptable and resistant to trauma.

An interlocking auricular composite graft.

BACKGROUND: Full-thickness defects of the nasal alar rim are relatively common following Mohs micrographic surgery for the treatment of long-standing or recurrent skin tumors. Composite grafts provide an excellent cosmetic and functional alternative for the repair of such defects. OBJECTIVE: A useful technique of auricular composite graft placement for reconstruction of full-thickness nasal alar rim defects is described. METHODS: The cartilaginous portion of the graft is extended beyond the borders of the soft tissue defect so that two cartilaginous pegs frame the lateral aspects of the graft. These pegs are then inserted into pockets prepared within the alar tissue of both sides of the defect, such that the graft interlocks with its recipient bed. A series of diagrams as well as a set of photographs from a representative case are provided, along with accompanying commentary, so as to enable the surgeon to incorporate this technique easily into his/her practice. CONCLUSION: The interlocking auricular composite graft technique permits increased graft stability, with decreased shearing forces of the graft over its recipient bed, and a larger surface area for revascularization, resulting in an increased probability of graft survival. This technique provides an elegant single stage alternative to current reconstructive techniques for full-thickness nasal alar rim defects measuring less than 1.5 cm in diameter.

Subdermal basal-cell carcinoma.

A case of recurrent basal-cell carcinoma at the mandibular ramus presented clinically with a subdermal nodule. The patient had previously been treated with aggressive curettage and electrodesiccation which had penetrated through the dermis. The authors postulate that either incomplete extirpation of the neoplasm with the curet or iatrogenic deep implantation of the tumor during the procedure may have led to the presentation of the recurrence as a subdermal nodule.

Dermatologic surgery of the hand. General principles and avoiding complications.

Dermatologists and dermatologic surgeons are frequently presented with significant pathology of the hand. Because the hand plays such a unique and important role in man's everyday life, preservation and restoration of its form and function is critical. The hand is both powerful and extremely delicate. Before performing any procedures in this area, dermatologists and dermatologic surgeons must have a clear understanding of the cutaneous and deep anatomy of the hand and digits, as well as a thorough knowledge of the disease process being treated and the modality being used. This article reviews the intricate anatomy, the proper hemostasis and anesthesia, and many of the complications seen in dermatologic surgery and procedures of the hand, digits, and nails. With appropriate preoperative evaluation and precautions, many dermatologic procedures may be safely performed on the hand.

Marsupial minigrafts for alopecia following surgical procedures of the scalp repaired by split-thickness skin grafts.

A technique is described for treating the alopecia resulting from scalp surgery repaired by split-thickness skin grafts with the method of marsupial minigrafts. This procedure provides an uncomplicated outpatient approach for treating this type of alopecia.