Secondary Intention Healing Over Exposed Bone on the Scalp, Forehead, and Temple Following Mohs Micrographic Surgery.

BACKGROUND: Removal of skin cancers on the scalp, forehead, and temple can result in surgical defects with exposed bone. In such cases, reconstruction becomes challenging due to limited vascularity for flap or graft repair. OBJECTIVE: Demonstrate the usefulness of secondary intention healing of scalp, forehead, and temple defects over exposed bone. METHODS/MATERIALS: A retrospective case series of 41 patients who had Mohs Micrographic Surgery with post-surgical scalp, forehead, or temple defects involving exposed bone. These patients then underwent secondary intention healing. RESULTS: 90% of patients successfully healed. Average time to complete granulation was 92 days, and average time to full re-epithelialization was 186 days. Visual analog scale assessment of final scar quality resulted in 57% being good, 35% being fair, and 8% being poor. No patient had infection or other serious complication. Mean follow-up duration was 272 days. CONCLUSION: This case series shows the viability of secondary intention healing of scalp wounds over exposed bone. Study power was not adequate to predict time to complete healing based on defect size, or allow association of patient factors with the risk of nonhealing. Managing patient expectations, and emphasizing the importance of early occlusive wound care is paramount for healing success.

Fixed Drug Eruption to Trimethoprim-Sulfamethoxazole and Doxycycline.

Fixed drug eruption (FDE) is a common cutaneous drug eruption. We are the first to report a case of polysensitive FDE to both trimethoprim-sulfamethoxazole (TMP-SMX) and doxycycline. Diagnosis of FDE is largely clinical, and it is important to establish a good medication history to identify the causative agent. Treatment depends on avoidance of the implicated drug.

Interpolation Flaps in the Outpatient Mohs Surgery Setting: A Prospective Cohort Study of Patient Pain, Anxiety, and Satisfaction.

BACKGROUND: Staged interpolation flaps (SIFs) have historically been performed under general anesthesia by specialties outside of dermatologic surgery. However, SIFs performed under local anesthesia by dermatologic surgeons have shown lower or equal complication rates. OBJECTIVE: To date, no studies have evaluated pain, anxiety, satisfaction, and use of perioperative analgesics in patients undergoing SIFs in an outpatient setting under local anesthesia. METHODS/MATERIALS: This is a prospective cohort study of 39 patients who received Mohs micrographic surgery and subsequent SIF repair in an outpatient setting under local anesthesia. Pain, anxiety, and satisfaction scores were recorded using 100-point validated visual analog scales. Perioperative analgesic use was quantified. RESULTS: The defect size was ≥4 cm2 in 72% of patients; 41% had full-thickness (skin/cartilage/mucosa) defects. All pain and anxiety measures were minimal to mild. Pain scores ranged from highest (mean = 39 ± 4.1) on postoperative Day (POD) 1 to lowest (mean = 12.3 ± 2.0) on POD 7. Anxiety scores ranged from highest (mean = 42 ± 4.5) on POD 1 to lowest (mean = 18.5 ± 3.7) on POD 7. Perioperative patient satisfaction was high (mean = 95 ± 1.7). Postoperative narcotic analgesics were prescribed in 15% of patients. CONCLUSION: Staged interpolation flaps performed under local anesthesia in the outpatient setting are well tolerated with low pain and anxiety, high patient satisfaction, and minimal analgesic use.

Gaining Large Coverage With Small Island Pedicle Flaps in Tight Cosmetic Subunits: Taking Advantage of Rotation and Pincer Principles on the Nasal Ala.

BACKGROUND: Island pedicle flaps (IPFs) are widely used in reconstructive surgery due to their versatility, tissue efficiency, and excellent clinical outcomes. While IPF rotations and 'pincer flap' modifications have previously been sparsely described, they are not often discussed in the literature. OBJECTIVE: We demonstrate the use of both rotating IPFs and pincer techniques for defects traditionally considered too large for classic IPF design on the nasal ala. METHODS: Forty-four patients underwent alar repair using the rotation or combined rotation with pincer modification to the standard IPF technique from August 2014 to May 2017. Our technique is described and case examples are presented with photographs. RESULTS: Forty-four patients with an average alar defect size of 1.2 cm underwent repair using rotation only or rotation with pincer modification of the classic IPF approach. CONCLUSIONS: Reconstruction of large defects in small facial cosmetic subunits such as the nasal ala can be performed using principles of both rotating IPFs and the 'pincer flap' technique. The degree of rotation is directly related to the length of coverage. Modifications to the flap are straightforward to perform. Using these techniques, larger defects that previously would have been reconstructed using flaps that cross cosmetic boundaries can now be reconstructed within the same cosmetic unit, thus, improving aesthetic outcomes.

Trophic factor-induced activity 'signature' regulates the functional expression of postsynaptic excitatory acetylcholine receptors required for synaptogenesis.

Highly coordinated and coincidental patterns of activity-dependent mechanisms ("fire together wire together") are thought to serve as inductive signals during synaptogenesis, enabling neuronal pairing between specific sub-sets of excitatory partners. However, neither the nature of activity triggers, nor the "activity signature" of long-term neuronal firing in developing/regenerating neurons have yet been fully defined. Using a highly tractable model system comprising of identified cholinergic neurons from Lymnaea, we have discovered that intrinsic trophic factors present in the Lymnaea brain-conditioned medium (CM) act as a natural trigger for activity patterns in post- but not the presynaptic neuron. Using microelectrode array recordings, we demonstrate that trophic factors trigger stereotypical activity patterns that include changes in frequency, activity and variance. These parameters were reliable indicators of whether a neuron expressed functional excitatory or inhibitory nAChRs and synapse formation. Surprisingly, we found that the post- but not the presynaptic cell exhibits these changes in activity patterns, and that the functional expression of excitatory nAChRs required neuronal somata, de novo protein synthesis and voltage gated calcium channels. In summary, our data provides novel insights into trophic factor mediated actions on neuronal activity and its specific regulation of nAChR expression.

Drug-induced subacute cutaneous lupus erythematosus associated with docetaxel chemotherapy: a case report.

BACKGROUND: Drug-induced subacute cutaneous lupus erythematosus is an uncommon disorder associated with the use of pharmacological agents including systemic chemotherapy. CASE PRESENTATION: We report a case of docetaxel-induced subacute cutaneous lupus erythematosus in a 60-year-old Caucasian female with Sjögren's syndrome diagnosed 2 months after receiving docetaxel as part of the adjuvant FEC-D (5-fluorouracil, epirubicin, cyclophosphamide, docetaxel) chemotherapy protocol for early stage breast cancer. Although the exact mechanisms behind the autoimmune response elicited by docetaxel are unclear, the involvement of anti-SSA/Ro antibodies has been implicated. CONCLUSION: This case highlights the symptom severity and clinical course of docetaxel-induced subacute cutaneous lupus erythematosus, and highlights the importance of recognizing this uncommon but potentially severe chemotherapy-associated cutaneous reaction.

Neuronal somata and extrasomal compartments play distinct roles during synapse formation between Lymnaea neurons.

Proper synapse formation is pivotal for all nervous system functions. However, the precise mechanisms remain elusive. Moreover, compared with the neuromuscular junction, steps regulating the synaptogenic program at central cholinergic synapses remain poorly defined. In this study, we identified different roles of neuronal compartments (somal vs extrasomal) in chemical and electrical synaptogenesis. Specifically, the electrically synapsed Lymnaea pedal dorsal A cluster neurons were used to study electrical synapses, whereas chemical synaptic partners, visceral dorsal 4 (presynaptic, cholinergic), and left pedal dorsal 1 (LPeD1; postsynaptic) were explored for chemical synapse formation. Neurons were cultured in a soma-soma or soma-axon configuration and synapses explored electrophysiologically. We provide the first direct evidence that electrical synapses develop in a soma-soma, but not soma-axon (removal of soma) configuration, indicating the requirement of gene transcription regulation in the somata of both synaptic partners. In addition, the soma-soma electrical coupling was contingent upon trophic factors present in Lymnaea brain-conditioned medium. Further, we demonstrate that chemical (cholinergic) synapses between soma-soma and soma-axon pairs were indistinguishable, with both exhibiting a high degree of contact site and target cell type specificity. We also provide direct evidence that presynaptic cell contact-mediated, clustering of postsynaptic cholinergic receptors at the synaptic site requires transmitter-receptor interaction, receptor internalization, and a protein kinase C-dependent lateral migration toward the contact site. This study provides novel insights into synaptogenesis between central neurons revealing both distinct and synergistic roles of cell-cell signaling and extrinsic trophic factors in executing the synaptogenic program.