Diagnosis and Treatment of Merkel Cell Carcinoma in Specialized Dermatology Units: A Clinical Practice Guideline of the Spanish Academy of Dermatology and Venereology. / Carcinoma de células de Merkel: diagnóstico y tratamiento en atención especializada dermatológica. Guía de práctica clínica de la Academia Española de Dermatología y Venerología.

BACKGROUND AND OBJECTIVE: Merkel cell carcinoma is a rare, aggressive skin cancer that is managed in a great variety of ways. However, international clinical practice guidelines give only partial coverage to issues considered major problems.The recommendations presented here aim to provide Spanish dermatologists with a guide to improving disputed aspects of diagnosis, staging, and treatment of localized Merkel cell carcinomas. MATERIAL AND METHODS: The ADAPTE process was used. Members of the Spanish Group of Oncologic Dermatology and Surgery (GEDOC) with experience in treating Merkel cell carcinoma and interest in drafting these guidelines were selected. The group described the care process and listed the most important clinical questions. They then searched for guidelines and assessed them with the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool. After consulting the guidelines for answers to their clinical questions, the group drafted the present statementand sent it for external review. RESULTS: The guidelines that scored highest in the AGREE II assessment step were the consensus-based interdisciplinary guideline of the European Association of Dermato-Oncology and the European Organization of Research and Treatment of Cancer, and those of the Comprehensive Cancer Network, the Alberta Health Services in Canada, the American Cancer Society, and the Cutaneous Oncology Group of the French Society of Dermatology. A total of 9 clinical questions were answered based on these guidelines. CONCLUSIONS: The guidelines presented here answer clinical questions that arise in routine practice. They can provide dermatologists with a starting point for decision-making, although available resources and patient preferences must always be borne in mind.

Skin Flaps for the Repair of Multiple Adjacent Tumors.

In daily clinical practice, the dermatologic surgeon frequently has to excise closely adjacent tumors in the facial region. In such cases, planning of an appropriate reconstruction technique is essential. The aim is to treat all of the lesions in a single surgical intervention, if possible, and to achieve a good functional and cosmetic outcome. We present 5 patients in whom a single flap was used to repair multiple adjacent defects.

Reconstruction of Surgical Defects of the Labial Commissure.

The main objective of oncologic dermatologic surgery is the complete excision of skin tumors. During reconstruction of the defect, we must attempt to preserve function and cosmetic appearance. At the labial commissure, fibers from the superior and inferior portions of the orbicularis oris muscle intersect and the vermillion inserts onto the modiolus, a complex, cone-shaped structure at the angle of the mouth. Surgical reconstruction of the labial commissure is challenging because of the need to preserve sphincter function and cosmetic symmetry. We present a number of cases of surgical defects at the labial commissure and describe the reconstruction techniques used. We also propose an algorithm to help determine the most suitable technique for different cases.

Subcutaneous pedicled V-Y advancement flap for surgical reconstruction of the auricle of the ear.

The subcutaneous pedicled V-Y advancement flap is useful for the repair of small and medium-sized defects in areas where it is easy to obtain a good subcutaneous pedicle (upper lip, cheek, eyebrow, and nasal tip and ala). The almost complete absence of subcutaneous tissue on the anterior aspect of the auricle of the ear can limit the use of this approach in this region. We present 4 patients in whom subcutaneous pedicled V-Y advancement flaps were used to repair surgical defects of the helix, scaphoid fossa, and antitragus, achieving a good functional and aesthetic result in all cases.

Surgical principles for achieving a functional and cosmetically acceptable scar.

Dermatologic surgery can sometimes result in scars that are less than satisfactory. Such results, and hence the need for scar revision, can be avoided with careful planning and the use of appropriate surgical techniques. In this practical review, we describe several techniques that will improve functional and cosmetic outcomes. While Z-plasty and its variants are simple yet essential surgical procedures, they can represent a challenge for less experienced surgeons. By gaining a clear understanding of the principles of Z-plasty, the dermatologic surgeon will be able to employ this technique, either alone or with other surgical techniques, in a range of clinical situations.

Partial nasal reconstruction with titanium mesh: report of five cases.

The nasal pyramid is frequently affected by nonmelanoma skin cancer. Sometimes the aggressiveness of tumours entails the extirpation of the mucosa, the cartilage, and the nasal skin. Reconstruction of the cartilaginous portion can be a surgical challenge. We demonstrate that titanium mesh can be an effective substitute for the cartilaginous portion of the nose in nasal reconstruction. We present five patients with nasal basal cell carcinoma who were treated by Mohs micrographic surgery. The partial loss of the cartilaginous structure was replaced by a 0.1 mm fenestrated titanium mesh. We have not observed any rejection or other complication in any of our patients. Good functional and aesthetic results have been obtained. Because of its biocompatibility, titanium mesh is a useful substitute for nasal cartilage. It avoids harvesting natural cartilage, reduces the risk of graft necrosis, and prevents morbidity in the donor area.