Follicular thyroid carcinoma metastasis to the facial skeleton: a systematic review.

BACKGROUND: Follicular thyroid carcinoma (FTC) metastasis to the facial skeleton is exceedingly rare. A case of FTC metastasizing to the mandible is presented and a systematic review of the literature describing thyroid metastasis to the facial skeleton is performed. CASE PRESENTATION: A 73-year-old female presented with metastatic FTC to the mandible and underwent total thyroidectomy, segmental mandibulectomy, bone impacted fibular free flap reconstruction, and adjuvant radioactive iodine treatment. The PubMed database was searched for literature describing thyroid cancer with facial skeleton metastasis using the key words "thyroid," "cancer," "carcinoma," "metastasis," and "malignancy" with "oral cavity," "maxilla," "mandible," "sinus," "paranasal," and "orbit." Reports that only involved the soft tissues were excluded. Systematic review revealed 59 cases of well-differentiated thyroid cancer with facial skeleton metastasis: 35 mandibular metastases (21 = FTC), 6 maxilla metastases (2 = FTC), 9 orbital metastases (4 = FTC), and 11 paranasal sinus metastases (7 = FTC). Treatment included surgery, RAI, external beam radiotherapy (XRT), or a combination of these modalities. The one, two, and five-year survival rates were 100%, 79%, and 16%, respectively. CONCLUSION: Facial skeleton metastasis of FTC is a rare clinical challenge. Optimal treatment appears to include total thyroidectomy and resection of involved structures with or without adjuvant treatment.

Towards an optimal paradigm for intraoperative auditory nerve monitoring with auditory steady state responses.

Auditory steady state responses (ASSR) may offer an alternative to brainstem auditory evoked potentials for monitoring of the auditory nerve during surgical procedures. In the current study, we evaluated the influence of noise on ASSR characteristics in total intravenous anesthesia (TIVA). Simulated ASSR in real noise recorded during surgery under TIVA were constructed with known parameters. Influence of amplitude, modulation frequency, averaging sweeps and detection threshold on ASSR were evaluated. High amplitude, more sweeps and a liberal threshold facilitated detection. High amplitude ASSR (80 nV) were detected in up to 45 % with 16 s of data, in 80-90 % with 112 s. Near-threshold ASSR were detected in 0.8-25 %. False positives ranged between 0.3 and 10.3 %. Number of sweeps did not influence false positives. Amplitude errors varied between -61 and +39 % and improved with more averages but not with different thresholds. Modulation rate demonstrated the strongest influence on all parameters. 110 Hz yielded best, 90 Hz the worst results. Choice of parameters strongly influences detection and characteristics of ASSR. Optimal parameters enabled detection after 16 s in 45 %. Due to specific noise characteristics, modulation has a critical impact, which is currently not sufficiently recognized in ASSR studies.

Indications for, and limitations of, the retroangular flap in facial reconstruction according to its vascular mapping.

We have used the retroangular flap for the reconstruction of facial defects after excision of tumours. Important variables such as vascular mapping, type of anaesthesia, duration of stay in hospital, and the diagnosis and treatment of complications were taken into account in assessing its effectiveness. We studied 187 patients, 103 men and 84 women, who were treated with the retroangular flap, and the morphological and cosmetic results analysed. There are many vascular variations of the flap The patients were followed up for a median of 12 (range 12-125) years and their reconstructions were successful. The technique can be considered as one of first methods of choice for the reconstruction of cutaneous defects of the middle third of the face.

Reconstruction of large rectangular infraorbital and malar skin defects in elderly patients with a modified "reading man flap" using local tumescent anesthesia.

BACKGROUND: The classical "reading man flap" is a recently described flap named after its appearance and mainly used for reconstruction of circular malar or infraorbital skin defects. It avoids surgical complications such as lower lid retraction and ectropion but is limited to circular skin defects. Local tumescent anesthesia uses a diluted local anesthetic together with diluted epinephrine to anesthetize large skin areas without the need for general anesthesia. OBJECTIVES: To assess the esthetic outcome, pain control, and complications of a modified "reading man flap" under local tumescent anesthesia in elderly patients with rectangular malar or periorbital skin defects. METHODS: Two flaps are used to close the surgical defect, the first rectangular flap is transposed to the defect area, then approximately half to two-thirds of the flap's donor site are closed directly as done with transposition flaps, whereas a second smaller triangular flap is advanced for the closure of the last third of the remaining now triangular donor site, where the greatest tension would occur if closed directly. RESULTS: The median age of patients was 83 years (range 64-92 years) of the total 12 patients, 10 (83%) were women, and two were men. The mean defect size was 9.2 cm(2) (5.5-22.1 cm(2) ). The defect closure was possible in all patients, no lasting postoperative complications occurred, and cosmetic results were satisfactory. Twenty to 70 ml of local tumescent anesthesia were used, and a larger volume (≥ 40 ml) was associated with better pain control (P = 0.03). CONCLUSIONS: The modified "reading man flap" is a good option for the closure of larger rectangular facial skin defects especially in elderly patients, and the use of at least 40 ml of tumescent solution is suggested to achieve optimal pain control.

See-and-treat surgery for facial skin cancer.

See-and-treat surgery has been described as an efficient means of streamlining specialist diagnosis and treatment, and is commonly employed in gynaecology to reduce the delay between cytological screening and definitive treatment of cervical neoplasia. Relatively young patients with predominantly benign skin lesions have been treated in see-and-treat clinics but only in the context of referrals from primary care. The author describes the treatment of tertiary referrals for facial skin malignancies under local anaesthesia at these clinics, and analyses their acceptability to patients. A total of 100 consecutive patients were included. Data on age, coexisting conditions, diagnosis, site and size of lesion, operation, and outcomes including complications and completeness of excision, were collected. A questionnaire seeking patients' opinions was also used. Ninety patients were treated and 98 lesions were removed, 94% of which were malignant. The complete excision rate was 95%. There were no complications, and 98% of patients were satisfied with the service. See-and-treat surgery is an effective, safe, and acceptable means of providing surgical management of facial skin malignancies.

Extensive basal cell carcinoma of the face: an extreme case of denial.

Patients with head and neck cancer are particularly susceptible to using denial as a coping mechanism. While some forms of denial may help patients achieve better levels of physical functioning, persistent denial can serve as a major barrier to treatment. We report a case of extreme denial by a 60-year-old woman with an extensive basal cell carcinoma of the face that had been neglected for more than 20 years. We present this case to raise awareness of the potential danger of denial, and we discuss strategies that physicians can undertake to properly manage patients who engage in it. Since the diagnosis and treatment of head and neck cancer can result in profound psychological trauma, gaining an appreciation for how patients cope with it is an important part of the comprehensive care of head and neck oncology patients.

[Medical indications for laser therapy in dermatology]. / Medische indicaties voor lasertherapie in dermatologie.

Laser therapy in dermatology is often associated with cosmetic procedures. However, nowadays laser therapy has become a treatment modality for many dermatological diseases. We present three cases of patients with different dermatological diseases that are highly therapy-resistant. The first case is a 19-year-old man with multiple angiofibromas in the face, who was treated with ablative laser therapy. We also administered ablative laser therapy to a 64-year-old man with a big tumourous nose due to granuloma faciale, who had already tried multiple treatment options without result. Finally, a 69-year-old woman with extensive neurofibromas in the face, which had been considered untreatable, was successfully treated with ablative laser therapy. We would like to show the extensive therapeutical options of laser therapy for difficult-to-treat dermatological diseases.

Microcystic adnexal carcinoma of the face treated with radiation therapy: a case report and review of the literature.

BACKGROUND: Microcystic adnexal carcinoma is a rare, locally aggressive neoplasm most commonly occurring on the face. Minimal data are available regarding the role of radiation therapy (RT). METHODS: Cases treated with RT from 2 comprehensive cancer centers are reviewed along with a review of the literature. RESULTS: Three patients with microcystic adnexal carcinoma of the face were treated with curative intent. One patient received RT as monotherapy. Two patients received postoperative RT (PORT). The patient receiving RT as monotherapy experienced excellent clinical regression, had an in-field recurrence at 48-month follow-up, and is now without evidence of disease after reirradiation. Both patients receiving PORT are without evidence of disease. CONCLUSION: PORT may improve local control in patients with microcystic adnexal carcinoma, and its use should be considered in patients with high-risk features for local recurrence. RT as monotherapy should be considered when poor cosmetic outcome can be anticipated via standard surgical treatments.

The managements of orofacial tumors of children in Iraq.

These studies were carried out in the maxillofacial unit, surgical specialties hospital, medical city, Baghdad, included 55 patients with orofacial tumors; their ages ranged from 2 days to 14 years (mean, 7 years). Twenty-eight of them were girls, and 27 were boys. Tumors included 20 cases of benign tumors and 35 cases malignant. Treatment modalities ranged from complete surgical excision, surgical shaving operations, and deep x-ray therapy (DXT; radiotherapy) for some benign tumors. The management of malignant tumors was carried out by the use of chemotherapy, chemotherapy and DXT to radical surgery, or radical surgery with DXT. Reconstruction of the mandible was carried out using a rib graft or a block of a corticocancellous bone graft from the iliac crest with reimplantation of the condyle after resection from the tumor and fixed by rigid fixation to the bone graft. Temporary reconstruction of the mandible done by Kirschner wire for malignant tumors required a postsurgical DXT. A temporalis muscle flap was used for the augmentation of the orbit with a frontoorbital flap after radical excision of a malignant tumor of the orbit, and a silastic implant (silicon rubber) was used for reconstruction of the orbital floor. A long-term follow-up ranged from 2 to 15 years. The aim of this study was to present a certain number of cases with an interesting pathologic tumor condition showing peculiar behaviors; the management of these cases was a challenge to our surgical experience.

Reconstruction of cheek skin defects by the 'Yin-Yang' rotation of the Mustardé flap and the temporoparietal scalp.

BACKGROUND AND PURPOSES: When the skin's laxity is limited, the preauricular cutaneous defect resulting from the Mustardé cheek rotation flap for the coverage of suborbital skin defects is very difficult to close even with a large undermining of the cervicofacial skin. The rotation of the temporoparietal scalp in an opposite direction compared to the Mustardé flap or the 'Yin-Yang' rotation of these flaps is interesting for two reasons: it allows an easy closure of this preauricular defect with a limited facial undermining and it suspends with efficiency the Mustardé flap at the temporal area avoiding the lower lid's ectropion. MATERIAL AND METHODS: From September 2001 to April 2005, nine patients aged between 35 and 78 years old, with no facial skin laxity, have benefited from this technique to cover suborbital defects secondary to excision of basal cell carcinomas with a mean diameter of 6 cm. The design of the Mustardé flap was classical but the skin undermining stopped at the mandible's lower border. The triangular preauricular defect has served as a geometrical base to design an opposite temporoparietal rotation flap which is undermined under the galea. RESULTS: This technique has allowed an easy primary closure of all these defects. No complications were reported. With a mean follow up of 36 months the aesthetic quality of these reconstructions was satisfying and there was no malposition of the lower lid. CONCLUSION: This is a good technique for the simple coverage of medium-sized suborbital skin defects.

A systematic multiple stage surgical approach for attainment of satisfactory and favourable surgical results in an extremely severe von Recklinghausen's disease, elephantiasis neurofibromatosa.

This disease was first described by von Recklinghausen and Festscher and has been known as the von Recklinghausen's disease or neurofibromatosis (NF). Numerous articles have been published on this subject where majority of the authors have stressed their difficulty in achieving favourable surgical results. This disease is pathologically accepted to be of neuroectodermal origin with a positive family history in approximately 50% of the cases, autosomal dominant trait and is known to involve the periorbital regions, orbit (preoperative CT scan: upper left and right photographs), temporal region to a variable extent, mid-facial region to the mandibular region. The indicated treatment for this disease is surgery including cranio-maxillofacial surgery even though re-evaluation of the conventional methods of surgery should be considered. This particular case is an extremely difficult and challenging case for any reconstructive plastic surgeon and required extensive preoperative planning. The systematic multiple stage surgical approach for an extremely severe von Recklinghausen's disease, elephantiasis neurofibromatosa is presented and discussed in detail.

Metastatic Merkel cell tumor to the prostate and bladder.

Merkel cell carcinoma is an uncommon cutaneous neoplasm of neuroendocrine origin. We report the case of a 71-year-old man with Merkel cell carcinoma metastases to the prostate and bladder presenting with lower urinary tract obstruction. Efforts should be made to optimize the patient's quality of life with the finding of metastatic Merkel cell carcinoma to the bladder or prostate until better adjuvant therapies are identified.

Consequences of using escharotic agents as primary treatment for nonmelanoma skin cancer.

BACKGROUND: The use of escharotic or caustic pastes to treat skin cancer is based on the centuries-old observation that selected minerals and plant extracts may be used to destroy certain skin lesions. Zinc chloride and Sanguinaria canadensis (bloodroot) are 2 agents that are used as part of the Mohs chemosurgery fixed-tissue technique. The use of escharotics without surgery has been discredited by allopathic medicine but persists and is promoted among alternative practitioners. Patients may now purchase "herbal supplements" for the primary self-treatment of skin cancer, and physicians will see patients who elect this therapy for their skin cancers. OBSERVATIONS: We reviewed the history of escharotic use for skin disease and performed an Internet search for the availability and current use of escharotics. Our search located numerous agents for purchase via the Internet that are advertised as highly successful treatments for skin cancer. We report 4 cases from our practice in which escharotic agents were used by patients to treat basal cell carcinomas in lieu of the recommended conventional treatment. One patient had a complete clinical response, but had a residual tumor on follow-up biopsy. A second patient successfully eradicated all tumors, but severe scarring ensued. A third patient disagreed with us regarding his care and was lost to follow-up. One patient presented with a nasal basal cell carcinoma that "healed" for several years following treatment elsewhere with an escharotic agent but recurred deeply and required an extensive resection. The lesion has since metastasized. CONCLUSIONS: Escharotic agents are available as herbal supplements and are being used by patients for the treatment of skin cancer. The efficacy of these agents is unproven and their content is unregulated. Serious consequences may result from their use. Conventional medicine has an excellent track record in treating skin cancer. Physicians should recommend against the use of escharotic agents for skin cancer, and the Food and Drug Administration should be given the authority to regulate their production and distribution.