Reconstruction of perioral defects post-Mohs micrographic surgery: a dermatological surgeon's approach.

BACKGROUND: The perioral location has great functional, aesthetic and social importance. Over 100 procedures have been described for lip reconstruction, emphasizing the challenges that reconstructive surgeons face when dealing with such defects. OBJECTIVES: To outline the surgical reconstruction techniques of perioral defects post-Mohs micrographic surgery (MMS). METHODS: The design and surgical techniques of reconstruction of perioral defects post-MMS are described. RESULTS: The results of the surgical techniques described are illustrated. CONCLUSIONS: Herein, we describe the nuances of reconstructive techniques that we have found useful for repairing perioral defects post-MMS.

The contralateral subgaleal sliding flap for the single-stage reconstruction of large defects of the temple and lateral forehead.

BACKGROUND: Due to the relative lack of a mobile tissue reservoir, the flap repair of large defects of the temple and lateral forehead is challenging. OBJECTIVE: To present our experience of the contralateral subgaleal sliding (CLASS) flap for the single-stage aesthetic repair of such defects. METHODS: Data were collated on all patients at one regional Mohs centre in whom the CLASS flap had been performed since 2011. RESULTS: The CLASS flap was performed on 16 patients (11 male, five female) with an average age of 63 years (range 42-90). The average defect size was 2·8 × 3·1 cm. A single case of postoperative infection occurred, which settled with appropriate therapy with no adverse sequelae. All patients rated their outcome as good or excellent. CONCLUSION: The CLASS flap is a reliable, aesthetic, single-stage reconstructive technique for large defects of the lateral forehead and temple.

The role of diffusion-weighted MRI in the accurate diagnosis of vertebral compression fractures: A comparative study.

INTRODUCTION: Accurately distinguishing between benign and malignant vertebral compression fractures is crucial for clinical management. This study evaluated the predictive accuracy of diffusion-weighted imaging (DWI) in differentiating the cause of vertebral fractures using MRI. METHODS: A longitudinal cross-over study was conducted at Jinnah Postgraduate Medical Centre (JPMC) Karachi from July 2018 to January 2021. Patients with vertebral compression fractures underwent T1-weighted, T2-weighted, and DWI imaging with ADC mapping on a 1.5 T MRI scanner. Imaging findings were compared with histopathologic results and clinical follow-up. Sensitivity, specificity, and ROC curve analyses were performed. RESULTS: The study enrolled 303 patients with a mean age of 43.6 ± 10.9 years, of whom 118 were male. DWI demonstrated high accuracy in predicting the cause of vertebral compression fractures, with a sensitivity of 96.2 %, a specificity of 76.2 %, and an area under the ROC curve of 0.857. The optimal ADC cut-off value was 0.82 × 10˄-3 mm˄2/s, which yielded a positive predictive value of 79.7 % and a negative predictive value of 95.4 %. CONCLUSIONS: DWI is a safe and non-invasive imaging modality with excellent predictive accuracy in differentiating between benign and malignant vertebral compression fractures. Iso- or hypointensity of collapsed vertebral bodies on DWI suggests a benign lesion, while T2-weighted hyperintensity is highly indicative of malignancy. Low signal on ADC is also highly indicative of malignant vertebral fractures. Incorporating DWI improves accuracy in assessing vertebral lesions, especially when standard sequences are inconclusive. IMPLICATIONS FOR PRACTICE: DWI revolutionizes vertebral compression fracture diagnosis, distinguishing between benign and malignant cases. This precision guides treatment decisions, minimizing the necessity for invasive procedures like biopsy. As a safe and reliable imaging method, DWI elevates patient care, ensuring accurate diagnostics and improved outcomes.

The Mohs histotechnician: a review of training and practice within 29 centres in the UK.

BACKGROUND: Although various assessments pertaining to the surgical aspect of Mohs micrographic surgery (MMS) have been performed, the pivotal role played by the MMS histotechnician (MH) has not previously been addressed in the UK. AIM: To undertake a review of the training and practice of MHs in all centres performing MMS within the National Health Service (NHS) in the UK. METHODS: NHS dermatology departments performing MMS in the UK were identified and contacted by telephone between November 2011 and January 2012. MMS practice data pertaining to the role of the MH in tissue processing was collected by speaking directly to a histotechnician in each department. RESULTS: In total, 29 centres were identified. The number of MHs at each centre varied from 1 to 13 (median 3). All MHs had undergraduate degrees in biomedical science. Most (85%) MHs worked full-time under the directorate of their local pathology department. In 19 centres (66%), the Mohs surgeon reviewed the slides, and in the remaining 10 centres (34%), a consultant histopathologist reviewed the slides, either alone or in partnership with the Mohs surgeon. There was significant variation in tissue handling and processing techniques across the centres. All centres used MMS to treat primarily high-risk basal cell carcinomas, with over half (55%) also treating squamous cell carcinomas. MHs from all centres had learned about the specifics of MMS tissue processing 'on the job', with a minority having received formal training by attending a larger MMS centre or an MMS course. CONCLUSIONS: Significant variation in MMS tissue-processing techniques exists across the UK. A standard of practice should perhaps be considered, as this has risk-management, quality-control and possible medicolegal implications.

Frontalis-based island pedicle flaps for the single-stage repair of large defects of the forehead and frontal scalp.

BACKGROUND: Medium- to large-sized surgical defects of the forehead and frontal scalp provide a challenge for the reconstructive surgeon. OBJECTIVES: To highlight the utility of a frontalis-based island pedicle flap (FIPF) for the single-stage, aesthetic reconstruction of such defects. METHODS: The design and detailed surgical technique required for a FIPF are described. RESULTS: The long-term results are illustrated. CONCLUSIONS: FIPFs, despite significant tissue dissection, are readily performed under local anaesthesia and are well tolerated by patients. The FIPF adds to the dermatological surgeon's armamentarium in the reconstruction of large defects of the central forehead and frontal scalp.

Patient satisfaction with post-operative telephone calls after Mohs micrographic surgery: a New Zealand and U.K. experience.

BACKGROUND: Mohs micrographic surgery (MMS) is regarded as the gold standard for treating nonmelanoma skin cancers of the head and neck. Surgical interventions can generate anxiety for patients and efforts to minimize this may enhance their experience. OBJECTIVES: To assess the perceived patient benefits of post-operative telephone follow-up (TFU) calls after MMS. METHODS: A prospective, controlled, questionnaire-based assessment of patient satisfaction with TFU calls in patients undergoing MMS was conducted in two centres (New Zealand and U.K.) over a 4-month period from June to September 2011. All individuals in the study group were telephoned on the evening of their surgery by the operating surgeon. Questionnaires were completed by all patients at the time of suture removal. RESULTS: The median Likert score on a 10-point scale relating to patients' perception of the TFU service was higher in the study group compared with the control group (10 vs. 9), with no correlation to closure type of the surgical defect. Overall patient satisfaction with the TFU service was high (94% New Zealand; 96% U.K.), and this was independent of the patient's place of residence. There was no age or sex difference in the minority who did not find the TFU call helpful. The majority of patients felt the best time to call was the night of the surgery (89% New Zealand; 94% U.K.). All patients who had undergone MMS previously found the TFU call just as useful as the first time. The majority of patients (94% New Zealand; 96% U.K.) did not need to call the doctor post-surgery, although 7% of patients in the control group rang the surgeon with issues that could have been readily dealt with by the TFU service. Comparatively, more patients from the U.K. felt their satisfaction would have been the same with a nurse-led TFU call service compared with New Zealand (94% vs. 66%). A significant proportion of those who preferred to be called by the doctor underwent cutaneous flap closures. Patients felt that other specialities that perform surgical procedures under local anaesthetic should adopt a TFU service post-surgery. CONCLUSIONS: TFU calls post-MMS are a cost-effective, time-efficient way of achieving high levels of patient satisfaction.

Surgical intervention of nonvertebral osseous metastasis.

BACKGROUND: Nonvertebral osseous metastases can result in pain and disability. The goals of surgical intervention are to reduce pain and to improve function if nonsurgical treatment fails. The indications for proceeding with surgical intervention depend on anatomic location, amount of local destruction, extent of skeletal and visceral disease and, most important, the patient's performance status and life expectancy. METHODS: This article reviews the evaluation and treatment of metastatic nonvertebral osseous lesions from the perspective of the orthopedic surgeon, based mainly on an assessment of the surgical literature. RESULTS: This article summarizes the approaches to preoperative evaluation, patient selection, and medical optimization. Guidelines for estimating osseous stability and fracture risk are discussed, and surgical implants and their relation to postoperative outcomes are examined. This review also describes less invasive ablative procedures currently available. CONCLUSIONS: The surgical management of nonvertebral osseous metastases involves multidisciplinary collaboration. The surgical construct must be a stable, reliable, and durable intervention that is individually tailored and matched to a patient's prognosis and performance status.

Regional nerve blockade prior to direct injection to achieve anaesthesia of the nasal ala.

BACKGROUND: Dermatological surgical procedures involving the nasal alae are commonplace in clinical practice. Direct infiltration of local anaesthetic into the nasal ala is extremely uncomfortable. OBJECTIVES: In this prospective clinical study, we investigate the effectiveness of alar anaesthesia provided by an infraorbital nerve block (IOB). METHODS: We recruited 100 consecutive patients requiring dermatological surgical procedures involving the nasal ala (or other sites necessitating an IOB). Following topical mucosal anaesthesia, an IOB was administered via the intraoral route. Effectiveness of anaesthesia was assessed after 10 min by testing the perception of a sharp stimulus at five standardized reference points on the nasal ala. If the ala was not completely anaesthetized, blockade of the external nasal branch of the anterior ethmoidal nerve (external nerve block, ENB) was performed. Sensation of the nasal ala was re-assessed after 10 min using the above method. RESULTS: Complete anaesthesia of the nasal ala was achieved with an IOB in 66 of 100 (66%) patients. Of the remaining 34 patients, the addition of an ENB achieved complete anaesthesia in 15 (44%). CONCLUSIONS: An IOB provides effective alar anaesthesia in the majority of patients. In those where it is ineffective for complete anaesthesia, an ENB is a useful adjunct. We recommend using an IOB (and ENB if required) prior to direct infiltration of local anaesthetic into the nasal ala to reduce patient discomfort.

Simplified surgical treatment of chondrodermatitis nodularis by cartilage trimming and sutureless skin closure.

BACKGROUND: Chondrodermatitis nodularis (CN) is a common painful ear condition, most commonly seen at the apex of the helix. Many different treatment methods for it have been advocated but excision of cartilage alone has been shown to be therapeutically and cosmetically effective. OBJECTIVES: To describe and present our experience of a simplified and minimally invasive method of cartilage trimming for CN with sutureless skin closure. METHODS: A retrospective review of all cases of CN seen in our department treated by this technique. RESULTS: Of 34 patients treated over 12 years, 19 were men (mean age 61 years; range 47-83) and 15 were women (mean age 65 years; range 48-92). Right (n = 18) and left (n = 17) ears were almost equally represented. One patient required treatment for both ears. The antihelix was involved in seven cases; the remainder involved the helix. All patients were reviewed at 4 months. An excellent response with no discomfort or clinical recurrence of CN was observed in 32 (94%). CONCLUSIONS: Our simplified technique of cartilage trimming and sutureless skin closure is a rapidly performed, minimally invasive and highly effective method of treating CN.