The Cheek Interpolation Flap for Reconstruction of Auricular Mohs Defects.

BACKGROUND: Surgical reconstruction of auricular defects after Mohs surgery may prove challenging secondary to the complex topography of the ear and few options for local flap repair that do not introduce inordinate risk of anatomic distortion. The matched preauricular skin may be used to overcome these limitations. OBJECTIVE: This study aims to examine the utility, technique, and outcomes of preauricular interpolated flaps used for auricular reconstruction. To the authors' knowledge, this study represents the only published series of cheek interpolation flaps for auricular reconstruction. METHODS: A retrospective review of interpolated cheek flaps used for auricular reconstruction performed by one surgeon (J.C., 2000-2018) after tumor removal by Mohs micrographic surgery (MMS) at a single institution. RESULTS: Twenty cheek interpolation flaps were identified that were used to reconstruct defects after complete removal of skin cancer on the ear. No major complications were observed. CONCLUSION: Interpolated flaps are a useful reconstructive technique for auricular defects after MMS. Using the hairless isthmus of the preauricular cheek as the donor site for a 2-stage interpolated flap is a means of repairing the auricle when other options are not ideal.

The superiorly based bilobed flap for nasal reconstruction.

BACKGROUND: The laterally based bilobed flap is commonly used for the reconstruction of small- to medium-sized defects of the distal portion of the nose; However, when this flap is used to repair defects that are larger, more cephalic, or more lateral on the nose, there is a risk for lower nasal distortion. Reorienting the base superiorly preserves the advantages of the traditional design while minimizing this risk. OBJECTIVE: To demonstrate the design, execution, and efficacy of the superiorly based bilobed flap. METHODS: A retrospective review examined all superiorly based bilobed flaps performed by 1 surgeon (J.C.) in 2000-2016 after tumor extirpation by Mohs micrographic surgery at a single institution. RESULTS: A total of 41 surgical defects were closed with 40 flaps between June 2000 and August 2016 (1 patient had 2 defects closed with a single flap). Of the tumors, 55% were located on the nasal dorsum, and the median of the longest postoperative tumor axis was 1.4 cm. Follow-up was available for 40 flaps, and no infections, hematomas, or episodes of full-thickness necrosis were observed. LIMITATIONS: Data were collected retrospectively from a single institution without a standardized assessment tool for aesthetic outcomes. CONCLUSION: The superiorly based bilobed flap is useful for nasal reconstruction.

Applications of Burow's Grafts in the Reconstruction of Mohs Micrographic Surgery Defects.

BACKGROUND: Surgical defects in anatomically challenging locations, such as near free margins or crossing cosmetic subunits, may present reconstructive challenges to the dermatologic surgeon. For selected defects, Burow's grafts may produce functional and aesthetic results in a single operative session. OBJECTIVE: To describe the applications of the Burow's graft technique for the repair of defects after Mohs micrographic surgery. METHODS: An institutional review board-approved retrospective database review of surgical defects repaired with Burow's grafting after Mohs micrographic surgery at the Medical University of South Carolina was performed. The general technique of Burow's grafting is described, emphasizing proper graft sizing and direction of tension vectors. Varying anatomic locations and defect types are presented, with site-specific considerations and operative photographs. RESULTS: Burow's grafting provides ideal color and textural match, preserves subunit boundaries, results in a compact single-site wound, and may avoid complications of alternate repair choices. The tension vectors produced in closing the graft's harvest site may be designed to prevent distortion of free margins. Burow's grafting may be combined with hinge flaps to repair deep or avascular defects. CONCLUSION: Burow's grafts are reproducible, aesthetic, and useful reconstructive choices for a variety of surgical wounds.

The utility of full-thickness skin grafts (FTSGs) for auricular reconstruction.

BACKGROUND: Full-thickness skin grafts (FTSGs) are a common repair option on the external ear, but there are few large case series examining graft sublocations, dimensions, and outcomes. OBJECTIVE: We sought to report our experience with FTSGs for repair of postsurgical defects of the external ear. METHODS: We conducted a retrospective review of all FTSGs on the ear performed by 2 surgeons (J. C., 2000-2014; B. C. L., 2007-2014) after clearance by Mohs micrographic surgery at a single institution. RESULTS: A total of 1519 FTSGs on the ear were performed between June 2000 and March 2014. The most common sublocations were the superior helix (38.8%), the crura of the antihelix or scapha (18.9%), and the back of ear/back of helix (15.4%). The overall complication rate was 1.6%, and the most common complication was graft failure (1.2%). LIMITATIONS: Data were collected retrospectively from a single institution. Follow-up beyond 3 months was limited. A standardized assessment tool for aesthetic outcomes was not performed. CONCLUSION: By taking advantage of predictable "pincushioning" and combining with local flaps or cartilage grafts, FTSGs can provide more volumetric replacement than previously described. They reliably preserve the height and complex topography of the ear with a low complication rate.

The Bilateral Dufourmentel Flap for Repair of Nasal Dorsum Defects After Mohs Micrographic Surgery.

BACKGROUND: Single-stage repairs of large nasal dorsum defects risk introducing lower nasal distortion. OBJECTIVE: To describe the authors experience with the "birhombic" flap, a bilateral Dufourmentel rhomboid flap, for repair of nasal surgical defects after Mohs micrographic surgery. MATERIALS AND METHODS: The authors performed a retrospective chart review of patients who underwent birhombic flap repair of the nose by a single physician after Mohs micrographic surgery from 2008 to 2013 at the Medical University of South Carolina. RESULTS: Thirty-eight patients were identified on whom the birhombic flap repair was performed on the nasal dorsum over a 6-year period. There were no significant complications. Alar position remained neutral and nasal profile remained unaltered in all cases. Postoperatively, pulsed dye laser was performed in 8 patients (21%) and dermabrasion in 11 patients (29%). All patients achieved very good or excellent final aesthetic results. CONCLUSION: The birhombic flap is a reproducible, one-stage flap for small to large defects of the nasal dorsum that consistently produces topographic restoration with minimal risk of aesthetic or functional complication. The use of 2 opposing flaps redistributes the secondary defect, thus minimizing the potential for lower nasal distortion when closing the flaps' donor sites.

The Slowly Enlarging Ventriculus Terminalis.

BACKGROUND: A cerebral spinal fluid (CSF) cavity within the conus medullaris has been described by the term ventriculus terminalis (VT) or the fifth ventricle. The finding of a VT on MRI imaging of the lumbar spine is often incidental but may be found in patients with low back pain or neuromuscular deficits. These lesions, when identified, are thought to regress or remain stable in terms of size, although some have been described to enlarge in the presence of post-traumatic meningeal hemorrhages or deformities of the vertebral canal. CASE REPORT: We describe a case of a slowly growing VT in a patient with progressing lower limb weakness without any history or imaging findings of trauma or spinal canal abnormalities. CONCLUSIONS: We present an intriguing case of a slowly growing VT in a woman with progressive neurological symptoms. Surgical fenestration provided complete symptomatic relief and follow-up imaging two years after surgery demonstrated no evidence of recurrence. This, to our knowledge, is the first described case of a slowly enlarging VT independent of any other imaging findings.

Do children without a known bleeding tendency undergoing PICC placement require coagulation laboratory testing?

BACKGROUND: Obtaining basic hemostatic laboratory investigations prior to peripherally inserted central catheter (PICC) insertion remains controversial, even if the procedure is converted to a tunneled central venous line (CVL) placement. OBJECTIVE: To determine the value of pre-procedural blood screening (hemoglobin level, platelet count, aPTT/INR) in hospitalized children without a known bleeding diathesis. MATERIALS AND METHODS: This retrospective review included pediatric patients undergoing PICC insertion who had both laboratory screening and post-PICC hemoglobin level. Two cohorts (A: 0-3 months; B: >3 months-18 years) were analyzed for procedural major/minor bleeding. RESULTS: Of 1,441 consecutive children identified during a 3-year period, 832 patients (226 in cohort A, 606 in cohort B) fulfilled the inclusion criteria. Overall, 36% (300/832) of the patients had at least one abnormal laboratory result. Only 0.2% (3/1,441) of patients required conversion to a central venous line. In cohort A no major bleeding occurred; the minor bleeding frequency was 30% (68/226). Neither abnormal laboratory results nor correction of abnormal laboratory results was associated with minor bleeding complications. The positive and negative predictive values (PPV/NPV) of having abnormal laboratory screening were 0.22 and 0.68, respectively. In cohort B the major bleeding frequency was 1% (6/606) but no patient required any blood transfusion; minor bleeding occurred in 29% (174/606). Neither abnormal laboratory results nor correction of abnormal laboratory results was associated with minor bleeding complications. The PPV and NPV of abnormal laboratory screening results were 0.24 and 0.72, respectively. CONCLUSION: Pre-procedural blood screening did not predict bleeding in hospitalized children without a known bleeding diathesis undergoing PICC insertion. The rarity of major bleeding complications and need for conversion to a central venous line did not support a need for laboratory screening.

Immunohistochemical application of a highly sensitive and specific murine monoclonal antibody recognising the extracellular domain of the human hepatocyte growth factor receptor (MET).

AIMS: Development of novel targeted therapies directed against hepatocyte growth factor (HGF) or its receptor (MET) necessitates the availability of quality diagnostics to facilitate their safe and effective use. Limitations of some commercially available anti-MET antibodies have prompted development of the highly sensitive and specific clone A2H2-3. Here we report its analytical properties when applied by an automated immunohistochemistry method. METHODS AND RESULTS: Excellent antibody specificity was demonstrated by immunoblot, ELISA, and IHC evaluation of characterised cell lines including NIH3T3 overexpressing the related kinase MST1R (RON). Sensitivity was confirmed by measurements of MET in cell lines or characterised tissues. IHC correlated well with FISH and quantitative RT-PCR assessments of MET (P < 0.001). Good total agreement (89%) was observed with the anti-MET antibody clone SP44 using whole-tissue sections, but poor positive agreement (21-47%) was seen in tissue microarray cores. Multiple lots displayed appropriate reproducibility (R(2)  > 0.9). Prevalence of MET positivity by IHC was higher in non-squamous cell NSCLC, MET or EGFR amplified cases, and in tumours harbouring abnormalities in EGFR exon 19 or 21. CONCLUSIONS: The anti-MET antibody clone A2H2-3 displays excellent specificity and sensitivity. These properties make it suitable for clinical trial investigations and development as a potential companion diagnostic.

Skin cancer in organ transplant recipients: more than the immune system.

Organ transplant recipients (OTRs) are at increased risk of developing nonmelanoma skin cancers. This has long been thought to be caused by immunosuppression and viral infection. However, skin cancer risk among individuals with AIDS or iatrogenic immunodeficiency does not approach the levels seen in OTRs, suggesting other factors play a critical role in oncogenesis. In clinical trials of OTRs, switching from calcineurin inhibitors to mammalian target of rapamycin inhibitors consistently led to a significant reduction in the risk of developing new skin cancers. New evidence suggests calcineurin inhibitors interfere with p53 signaling and nucleotide excision repair. These two pathways are associated with nonmelanoma skin cancer, and squamous cell carcinoma in particular. This finding may help explain the predominance of squamous cell carcinoma over basal cell carcinoma in this population. Mammalian target of rapamycin inhibitors do not appear to impact these pathways. Immunosuppression, viral infection, and impaired DNA repair and p53 signaling all interact in OTRs to create a phenotype of extreme risk for nonmelanoma skin cancer.

Single-stage interpolation flaps in facial reconstruction.

BACKGROUND: Relatively deep and complex surgical defects, particularly when adjacent to or involving free margins, present significant reconstructive challenges. When the use of local flaps is precluded by native anatomic restrictions, interpolation flaps may be modified to address these difficult wounds in a single operative session. OBJECTIVE: To provide a framework to approach difficult soft tissue defects arising near or involving free margins and to demonstrate appropriate design and execution of single-stage interpolation flaps for reconstruction of these wounds. METHODS: Examination of our utilization of these flaps based on an anatomic region and surgical approach. RESULTS: A region-based demonstration of flap conceptualization, design, and execution is provided. CONCLUSION: Tunneled, transposed, and deepithelialized variations of single-stage interpolation flaps provide versatile options for reconstruction of a variety of defects encroaching on or involving free margins. The inherently robust vascularity of these flaps supports importation of necessary tissue bulk while allowing aggressive contouring to restore an intricate native topography. Critical flap design allows access to distant tissue reservoirs and placement of favorable incision lines while preserving the inherent advantages of a single operative procedure.

Safety of staged interpolation flaps after Mohs micrographic surgery in an outpatient setting: a single-center experience.

OBJECTIVE: To establish the safety of staged interpolation flaps performed in an outpatient dermatologic clinic setting. METHODS: A retrospective chart review was performed of patients who underwent staged interpolation flap reconstruction by a single dermatologic surgeon after tumor clearance using Mohs micrographic surgery from 2000 to 2012 at the Department of Dermatology, Medical University of South Carolina. RESULTS: Six hundred fifty-three staged flaps were performed in 639 patients (mean age 65) between June 2000 and November 2012. Types of flaps included paramedian forehead flaps (n = 291, 45%), two-stage melolabial flaps (n = 256, 39%), retroauricular flaps (n = 58, 9%), interpolated paranasal flaps (n = 40, 6%), and Abbe or Abbe-Estlander flaps (n = 8, 1%). No major complications were observed. Of the minor complications, problems related to bleeding were the most prevalent; active bleeding requiring physician intervention was seen in 8.4% and hematoma formation in 0.4% of flaps. Postoperative infections were seen in 1.7% of patients after the initial surgery and 3.4% after division of the pedicle. Primary or secondary dehiscence was seen in 0.5%. Partial full-thickness flap necrosis was seen in 2.3% and total flap necrosis in 0.6%. CONCLUSION: The rate of complications associated with dermatologic surgeons performing interpolated flaps in an outpatient setting under local anesthesia is low. Our complication rates are equal to or lower than published complication rates from other surgical specialties.

Facing the block and false positives in Mohs surgery: a retrospective study of 2,198 cases.

BACKGROUND: "Facing the block" is defined as trimming tissue on a microtome from peripheral or deep surgical margins before sectioning. Facing includes trimming performed intentionally but unnecessarily, accidentally, or out of necessity because of one's choice of embedding and freezing method. OBJECTIVE: To assess whether facing the block is associated with a greater number of stages to clear tumor and, by inference, a significant false positive rate. MATERIALS AND METHODS: A retrospective analysis was performed comparing the average number of stages per Mohs case at two surgical facilities with the same physician over a 1-year period. Site A histotechnologists intentionally face the block, whereas site B histotechnologists do not. Tissue thickness lost during trimming at each site was recorded for 4 weeks. RESULTS: Comparing Sites A and B, stages per case were 1.92 and 1.53, respectively (p < .01) and trimming depths before the first section were 325 and 187 µm (p < .01). CONCLUSION: Facing the block is associated with 0.39 more stages per case and, by inference, a false-positive rate of approximately 39%. Mohs surgeons should evaluate the methods of tissue preparation that their histotechnologists use. Facing the block should not be performed.

The safety of Mohs surgery: a prospective multicenter cohort study.

BACKGROUND: Complications associated with Mohs surgery have been evaluated by single-surgeon studies. While these studies provide evidence for the safety of the procedure, prospective, multicenter studies afford a higher level of clinical evidence and establish further the safety profile of Mohs surgery in the ambulatory setting. OBJECTIVE: This study was designed to prospectively evaluate major and minor complications as well as postoperative pain associated with Mohs surgery. METHODS: A multicenter prospective cohort study was conducted evaluating the rate of major and minor complications as well as postoperative pain associated with the treatment of skin cancer using Mohs surgery in 1550 patients with 1792 tumors. Follow-up was obtained in 1709 of the 1792 tumors treated (95.3%). RESULTS: No major complications occurred during Mohs surgery or reconstruction. A total of 44 (2.6%) minor primary postoperative complications occurred during the study. On a scale from 0 to 10, the average peak postoperative pain level was 1.99. LIMITATIONS: Limitations of the study include the variability of practice patterns across practice sites as well as the 4.7% of patients lost to follow-up. CONCLUSION: Mohs surgery is performed with a high degree of safety and is well tolerated by patients.

The spiral flap for nasal alar reconstruction: our experience with 63 patients.

OBJECTIVE: To describe our patient selection, design, execution, and results with the spiral flap for distal nasal surgical defects after Mohs micrographic surgery. MATERIALS AND METHODS: We performed a retrospective analysis of all spiral flaps performed over a 5-year period. Sixty-three patients were identified, and charts and photographs were examined. Surgical defects were classified according to alar location. All follow-up encounters were reviewed to assess for complications and need for revisionary procedures. Intraoperative photographs were taken of representative cases to describe the surgical technique. RESULTS: Sixty-three patients on whom the spiral flap was performed were identified over a 5-year period. The flap was used to successfully reconstruct alar defects ranging in size from 5 to 15 mm in diameter. No persistent complications were noted. CONCLUSION: The spiral flap is a reproducible, one-stage flap for small to medium-sized defects of the nasal ala and alar groove that consistently produces topographic restoration with minimal risk of aesthetic or functional complication.

Antihelical cartilage grafts for reconstruction of mohs micrographic surgery defects.

OBJECTIVE: To illustrate the safety, efficacy, and versatility of the antihelix as the preferred donor site for auricular cartilage autografts in the reconstruction of nasal and auricular Mohs micrographic surgery defects. MATERIALS AND METHODS: Retrospective chart review of all cartilage autografts performed at the Medical University of South Carolina for the 5-year period July 1, 2006, to June 30, 2011; 307 auricular cartilage autografts were performed in 297 patients. Each case was reviewed for demographic data, graft donor site, repair type, complications, and revisions. RESULTS: Three hundred five of the grafts (99.3%) were harvested from the antihelix and the remaining two (0.7%) from the conchal bowl. The donor site complication rate was 3%. No patients experienced cosmetic or functional deformity of the donor ear. No patients experienced cartilage graft resorption or infection. CONCLUSION: Antihelical cartilage grafts can serve as safe, effective, and versatile alternatives to septal, conchal bowl, and costal margin grafts. The authors feel strongly that the antihelix donor site should be favored when harvesting auricular cartilage for its easy accessibility, large dimension that may be harvested without aesthetic penalty, character of graft, and minimal operative morbidity.