Expertise in Head and Neck Cutaneous Reconstructive Surgery.

BACKGROUND: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature. OBJECTIVE: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature. METHODS: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors. RESULTS: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%). CONCLUSION: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

Functionality of Patients 75 Years and Older Undergoing Mohs Micrographic Surgery: A Multicenter Study.

BACKGROUND: Mohs surgery is indisputably a highly effective treatment for nonmelanoma skin cancers. In the current health care environment, physicians are challenged to provide high quality, efficacious care in a manner that is mindful of the patient's general health and well-being. We have used a functional assessment to evaluate older patients who present for Mohs surgery. OBJECTIVE: The purpose of this study is to categorize the functional status, using the Karnofsky Performance Status (KPS) Scale, of patients 75 years and older undergoing Mohs surgery of a nonmelanoma skin cancer and to identify distinguishing characteristics of lower functioning patients. METHODS: Patients 75 years and older undergoing Mohs surgery for nonmelanoma skin cancer at 8 separate geographically diverse sites were included. Patient and tumor characteristics were recorded. Physicians scored subjects on the KPS scale and administered a questionnaire to categorize the symptoms and impact of their skin cancer. RESULTS: A total of 291 subjects completed the study. The average KPS score was 90.1. 93.1% of our subjects had a KPS score of ≥70. Subjects with a KPS score <70 were more likely to be older with larger symptomatic tumors. CONCLUSION: The vast majority of patients 75 years and older undergoing Mohs surgery are highly functioning. Lower functioning patients are older with larger symptomatic tumors that negatively impact their lives.

Versatility of the O-Z Flap in the Reconstruction of Facial Defects.

BACKGROUND: The O-Z flap has traditionally been used for surgical defects adjacent to critical anatomic structures requiring a repair option that minimizes distortion and functional impairment. However, another advantage of the O-Z flap is that it is tissue conservative, particularly in comparison to primary closure. In fact, the design simply takes the Burow's triangles that would be discarded and rotates them inward. OBJECTIVE: The purpose of this work is to detail the type of post-Mohs defects, which might benefit from consideration of the O-Z flap with emphasis on tissue conservation and restoration of contour to the surgical site. Furthermore, the authors wish to describe unique considerations in each location and methods to appropriately plan the O-Z flap in each circumstance. METHODS AND MATERIALS: The authors reviewed all flaps classified as O-Z in their tumor registry. The approximate size of the defect reconstructed, complications, and long-term outcomes were recorded. RESULTS: O-Z flap implementation is described in detail for repair of defects located at the lateral nasal tip, nose-cheek junction, medial canthus, and mid-cheek. CONCLUSION: The O-Z flap can be effectively used to repair defects located at the lateral nasal tip, nose-cheek junction, medial canthus, and mid-cheek. It is a mechanically simple flap with predictable tension vectors, which can be specifically oriented to protect the free margin.

Suture Products and Techniques: What to Use, Where, and Why.

BACKGROUND: There are an increasing number of wound closure materials and suturing techniques described in the dermatologic and surgery literature. A dermatologic surgeon's familiarity with these materials and techniques is important to supplement his or her already established practices and improve surgical outcomes. OBJECTIVE: To perform a thorough literature review of wound closure materials (sutures, tissue adhesives, surgical tape, and staples) and suturing techniques and to outline how and when to use them. MATERIALS AND METHODS: A literature review was conducted using PubMed and other online search engines. Keywords searched included suture, tissue adhesive, tissue glue, surgical tape, staples, dermatologic suturing, and suturing techniques. RESULTS: Numerous articles outline the utility of various sutures, surgical adhesives, surgical tape, and staples in dermatologic surgery. In addition, there are various articles describing classic and novel suturing techniques along with their specific uses in cutaneous surgery. CONCLUSION: Numerous factors must be considered when choosing a wound closure material and suturing technique. These include wound tension, desire for wound edge eversion/inversion, desired hemostasis, repair type, patient's ability to care for the wound and return for suture removal, skin integrity, and wound location. Careful consideration of these factors and proper execution of suturing techniques can lead to excellent cosmetic results.

Interstitial granulomatous drug reaction to anakinra.

Interstitial granulomatous drug reactions are an uncommon entity presenting as asymptomatic, annular, erythematous to violaceous plaques. The incidence of such reactions has been increasing with the use of biologic agents. We report, to the best of our knowledge, the first such reaction to the interleukin (IL)-1 inhibitor anakinra. Our patient presented with pink dermal plaques and nodules in the periaxillary region which resolved with discontinuation of anakinra and recurred upon restarting anakinra. Biopsy revealed a diffuse dermal infiltrate of lymphocytes and histiocytes with interspersed neutrophils and eosinophils. Fragmentation and degeneration of collagen and elastic fibers was also present. Withdrawal of anakinra led to complete resolution of the lesions. Interstitial granulomatous drug reactions are increasing in frequency and we add anakinra to the list of causative agents.