The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases.

BACKGROUND: Skin tumors commonly occur on the legs and are treated in first line by surgery. Several techniques are available to repair lower limb defects: secondary-intention healing, partial closure, primary closure with or without an s-plasty, or a skin graft. The lack of tissue laxity of the surrounding skin does not allow several local flaps (advancement, rotation, or transposition). Closing large skin defects at this site may be challenging. PATIENTS AND METHODS: We retrospectively reviewed a series of consecutive patients undergoing malignant tumor wide excision on lower limbs, with a keystone flap or its simplified technique (releasing incision) for closure of a skin defect. RESULTS: Twenty-five patients, 17 women and 8 men, ranging from 19 to 95 years old (mean age: 70 years) were included. Keystone flap reconstruction on the lower limbs was performed in 19 cases and the simplified technique in 6. The excised tumors were as follows: squamous cell carcinoma (n=6), basal cell carcinoma (n=9), melanoma (n=9) and Bowen's disease (n=1). Three local complications were observed. No cases of recurrence were observed. CONCLUSION: Keystone flap is a reliable surgical method for reconstruction of lower limb skin defects. Aesthetic results are better than when a skin graft is used, complications are uncommon, and prolonged operative time is avoided.

[Haemorrhagic complications following ibrutinib intake after dermatological surgery]. / Complication hémorragique secondaire à la prise d'ibrutinib après chirurgie dermatologique.

INTRODUCTION: Ibrutinib is a selective oral inhibitor of Bruton's tyrosine kinase. It is used in haematology to treat lymphoid B disorders. Haemorrhagic complications in dermatological surgery are occasionally associated with the use of anti-platelet and/or anticoagulant medication. Herein, we report a case of haemorrhage under ibrutinib following skin surgery. PATIENTS AND METHODS: A 70-year-old male patient began treatment with ibrutinib for chronic lymphocytic leukaemia had 2 basal cell carcinomas of the face. The next day he had a persistent haemorrhage lasting more than 48h, with no effects on the final scarring result. DISCUSSION: Ibrutinib is a tyrosine kinase inhibitor whose mechanism of action plays a role in platelet adhesion. It is known to cause haemorrhaging, either spontaneously or following invasive procedures, especially at the beginning of treatment. In the case of low-risk haemorrhagic procedures in which bleeding may be controlled by mechanical haemostasis, ibrutinib should be discontinued 3 days before and after surgery. In the event of recent initiation of ibrutinib and in the absence of urgent dermatological management, it is preferable to schedule any surgical procedures 3 months after the start of ibrutinib.

[Vemurafenib-induced radiation recall dermatitis]. / Dermite de rappel induite par le vémurafénib.

INTRODUCTION: Radiation recall dermatitis is an uncommon inflammatory reaction of the skin appearing after several days to several years at the site of previous irradiation; it is precipitated by the use of triggering drugs, although rarely by BRAF or MEK inhibitors. PATIENTS AND METHODS: We report an unusual case of recall dermatitis induced 3 months after initiation of vemurafenib and cobimetinib therapy. DISCUSSION: Radiation recall dermatitis is a cutaneous reaction that must be known and which in rare cases such as ours may occur a long time after the end of radiotherapy.

[Superficial temporal artery pseudoaneurysm: 2 cases]. / Pseudo-anévrisme de l'artère temporale superficielle : deux cas.

BACKGROUND: Pseudoaneurysm of the superficial temporal artery causes tumefaction in the temporal region. Herein, we report two cases. PATIENTS AND METHODS: Case 1 : a 32-year-old man presented with a slightly pulsatile nodular formation measuring 2 cm in the right temporal region that had appeared nine months after traumatic injury. A diagnosis of superficial temporal artery pseudoaneurysm was considered. Excision was performed with ligation of the afferent and efferent artery. The clinical diagnosis was confirmed by histopathology. Case 2 : a 24-year-old man presented with a nonpulsatile subcutaneous tumefaction on his left temple. Surgery was proposed based on a supposed epidermal cyst. However, the perioperative aspect suggested a lesion of arterial origin and excision was performed following ligation of the afferent and efferent artery. CONCLUSION: Pseudoaneurysm of the superficial temporal artery must be considered for all temporal cutaneous formations, particularly when there is a history of trauma. The clinical diagnosis may be confirmed by Doppler ultrasound. Surgery is the treatment of reference.

[Advancement cheek flap for nasal sidewall defects]. / Lambeau d'avancement-rotation jugal pour pertes de substance latéronasale et paranasale moyenne.

BACKGROUND: The nasal sidewall and adjacent cheek are frequent sites of cutaneous tumour. The aim of this study is to present an advancement-rotation cheek flap technique for nasal sidewall and paranasal cheek defects. PATIENTS AND METHODS: This is a retrospective, non-comparative study of patients undergoing a cheek advancement-rotation flap for nasal sidewall and paranasal cheek defects between September 2008 and October 2012. Sex, age, histological type of the excised lesion, method of anaesthesia, size of the defects, any occurrence of complications and results were compiled from the medical record. RESULTS: Eleven patients with a mean age of 66 years were included. For 10 patients, the tumour was a basal cell carcinoma and in one case was a squamous cell carcinoma. The defects were located in the nasal sidewall and paranasal cheek in four cases, the paranasal cheek/lower eyelid in five cases and in the nasal sidewall, anterior cheek and lower eyelid in two cases. All but one had surgery under a local anaesthetic. No patients presented post-surgical complications. One patient had a subcutaneous granuloma which subsequently subsided completely. The aesthetic result was good: two of the 11 patients had a marked nasolabial fold, one patient had a mild cutaneous deformity due to flap movement under eyelid. No recurrence of carcinoma was observed during follow-up of between 14 and 40 months. CONCLUSION: This flap should be considered for defects measuring under 3 cm on all or part of the nasal sidewall, paranasal cheek and lower eyelid fold.

[Multiple familial trichoepithelioma: a new CYLD gene mutation]. / Trichoépithéliomes multiples familiaux : nouvelle mutation du gène CYLD.

BACKGROUND: Multiple familial trichoepithelioma (MFT) is an autosomal dominant disease characterized by the development of numerous skin-coloured papules on the central area of the face. It is associated with various CYLD gene mutations that are also responsible for familial cylindromatosis and Brooke-Spiegler syndrome. PATIENTS AND METHODS: We report a novel mutation in the CYLD gene in a family with MFT and discuss new developments in therapeutic options. DISCUSSION: Recent studies indicate that CYLD is a tumour-suppressor gene.

[Use of a rhomboid flap to repair temporal and frontotemporal cutaneous defects: 11 cases]. / Réparation de pertes de substance temporales et frontotemporales par un lambeau de transposition de type rhomboïdal : 11 observations.

BACKGROUND: Temporal and frontotemporal skin defects can be repaired using various reconstruction procedures: temporojugal rotation-advancement flaps, frontotemporal advancement flaps, skin grafts, etc. We propose an alternative method using a rhomboid transposition flap, thus extending the possibilities for repair in this region. MATERIALS AND METHODS: This is a retrospective, non-comparative study of patients in whom a rhomboid transposition flap of the temporal or frontotemporal region was created between February 2008 and March 2010. Sex, age, hospitalization, histological type of the excised lesion, type of anaesthesia, defect size, possible occurrence of complications and outcome were compiled from the medical records. RESULTS: Eleven patients (five women and six men) of average age 76 years were included. The lesions were due in all cases to basal cell carcinoma. Five patients were ambulatory and seven were hospitalized. All patients underwent surgery under local anaesthesia in a single session. Hospitalized patients had more extensive cutaneous defects, were older and had more comorbidities. One patient presented incomplete lateral resection. The most frequent complication was bruising on the lower eyelid (5/11), and two more severe complications occurred: distal flap necrosis and haematoma. The aesthetic result was good for all patients after a mean 20months of follow-up. CONCLUSION: Rhomboid transposition flaps appear to be a reconstruction option that warrants consideration in cutaneous defects in the temporal or frontotemporal region.

[Leg ulcers and antiphospholipid antibodies. Prospective study of 48 cases]. / Ulcères de jambes et anticorps anti-phospholipides. Etude prospective de 48 observations.

BACKGROUND: Leg ulcres can be seen as manifestations of antiphospholipid syndromes but their pathogenic relationship with vascular thrombotic events secondary to antiphospholipid antibodies remains to be defined with precision. A significant association between anticardiolipin antibodies and venous leg ulcers has been described. We conducted this study to determine whether such an association is found in venous ulcers and if it could also be present in cases involving the arterial and/or arteriolar circulation. PATIENTS AND METHODS: From December 1995 to March 1997, 48 patients with leg ulcers involving venous (27 cases), arteriovenous (9 cases) or arteriolar (12 cases) circulations were admitted. The etiologic diagnosis was based on clinical presentation and duplex Doppler findings examining the superficial and deep venous and arterial circuits. Antiphospholipid antibodies were searched for in all cases: VDRL, ELISA for IgG and IgM antiphospholipid antibodies, antiprothrombinase circulating anticoagulant. RESULTS: Circulating anticoagulants were found in 22 of the 48 patients (46%): 12/27 (44%) involved venous leg ulcers (anticardiolipin antibodies, 5 cases; circulating anticoagulants, 4 cases; both, 2 cases); 1/9 involved arteriovenous ulcers (anticardiolipin antibodies, 5 cases); 9/12 involved arteriolar ulcers (anticardiolipin antibodies, 3 cases; circulating anticoagulants, 6 cases; both, 3 cases). Seven of the 9 patients also had severe arteritis. A past history of venous thrombosis was found in 3 cases with venous ulcers and antiphospholipid antibodies. One patient among the 5 with arteriolar ulcers had a past history of arterial thrombosis. DISCUSSION: Our cohort is too small for a formal conclusion but underlines two points: 1. antiphospholipid antibodies can be associated with venous ulcers independently of thrombosis history. The hypothesis that leukocyte stasis and endothelial cell activation causes an immune reaction implicating antiphospholipid antibodies has been put forward. The usefulness of an antiaggregate treatment or an anticoagulant treatment should be discussed, 2. The possible association between arteriolar ulcers and antiphospholipid antibodies requires further large scale studies.

Acropathia ulcero-mutilans acquisita of the upper limbs.

We report an 80-year-old woman with a bilateral mutilating acro-osteolysis of the fingers progressing over a period of 3 years. As the patient refused nerve or muscle biopsies, our diagnosis of acropathia ulcero-mutilans acquisita or Bureau-Barrière syndrome, characterized by osteolysis, remains hypothetical. Sporadic sensory mutilating acropathy of the upper limbs is rare, and we discuss the differential diagnosis.

[Toxic dermatitis caused by tramadol]. / Toxidermie au tramadol.

BACKGROUND: Tramadol chlorhydrate (Topalgic) is a powerful analgesic recently introduced in France where its use has spread rapidly. We report a case where this drug induced a maculopapulous toxic skin reaction with secondary erythrodermia. CASE REPORT: A 47-year-old man was treated for lower back pain with tramadol chlorhydrate (50 mg b.i.d.). Otherwise, he was in good general health and was taking no other medications. Shortly after beginning the treatment, he developed a highly pruriginous maculopapulous eruption involving the entire skin surface, hyperthermia and general degradation. There was no skin exfoliation, mucosal involvement nor nodal enlargement. Tramadol was withdrawn and the patient was given corticosteroid therapy. Secondary erythrodermia developed after termination of the corticosteroids. The lesions regressed after tramadol withdrawal. DISCUSSION: Tramadol-induced skin reactions are uncommon and usually benign. In our case, the delay from onset of tramadol and the development of the maculopapulous eruption was very short (four days). The patient was taking no other medication. We hypothesize that the patient had been sensitized by cross-reaction with another compound and recall the fundamental aspects of tramadol and opiate drugs.

[Chilblains]. / Engelures.

Chilblain is an erythrocyanotic lesion of hands or feet, occurring after prolonged exposure to moderate to cold humidity. Most common in young and slim women, it can happen at every age, and relapses characteristically in autumn and winter. Clinical diversity is the rule, in frequent association with microvascular dysreactivity (mostly acrocyanosis). Chilblain is benign in most cases.

[Serum bisalbuminemias: their clinical value]. / Les bisalbuminémies sériques: leur intérêt en clinique.

Bisalbuminemias are characterized on serum electrophoresis with a double band of albumin. They could be hereditary or acquired. This double band is composed of a protein with a normal mobility and with a protein with an other mobility which migrates in a more anodic or more cathodic position.