Reconstruction of cervical necrotizing fasciitis defect with the modified keystone flap technique: Two case reports.

BACKGROUND: Cervical necrotizing fasciitis (CNF) is a rare, aggressive form of deep neck space infection with significant morbidity and mortality rates. Serial surgical debridement acts as the cornerstone of CNF treatment; however, it often results in defects requiring complex reconstructions. CASE SUMMARY: We report two cases in which the keystone flap (KF) was used for CNF defect coverage: Case 1, an 85-year-old patient with CNF in the anterior neck, and Case 2, a 54-year-old patient with CNF in the posterior neck. Both patients received empirical intravenous antibiotic therapy and underwent serial debridement, enabling adequate wound preparation and stabilization. The final defect size measured 5.5 cm × 12 cm in Case 1 and 6 cm × 11 cm in Case 2. For defect coverage, we employed an 8 cm × 19 cm type II KF based on perforators from the superior thyroid artery in Case 1 and a 9 cm × 18 cm type II KF based on perforators from the transverse cervical artery in Case 2. Both flaps showed complete survival. No postoperative complications occurred in both cases, and favorable outcomes were observed at 7- and 6-month follow-ups in case 1 and 2, respectively. CONCLUSION: We effectively treated CNF-associated defects using the KF technique; KF is viable for covering CNF defects in carefully selected cases.

Increased risk of recurrence and disease-specific death following delayed postoperative radiation for Merkel cell carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is often treated with surgery and postoperative radiation therapy (PORT). The optimal time to initiate PORT (Time-to-PORT [ttPORT]) is unknown. PURPOSE: We assessed if delays in ttPORT were associated with inferior outcomes. METHODS: Competing risk regression was used to evaluate associations between ttPORT and locoregional recurrence (LRR) for patients with stage I/II MCC in a prospective registry and adjust for covariates. Distant metastasis and death were competing risks. RESULTS: The cohort included 124 patients with median ttPORT of 41 days (range: 8-125 days). Median follow-up was 55 months. 17 (14%) patients experienced a LRR, 14 (82%) of which arose outside the radiation field. LRR at 5 years was increased for ttPORT >8 weeks vs ≤ 8 weeks, 28.0% vs 9.2%, P = .006. There was an increase in the cumulative incidence of MCC-specific death with increasing ttPORT (HR = 1.14 per 1-week increase, P = .016). LIMITATIONS: The relatively low number of LRRs limited the extent of our multivariable analyses. CONCLUSIONS: Delay of PORT was associated with increased LRR, usually beyond the radiation field. This is consistent with the tendency of MCC to spread quickly via lymphatics. Initiation of PORT within 8 weeks was associated with improved locoregional control and MCC-specific survival.

Single-stage reconstruction of a large defect of the ear.

To reconstruct a large anterior skin and cartilage defect of the upper half of the external ear in an elderly patient after cancer surgery, different techniques are possible, but single-stage procedures should be advised. Combining flaps with reliable vascular supply, like the revolving door post-auricular flap and a mastoid advancement flap, is an attractive single-stage reconstructive option to rebuild a sturdy auricle.

Histopathological Pattern of Head and Neck Recurrent BCC After Previous Cryotherapy.

Surgical resection is the gold standard treatment for basal cell carcinomas, although there is literature supporting cryotherapy for low-risk cases. Our aim was to compare the histopathological aspects of recurrent postcryotherapy head and neck cutaneous BCC with de novo tumors, using a case-control study. 51 Recurrent postcryotherapy cases were selected between January 2017 and December 2021 and compared to 132 controls filtered from a consecutive series of de novo head and neck cutaneous BCC operated between January and December 2021. Aggressive variants, multifocality, invasion beyond adipose tissue and higher Clark levels were associated with recurrent cases on multivariate analysis. Previous cryotherapy treatment may have contributed to an increased risk of more aggressive recurrent disease and caution using this treatment modality is advised. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03919-7.

Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas / Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures

En el presente artículo de la serie «Seguridad en procedimientos dermatológicos» se aborda la sección quirúrgica accidental de grandes vasos sanguíneos y estructuras nerviosas. Se aborda, en primer lugar, la localización anatómica y recorrido de las distintas estructuras vasculares y nerviosas de más riesgo. A continuación, se explican las consecuencias de dicha lesión. Por último, se emiten algunas recomendaciones para evitar el daño accidental de las estructuras en dichas áreas de riesgo y se plantean algunas maniobras terapéuticas de reparación ante un eventual daño (AU)

This article in the series «Safety in Dermatologic Procedures» deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised (AU)

[Translated article] Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures / Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas

This article in the series «Safety in Dermatologic Procedures» deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised (AU)

En el presente artículo de la serie «Seguridad en procedimientos dermatológicos» se aborda la sección quirúrgica accidental de grandes vasos sanguíneos y estructuras nerviosas. Se aborda, en primer lugar, la localización anatómica y recorrido de las distintas estructuras vasculares y nerviosas de más riesgo. A continuación, se explican las consecuencias de dicha lesión. Por último, se emiten algunas recomendaciones para evitar el daño accidental de las estructuras en dichas áreas de riesgo y se plantean algunas maniobras terapéuticas de reparación ante un eventual daño (AU)

Surgical site infection in skin surgery-An observational study.

BACKGROUND: Surgical site infection (SSI) has a significant impact on patients' morbidity and aesthetic results. OBJECTIVE: To identify risk factors for SSI in dermatologic surgery. PATIENTS AND METHODS: This prospective, single-centre, observational study was performed between August 2020 and May 2021. Patients that presented for dermatologic surgery were included and monitored for the occurrence of SSI. For statistical analysis, we used a mixed effects logistic regression model. RESULTS: Overall, 767 patients with 1272 surgical wounds were included in the analysis. The incidence of SSI was 6.1%. Significant risk factors for wound infection were defect size over 10cm2 (OR 3.64, 95% confidence interval [CI] 1.80-7.35), surgery of cutaneous malignancy (OR 2.96, CI 1.41-6.24), postoperative bleeding (OR 4.63, CI 1.58-13.53), delayed defect closure by local skin flap (OR 2.67, CI 1.13-6.34) and localisation of surgery to the ear (OR 7.75, CI 2.07-28.99). Wound localisation in the lower extremities showed a trend towards significance (OR 3.16, CI 0.90-11.09). Patient-related factors, such as gender, age, diabetes, or immunosuppression, did not show a statistically significant association with postoperative infection. CONCLUSION: Large defects, surgery of cutaneous malignancy, postoperative bleeding, and delayed flap closure increase the risk for SSI. High-risk locations are the ears and lower extremities.

Modified trilobed transposition flap for a distal nasal defect.

Reconstruction of a distal nasal defect is challenging due to poor skin mobility and the potential for nasal alar retraction. A trilobed flap can utilize more mobile proximal skin, increase the total rotational arc, and decrease the tension associated with flap transposition. However, the trilobed flap may not be ideal for distal nasal defects because each flap is designed using immobile skin, which may lead to flap immobility and free margin distortion. To overcome these problems, the base and tip of each flap were extended further from the pivot point than those of the conventional trilobed flap. Herein, we report the use of the modified trilobed flap to treat 15 consecutive cases of distal nasal defects that occurred from January 2013 to December 2019. The mean duration of follow-up was 15.6 months. All flaps survived completely, and satisfactory aesthetic outcomes were achieved. No complications such as wound dehiscence, nasal asymmetry, or hypertrophic scarring were observed. The modified trilobed flap is a simple and reliable treatment for distal nasal defects.

Various Applications of Purse-String Suture and Its Cosmetic Outcome in Cutaneous Surgical Defects.

BACKGROUND: Purse-string suture is a simple technique to reduce wound size and to achieve complete or partial closure of skin defects. OBJECTIVE: To classify situations in which purse-string sutures can be utilized and to assess the long-term size reduction and cosmetic outcome of the final scar. METHODS: Patients (93 from Severance hospital and 12 from Gangnam Severance hospital) in whom purse-string sutures were used between January 2015 and December 2019 were retrospectively reviewed. Wound site, final reconstruction method, repair duration, final wound size, and Vancouver scar scale were assessed. RESULTS: A total of 105 patients were reviewed. Lesions were located on the trunk (48 [45.7%]), limbs (32 [30.5%]), and face (25 [23.8%]). Mean ratio of wound length/primary defect length was 0.79±0.30. Multilayered purse-string suture showed the shortest duration from excision to final repair (p<0.001) and most effectively minimized the scar size (scar to defect size ratio 0.67±0.23, p=0.002). The average Vancouver scar scale measured at the latest follow-up visit at least 6 months postoperatively was 1.62, and the risk of hypertrophic scarring was 8.6%. There was no significant difference in the Vancouver scar scale and the risk of hypertrophic scarring between the different surgical method groups. CONCLUSION: Purse-string sutures can be utilized in many stages of reconstruction to effectively reduce scar size without compromising the final cosmetic outcome.

Safety in Dermatologic Procedures: Accidental Injury to Major Blood Vessels and Nerve Structures. / Seguridad en procedimientos dermatológicos: sección de grandes vasos sanguíneos y estructuras nerviosas.

This article in the series «Safety in Dermatologic Procedures¼ deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised.

[Preoperative marking options]. / Optionen zur präoperativen Markierung.

In dermatosurgery, a large number of operations involve nonsterile preoperative marking and sterile intraoperative marking to define the surgical area. This includes marking of veins and sentinel lymph nodes as well as marking of borders of malignant or benign tumors. Ideally, the markings should be resistant to disinfectant without leaving a permanent tattoo on the skin. For this purpose, a variety of commercial and noncommercial, pre- as well as intraoperative color marking options are available, such as surgical color marking pens, xanthene dyes, autologous patient blood, or permanent markers. The permanent pen is suitable for preoperative marking. It is inexpensive and can be reused. Nonsterile surgical marking pens can also be used for this purpose, but they are more expensive to purchase. Patient blood, sterile surgical marking pens, and eosin are suitable for intraoperative marking. Eosin is inexpensive and has many advantages, such as good skin compatibility. The marking options presented are good alternatives to the use of expensive colored marking pens.

Thoughts on surgical excision of onychopapilloma.

Although onychopapilloma (OP) is a benign tumor of the nail bed and distal matrix, there is nevertheless a demand for treatment in some patients. Classical longitudinal excision (CLEx) with avulsion of the nail plate was the most suitable surgical procedure. However, there may be better ways to produce a pleasing esthetic effect. The aim of this study was to modify CLEx to render it more effective, reduce the rate of recurrence, and achieve better esthetic results. We identified 23 patients with OP in varying clinical manifestations that were treated with CLEx and modified CLEx with or without avulsion of the nail plate. With the procedure of modified CLEx without avulsion of the nail plate, there was no bleeding as a side effect and recovery was faster. The appearance of the nail was nearly unchanged and no patient complained about the cosmetic results. We modified CLEx to treat OP to improve the esthetic effect while maintaining surgical effectiveness.

Inappropriate Topical Antibiotics Use in Clean Dermatological Procedures in South Korea in 2018: A Nationwide Population-Based Cross-Sectional Study.

BACKGROUND: The use of topical antibiotics (TA) for prophylactic purposes after clean dermatologic procedures (CDP) is generally not recommended, and the prescription of TA needs to be individualized in consideration of each patient's situation and underlying disease. The aim of this study was to determine the proportion of patients who underwent CDP in outpatient settings and were prescribed TA inappropriately, as well as the factors that may affect the prescription of TA. METHODS: Outpatient visits coded for CDP were selected using claims data from the Health Insurance Review and Assessment Service in 2018. Of these, patients receiving TA prescriptions were classified as having inappropriate TA use, and the proportion was estimated through technical analysis. A logistic regression analysis was used to identify factors influencing inappropriate prescriptions. RESULTS: Data were analyzed using 423,651 visits, and TA was prescribed for approximately 1.9% of the visits. TA usage was higher among women (2.0%), 0-19 years of age (2.2%), medical aid (2.2%), clinic settings (2.4%), and metropolitan areas (2.0%). TA was prescribed more frequently in urology (8.6%), pediatrics (5.0%), and dermatology (4.2%) than in other specialties. CONCLUSION: The prescription rate of TA after CDP was 1.9% using the 1.4 million patient sample from the national health insurance claims data in Korea, which is equally weighted to represent 50 million people. Although the proportion of inappropriate TA prescriptions in Korea is lower than that in other nations, it cannot be overlooked because of the large number of cases. Efforts to improve quality are required to reduce the number of inappropriate prescriptions.

Dermatology Care in Spanish Public Hospitals: A Mapping Study of Health Care Resources and Medical and Surgical Activity in Dermatology Departments in 2019. / Mapa asistencial dermatológico: descripción de los recursos estructurales y de la actividad médico-quirúrgica de los servicios de dermatología de los hospitales públicos españoles en 2019.

BACKGROUND AND OBJECTIVE: No recent data on health care resources and medical and surgical activity in Spanish dermatology departments are available in the literature. The aim of this study was to compile this information for 2019. MATERIAL AND METHODS: Cross-sectional study based on an online survey sent to the heads of dermatology departments at public hospitals in Spain. RESULTS: Of the 162 department heads contacted, 59 answered the survey (participation rate, 36.4%). General findings included a shortage of staff, especially dermatologists, in hospitals of low and medium complexity. The main reason given for the shortage of dermatologists was a lack of interested applicants. Large hospital complexes had more infrastructure and equipment. Over 50% of the departments surveyed used a combination of in-person and virtual visits. Psoriasis units were the most common specialized care units. Approximately 75% of the hospitals had operating rooms with an anesthetist. More complex procedures such as sentinel lymph node biopsy and Mohs micrographic surgery were performed more often in large hospital complexes. Hospitalization and the presence of dermatology residents working call shifts were also more common in these hospitals. Teaching and research activity differed according to hospital complexity. CONCLUSIONS: We have mapped health care resource availability and medical and surgical activity in Spanish dermatology departments prior to the COVID-19 pandemic. Our findings could be useful for improving clinical management and defining future actions and areas for improvement.