Congenital lateral facial teratoma: A case report and review of literature.

Facial teratomas are uncommon tumours in children that distort the face and may be associated with functional problems. They are less common than cervical teratomas though they are often grouped together and considered an emergency due to their tendency to cause respiratory compromise. They tend to be large and cause cosmetic issues; hence usually noticed early and medical help sought promptly by parents. The close proximity of facial teratomas to structures like eyes, parotid gland, facial nerve, vessels and brain makes them challenging and requires a patient and meticulous exploration during surgery. We present a case of an 11 month old girl with left sided temporal teratoma. Well planning of the incision and complete excision of the tumour with careful sparing of the facial nerves and parotid gland yielded good result.

Multifocal Recurrent Microcystic Adnexal Carcinoma.

Microcystic adnexal carcinoma (MAC) is a rare and locally aggressive neoplasm with preponderance for local recurrence but rarely nodal or distant metastasis. A 38-year-old male was referred to our clinic for definitive treatment of known recurrent and concern for multifocal MAC from previous biopsy. The patient was treated with modified Mohs and reconstruction with an anterolateral thigh (ALT) free flap for tissue coverage. This case highlights the rare nature of multifocal MAC, treatment challenges of Mohs clearance versus wide local excision, and reconstructive challenge associated with large post treatment defects.

GIANT BASAL CELL CARCINOMA ON THE FOREHEAD AND WHY WE SHOULD PREVENT THEM - CASE REPORT.

Basal cell carcinoma (BCC) is the most prevalent malignancy, with rising incidence worldwide. Despite its naturally slow growth and initially low metastatic potential, it can cause significant morbidity and mortality when unrecognized, inadequately treated or poorly followed up. Authors present the case of a 61-year-old male with a 7-year history of multiple incomplete excisions of a “simple” BCC on the forehead. A CT scan of the head revealed an invasive mass (5.2 cm laterolateral x 4.0 cm craniocaudal) in the frontal area. There was no evidence of metastasis. Complete resection of the lesion and reconstruction was achieved in three stages. Final reconstruction was achieved using a left frontal fasciocutaneous flap. The secondary defect was closed with an advancement flap of the scalp and donor sites were covered using a split-thickness skin graft from the upper limb. This case demonstrates the necessity for vigilance in the approach to, diagnosis, treatment and follow-up of these skin neoplasms. The development of giant BCCs should be avoided at all costs. Increased size of BCCs corresponds with increased recurrence rate, metastatic rate, morbidity, mortality, treatment difficulties and overall costs.

Complex reconstruction of the orbitofrontal regions using three regional flaps after orbital exenteration for the treatment of basal cell carcinoma.

Objective. The current paper presents an interesting case of facial reconstruction after the excision of a giant basal cell carcinoma located in the orbitofrontal region. Methods. Performing the excision while securing the appropriate oncologic safety margin has determined the appearance of a soft tissue defect that required a complex reconstruction using three regional flaps: frontal, temporal fascial and temporal muscle flaps. Results. After the excision and reconstruction in a single surgical stage, the postoperative result was favorable, the 12 months assessment showing that the patient was satisfied with the aesthetic aspect. Conclusion. Including the orbital exenterations in the excisional treatment of giant neoplasms located in the facial region requires a complex reconstructive plan. The surgical team has to consider the relief of the anatomical structures that are targeted, as well as the necessity of achieving satisfactory aesthetic results while ensuring oncological radicality.

Risk of Intracranial Extension of Craniofacial Dermoid Cysts.

BACKGROUND: Dermoid cysts are benign lesions lined by keratinizing squamous epithelium that also contain epidermal adnexa (hair follicles, hair shafts, sebaceous glands, and both apocrine and eccrine sweat glands) and mesodermal derivatives (smooth muscle fibers, vascular stroma, nerves, and collagen fibers). Craniofacial dermoid cysts represent approximately 7 percent of all dermoids and have an incidence ranging between 0.03 and 0.14 percent. METHODS: The authors conducted a single-center, consecutive, nonrandomized comparative case series over a 20-year period of all patients treated surgically for craniofacial dermoid at the Royal Children's Hospital in Melbourne, Australia. Six hundred forty-seven patients had craniofacial dermoids and adequate information to be included in the study. The authors also conducted a thorough review of the literature using the MEDLINE and Embase databases. RESULTS: Six hundred forty-seven patients amounted to 655 lesions in our case series. The age at surgery ranged from 2 months to 18 years, with an average age of 25.65 months. The depth of the lesions was stratified using a classification system, and the risk of intracranial extension was assessed using these data. Midline nasal lesions are established as high risk by other studies, but frontal, temporal, and occipital lesions were found to be as risky if not more risky for intracranial extension. CONCLUSIONS: Several classification systems for craniofacial dermoid cysts have used both broader anatomical locations and physical characteristics to group these lesions and identify those warranting preoperative imaging. The authors propose a system using more specific classification of anatomical location to assist in the prompt identification of high-risk lesions and facilitate sound preoperative planning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Utility of a diffusion kurtosis model in the differential diagnosis of orofacial tumours.

AIM: To compare the goodness of fit and correlations between diffusion kurtosis imaging (DKI) and a mono-exponential (ME) model, to compare the corrected apparent diffusion coefficient (Dapp) and apparent kurtosis (Kapp) of the DKI model, and the apparent diffusion coefficient (ADC) of the ME model among the various orofacial lesions, and to evaluate the diagnostic performances between the two models. MATERIALS AND METHODS: A total of 100 orofacial lesions underwent echo-planar diffusion magnetic resonance imaging (MRI) with four b-values. The goodness of fit was evaluated using Akaike information criterion. The correlations of the diffusion-derived parameters were evaluated. The diagnostic performance was analysed by receiver operating characteristics (ROC). RESULTS: The DKI model showed a significantly better goodness of fit than the ME model (p<0.0001). The Kapp had a strongly negative correlation with the Dapp (ρ=-0.749) and ADC (ρ=-0.938). A strongly positive correlation existed between the Dapp and ADC (ρ=0.906). All parameters differed significantly between benign tumours and malignant tumours (p<0.05). In differentiating benign tumours from the malignant tumours, the AUC of Dapp (0.871) was larger than that of ADC (0.805); however, a significant difference was not found (p=0.102). CONCLUSION: The DKI model had better goodness of fit than the ME model. Furthermore, the Dapp and Kapp were also characteristic for each pathological category; however, the DKI model did not yield a significantly higher diagnostic performance than the ME model, which might be related to the high correlation among the diffusion-derived parameters and wide variation among categories.

A rare case of benign teratoma of the facial fronto-temporal region in adult male.

Teratoma is a germ cell neoplasm composed of tissue derived from at least two of three blastodermic embryonic layers (ectoderm, mesoderm and endoderm). The incidence of teratoma in the head and neck region is rare, in particularly in adults. A CASE REPORT: We reported an uncommon case of teratoma in a 30 years male with a mass in the right fronto-temporal region of the face. Magnetic resonance imaging revealed a well encapsulated heterogenous mass with solid-cystic component extending from the fissure zygomatofrontal and the fissure zygomato-temporal. Serum alfa-fetoprotein levels were not elevated. Surgery was performed, the mass was completely removed, and microscopical analysis confirmed a diagnosis of mature benign teratoma. The patients showed no clinical signs of recurrence in 10 years follow-up. This case of teratoma is extraordinary due to three reasons: the location, the age of patient and benign nature of the tumor in patient at this age. Because such tumors occur exceptionally, each case should be studied with a long-term follow-up and reported.

A case of congenital rhabdomyosarcoma.

A 6-month-old girl presented with a congenital orbital tumor diagnosed as congenital embryonal rhabdomyosarcoma. Given the location, complete surgical resection was impossible. Management with chemotherapy and proton therapy resulted in complete clearance. This case highlights the clinical and histologic features of cutaneous congenital embryonal rhabdomyosarcoma.

Optimal cosmetic outcomes for basal cell carcinoma: a retrospective study of nonablative laser management.

Although Mohs micrographic surgery (MMS) is the gold standard for treatment of nonmelanoma skin cancers (NMSCs), laser management has been an emerging treatment option that continues to be studied. Nonablative laser therapy is a noninvasive alternative. This study used a combined pulsed dye laser (PDL) and fractional laser approach to treat basal cell carcinomas (BCCs) in conjunction with noninvasive imaging such as reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) to enhance efficacy rates.

Perineural Invasion in Cutaneous Squamous Cell Carcinoma. / Invasión perineural en el carcinoma epidermoide cutáneo.

Cutaneous squamous cell carcinoma is sometimes characterized by an increased risk of locoregional recurrence and occasionally distant metastasis. Several clinical and pathological factors, including perineural invasion, have been shown to have prognostic value in this setting. Perineural invasion, that is, the spread of tumor cells into the space surrounding a nerve, is usually an incidental finding. In the presence of symptoms or radiographic evidence of perineural spread, the diagnosis is clinical perineural invasion, which is associated with an increased risk of local recurrence and mortality.

Diagnostic impact of reflectance confocal microscopy as a second-level examination for facial skin lesions.

BACKGROUND AND OBJECTIVE: Benign and malignant facial skin lesions may be difficult to differentiate clinically and with dermoscopy. The present study aimed to evaluate the potential utility of in vivo reflectance confocal microscopy (RCM) as a second-level examination for facial skin neoplasms. PATIENTS AND METHODS: Retrospective and blinded evaluation of 160 consecutive facial lesions was carried out in two separate steps. Clinical and dermoscopic images were assessed first, followed by combined evaluation of clinical/dermoscopic and RCM images. Our study included 60 % malignant lesions, comprising 43 % melanomas, 9 % basal cell carcinomas, 5 % in situ squamous cell carcinomas and 3 % lymphomas. RESULTS: Ancillary RCM significantly improved diagnostic specificity for the detection of malignancy compared to clinical/dermoscopic evaluation alone (58 % vs 28 %). However, sensitivity was slightly lower for RCM-based image evaluation (93 % vs 95 %) due to misclassification of one in situ SCC and one lymphoma. In terms of melanoma diagnosis, RCM-based image evaluation was generally superior; sensitivity was only slightly increased (88 % vs 87 %), but melanoma specificity was significantly higher (84 % vs 58 %). CONCLUSION: RCM is a valuable diagnostic adjunct for facial skin lesions; unnecessary biopsies in this cosmetically sensitive area could be reduced by one third without missing a melanoma.

Subcutaneoscopic Excision of External Angular Dermoid Cysts: Our Covert Scar Approach in 11 Cases.

INTRODUCTION: External angular dermoid cysts, or epidermoid inclusion cysts, are a common subcutaneous tumor of the head and neck. For the majority of these lesions, excision is relatively simple and performed through an incision immediately overlying the mass. Facial lesions in pediatric patients present a unique challenge in that a direct approach carries the potential for visible scar formation. OBJECTIVE: This article aims to detail our experience with subcutaneoscopic excision of external angular dermoid cysts in pediatric patients using endoscopic instrumentation. MATERIALS AND METHODS: Retrospectively, we reviewed 11 cases, between the ages of 4 months and 3 years with external angular dermoid cysts. An incision is made on the scalp above the hairline, then a tunneled working space is created underneath the skin. 3 mm laparoscopy instruments were then used for providing excellent visualization and precise subcutaneoscopic dissection. RESULTS: There were no complications apparent in any of the 11 cases (except cyst rupture in one case), with mean procedure duration at 61 minutes. Final results at follow-up revealed aesthetically pleasing and well-healed skin incisions, hidden from view behind the hairline. CONCLUSION: The subcutaneoscopic technique utilizing endoscopic instrumentation has the advantage of improved visualization of the cyst, greater precision of dissection, and excellent cosmesis. One disadvantage of this procedure is that this involves learning a new technique while the majority of surgeons are already comfortable with the open approach. Given the safety and efficacy observed for this subcutaneoscopic procedure, this technique can have tremendous possibilities.

Increased Marginal Stiffness Differentiates Infiltrative From Noninfiltrative Cutaneous Basal Cell Carcinomas in the Facial Area: A Prospective Study.

OBJECTIVES: Basal cell carcinoma (BCC) is the most common dermatologic malignant skin cancer. Infiltrative histologic variants are more aggressive and require wider surgical margins or Mohs surgery, in contrast with noninfiltrative variants, which are commonly treated with standard surgical excision. Elastography has not been used to date to differentiate between the histologic variants of BCC. The purpose of this study was to differentiate infiltrative from noninfiltrative BCCs on elastography. METHODS: A total of 31 facial BCCs were studied. Preoperatively, color Doppler ultrasound and strain elastographic examinations of the lesions were performed. The size, intralesional vascularization, and presence of hyperechoic dots were considered relevant B-mode and color Doppler variables. Strain ratios of the tumors were obtained with respect to adjacent healthy tissue. Increased marginal stiffness, which was considered hardness in greater than 50% of the tumor margin, was also blindly evaluated. Histologic confirmation and subtyping (infiltrative or noninfiltrative) were performed in all cases. RESULTS: Infiltrative BCCs did not differ in the size, presence or absence of hyperechoic dots, or vascularization from noninfiltrative BCCs. Strain ratios were similar in both infiltrative and noninfiltrative BCCs (mean ± SD, 1.82 ± 0.879 versus 2.2 ± 1.11). However, infiltrative BCCs had statistically increased marginal stiffness in comparison with noninfiltrative BCCs (88.0% versus 18.8%). Increased marginal stiffness had sensitivity and specificity of 0.89 and 0.82 respectively, with a positive predictive value of 0.67 for infiltrative BCCs and a negative predictive value of 0.95 for noninfiltrative BCCs. CONCLUSIONS: Histologic variants of BCC have different elastographic patterns. These differences may be of help in preoperative assessments of the BCC subtype and specific surgical planning, avoiding unnecessary skin biopsies.