Reconstruction of Large Transmural Nasal Defects With a Nasolabial Turnover Interpolation Flap.

BACKGROUND: Reconstruction of large nasal surgical defects often warrant the use of mucosal flaps to repair the inner lining. This often presents a challenge for surgical reconstruction. OBJECTIVE: To describe a unique reconstructive option for the repair of large surgical wounds that necessitate mucosal nasal lining. MATERIALS AND METHODS: This study is a retrospective review of 10 patients who underwent surgical reconstruction of large nasal and/or heminasal surgical defects following Mohs micrographic surgery. A nasolabial turnover interpolation flap was used to repair missing nasal mucosal lining, coupled with a cutaneous flap which typically involved a paramedian forehead flap. The duration of follow-up was 8 months. An aesthetic and functional surgical outcomes measure was used to assess the final repair. RESULTS: Favorable aesthetic outcomes were obtained in all patients and without need of revision surgery by the use of a nasolabial turnover interpolation flap. CONCLUSION: The nasolabial turnover interpolation flap offers a reliable and effective method of repair for large transmural nasal surgical wounds. We typically paired this nasal lining flap with a paramedian forehead flap with reliable and aesthetic outcomes. This technique is straightforward, reproducible, and with both good aesthetic and functional outcomes.

From Didactics to Disasters: Unveiling CBRNe and Counter-Terrorism Medicine Training in US Medical Schools.

INTRODUCTION: The threat of chemical, biological, radiologic, nuclear, and explosive (CBRNe) terrorist attacks has increased over time. The need for rapid and effective responses to such attacks is paramount. Effective medical counter-measures to CBRNe events are critical and training for such may effectively occur early in physician training. While some medical specialties are more involved than others, counter-terrorism medicine (CTM) spans all medical specialties. METHODS: All United States allopathic medical schools were examined via online curriculums and queries for academic content related to CBRNe and terrorist medical counter-measures. RESULTS: Analysis of 153 United States allopathic medical schools demonstrated that 15 (9.8%) medical schools offered educational content related to CBRNe and terrorist counter-measures. This is in contrast to legislation following the September 11, 2001 attacks that called for high priority for such education. CONCLUSION: Effective CBRNe medical counter-measures are currently in place; however, there is room for improvement in education that may begin during medical school. While certain medical specialties such as emergency medicine, primary care, and dermatology may have specific niches in such events, physicians of all medical specialties have something to offer, and even a basic education in medical school can help best prepare the nation for future attacks.

Low-Cost Model for Battlefield Wound and Hemorrhage Training.

INTRODUCTION: Exsanguination is the leading cause of preventable death on the battlefield and in austere environments. Multiple courses have been developed to save lives by stopping hemorrhage. Training for this requires simulation models; however, many models are expensive, preventing the further expansion of this life-saving training. We present a low-cost model for hemorrhage training and realistic moulage based on simple medical supplies and grocery store meats. MATERIALS AND METHODS: Wound packing training was completed by use of a block of pork shoulder roast with an incision simulating a wound and IV tubing connected to a syringe with fake blood. Hemostasis was obtained with proper wound packing by the student, causing the bleeding to be tamponaded. Wound moulage utilized remaining supplies of pork roast being attached to patient actors or mannequins and adorned with fake blood creating wounds with the appearance and feel of real tissues. RESULTS: Tactical Combat Casualty Care (TCCC) training was completed at a small military medical facility with a start-up cost of less than $70 and a single course as cheap as $15. These methods have been utilized to establish other TCCC training centers while keeping costs low. CONCLUSIONS: We present low-cost models for simulating massive hemorrhage for wound packing with pork roast and realistic moulage. These methods can be utilized for other hemorrhage training courses such as TCCC, Advanced Wilderness Life Support, and Stop the Bleed.

Perineural involvement of squamous cell carcinoma presenting with formication.

Perineural involvement of a cutaneous neoplasm marks an aggressive feature. Tumors with perineural involvement share an increased propensity for local invasion via perineural spread. Formication may be an indicator of perineural involvement by cutaneous neoplasms. We present a case of an 82-year-old man with perineural involvement of a squamous cell carcinoma (SCC) identified by clinical symptoms of formication. Successful resolution of these symptoms was achieved with radiation therapy.

A report of Epstein-Barr virus-positive primary cutaneous natural killer-/T-cell lymphoma.

We describe a patient who presented with Epstein-Barr virus-positive tumor-stage primary cutaneous lymphoma. Our patient had previously been treated with oral methotrexate for long-standing rheumatoid arthritis. Tissue analysis revealed large tumor cells that were surface CD2- and CD3-positive; T-cell-restricted intracellular antigen-positive; CD56-, CD20-, and CD30-negative; and stained positively for Epstein-Barr virus. Our case is noteworthy for several reasons. Although the presence of rheumatoid arthritis and therapy with methotrexate are putative risk factors for the development of immune suppression-related and Epstein-Barr virus-related lymphomas, the vast majority of lymphomas in this setting are of B-cell origin, and rarely are these primary cutaneous in nature. In addition, our patient's tumor displayed an unusual phenotype, with immunophenotypic features suggestive of an atypical natural killer-/T-cell lymphoma. Methotrexate was withdrawn, and our patient was successfully treated with local radiotherapy. She has remained in complete remission 28 months since diagnosis.

Self-induced nasal ulceration from trigeminal trophic syndrome.

Trigeminal trophic syndrome is a rare entity characterized by the presence of ala nasi ulceration, trigeminal anesthesia, and paresthesia. It arises secondary to trigeminal nerve injury. Patients with this diagnosis often undergo repeated skin biopsies to rule out suspected nonmelanoma skin cancer due to the clinical appearance. Recognition of this entity is paramount to avoid unnecessary surgical intervention and to attempt therapy.

Brachioradial pruritus: a case report and review of the literature.

Brachioradial pruritus is an enigmatic pruritic sensation that characteristically involves the proximal lateral forearm of middle-aged women residing in tropical to temperate climates. There are often no associated cutaneous signs. The pathophysiology has been debated but is believed to involve UV radiation and/or cervical spine disease. We present a patient with brachioradial pruritus and a review of the literature. Brachioradial pruritus should be suspected in patients with intractable pruritus overlying the brachioradialis muscle of the forearm that is recalcitrant to standard therapies. These patients commonly report a history of chronic solar damage and/or cervical spine disease.

Treatment of recalcitrant atopic dermatitis with omalizumab.

Atopic dermatitis is a common diagnosis that presents a therapeutic challenge. Although multiple therapeutic modalities exist, there is no single monotherapy that has proven exceptional in ameliorating the symptoms of this disease. Current topical and systemic therapeutic options offer benefit but carry varying degrees of adverse effects that often limit their application. We present 3 patients with severe, recalcitrant atopic dermatitis successfully treated with omalizumab.

Borderline tuberculoid leprosy in a woman from the state of Georgia with armadillo exposure.

In the southern and southeastern United States, the 9-banded armadillo is an important reservoir for Mycobacterium leprae, the causative agent of leprosy (Hansen's disease). Here, we describe a woman living in Georgia with borderline tuberculoid leprosy who worked for many years in a garden where armadillos burrowed or were buried. There was no history of foreign travel or known exposure to a person with leprosy. Treatment with 6 once-monthly combined doses of rifampin, ofloxacin, and minocycline was successful.

High rates of apoptosis in human Mycobacterium ulcerans culture-positive buruli ulcer skin lesions.

Buruli ulcer, a disease caused by Mycobacterium ulcerans, causes ulcerative skin disease likely generated by a toxin that mediates apoptosis. We analyzed paraffin-embedded sections of surgically excised Buruli ulcer lesions (two ulcers and one edematous plaque) and adjacent non-lesional skin samples (n = 9) for apoptosis by an indirect immunofluorescent terminal deoxynucleotide transferase-mediated dUTP-digoxigenin nick end labeling (TUNEL) assay. All samples were stained for acid-fast bacilli (AFB) and cultured for mycobacteria, and most were analyzed with an M. ulcerans-specific diagnostic polymerase chain reaction (PCR). TUNEL (+) bodies were numerous in both ulcers and the plaque, and sparse or absent in adjacent non-lesional skin. The AFB tissue stains and cultures for M. ulcerans were positive only in the three lesions. The result of the PCR for M. ulcerans was positive in all three lesions and in four of six non-lesional tissue samples; three contained sparse TUNEL (+) bodies. An abundance of TUNEL (+) bodies in the three AFB stain (+), culture (+), and PCR (+) Buruli ulcer lesional samples, but not in nearby AFB stain (-), culture (-), and PCR (+) non-lesional skin samples, strengthen the evidence that apoptosis is an important tissue destruction mechanism in human lesions closely associated with viable M. ulcerans.

Case reports: suicidal ideation in the dermatology clinic.

Many dermatology patients have significant psychiatric comorbidities, including depression and suicidal ideation. In light of the isotretinoin controversy, the relevance of this subject has never been greater. Therefore, it is imperative for dermatologists to understand the appropriate actions to take when faced with a potentially suicidal patient. We present a case of a clinic patient who expressed suicidal intent and discuss necessary steps to take in such a situation.

Furuncular myiasis secondary to Dermatobia hominis.

Dermatobia homininis is the most common cause of furuncular myiasis in Central and South America. It is diagnosed based on a history of travel to an endemic region and the characteristic cutaneous lesion. We present a 54-year-old patient who presented with both a travel history and cutaneous findings of furuncular myiasis.

Surgical margins in the treatment of nonmelanoma skin cancer and mohs micrographic surgery.

Traditional surgical treatment of nonmelanoma skin cancer includes excision with subsequent evaluation of surgical margins, either via frozen sections intraoperatively or after excision and closure. Accurate communication between surgeon and pathologist regarding the meaning of surgical margins should be confirmed. Recurrences of tumor growth may in part be attributed to asymmetrical tumor growth patterns with extension of tumor in an unanticipated direction. Mohs micrographic surgery is an outpatient procedure that maximizes surgical margin evaluation while minimizing the amount of tissue that must be excised. This article will discuss the concept of surgical margins in excisions of nonmelanoma skin cancer and the role of Mohs micrographic surgery.