How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study.

BACKGROUND: Few studies show how dermatologic surgeons manage problems with site identification. OBJECTIVE: To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question. METHODS: Nationwide, prospective, multisite cohort study. RESULTS: Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites. LIMITATIONS: Sites were academic centers. CONCLUSIONS: When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

Epidemiology, survival, and risk of subsequent primary malignancies in patients with digital papillary adenocarcinoma: a retrospective study of 213 patients in the Surveillance, Epidemiology, and End Results (SEER) Program.

Digital papillary adenocarcinoma (DPAc) is a rare, aggressive cutaneous malignancy of sweat gland derivation. Herein, we conduct a retrospective study of 213 DPAc patients using the 17 registries of the Surveillance, Epidemiology, and End Results (SEER) program. We estimate the incidence of DPAc to be 0.11 per million persons per year, with the incidence rising over the past two decades. Our study shows DPAc to most commonly afflict White males, typically in their 40s-60s. We note a 5-year disease-specific survival of 98.3% and 5-year overall survival of 95.7%. We also show advanced age to be associated with more aggressive disease and identify tumor size as an independent risk factor impacting disease-specific survival. Our results also suggest that patients with DPAc have an elevated risk of developing subsequent primary malignancies, with males being at increased risk of developing lung/bronchial neoplasms and females being at increased risk of developing breast cancer.

Cerebriform eruption related to acute coral dermatitis.

A 27-year-old woman presented with an acute, tender, geographic lesion on her left shin that developed after contact with a brain coral while scuba diving. Photographs obtained two hours after the incident reveal a well-demarcated, geographic, erythematous plaque with a serpiginous and cerebriform pattern at the site of contact, resembling the outermost surface contour of brain coral. The plaque resolved spontaneously over a three-week period. The biology of corals and potential biological features that lead to cutaneous eruptions are reviewed.

Techniques to Relieve Pain Associated With Botulinum Injections for Palmar and Plantar Hyperhidrosis.

BACKGROUND: Palmar and plantar hyperhidrosis (HH) is a common condition characterized by excessive sweating of the palms and soles. Botulinum neurotoxin (BTX) is a very effective and safe treatment. However, the associated intense injection pain is a major limiting factor deterring patients from selecting this treatment. OBJECTIVE: The aim of this study was to review the numerous techniques used to minimize pain accompanying injections for palmoplantar HH. Additionally, the advantages and limitations of each modality will be discussed. MATERIALS AND METHODS: The authors performed a comprehensive literature search in PubMed/MEDLINE, Embase, Cochrane Central, and Google Scholar on randomized controlled trials, cohort studies, and case series on techniques to relieve pain of BTX injections for treatment of palmar and plantar HH. RESULTS: Current available techniques in reducing botulinum injection with merits and drawbacks are nerve blocks, Bier blocks, cryoanalgesia, needle-free anesthesia, topical anesthetics, and vibration anesthesia. CONCLUSION: Topical anesthesia, ice, and vibration are the safest and most convenient noninvasive available methods to relieve pain associated with botulinum injection. Nerve blocks, Bier block, and needle-free anesthesia provide better anesthesia but are limited by the need for training and equipment.

Repair of Anterior Ear Defects Using Transcartilage Island Pedicle Flaps.

BACKGROUND: Surgical reconstruction of the anterior surface of the ear (concha, antihelix, scapha, and triangular fossa) is complicated by the paucity of mobile local skin. OBJECTIVE: This is a retrospective study of the transcartilage island pedicle flap for reconstruction of surgical defects of the anterior ear. METHODS AND MATERIALS: Two hundred thirty-two Mohs micrographic surgery defects were included in the study. The technique involves circumferential incision of the flap in the postauricular sulcus, transfer of the flap to the anterior ear through a surgically created cartilage slit, suturing of the flap on the anterior surface of the ear, and repair of the secondary postauricular defect. Preoperative, intraoperative, and postoperative details of each case were tabulated and analyzed. RESULTS: The mean defect size was 1.9 × 1.5 cm. Complications included flap edema (n = 6, 2.6%), postoperative bleeding (n = 4, 1.7%), partial thickness flap necrosis (n = 2, 0.9%), pinning back of the ear (n = 2, 0.9%), and central flap dimpling (n = 2, 0.9%). There was 1 acute staphylococcal abscess and 1 sterile abscess that developed 13 months postoperatively. All complications resolved with medical or surgical management. CONCLUSION: Transcartilage island pedicle flaps may be considered for single-stage surgical reconstruction of defects involving the anterior ear.

Repair of Apical Triangle Defects Using Melolabial Rotation Flaps.

BACKGROUND: The apical triangle of the upper cutaneous lip, also known as the alar-facial sulcus, is an anatomical structure bound medially by the nasal ala, laterally by the medial cheek, and inferiorly by the remainder of the upper cutaneous lip. During reconstruction, retaining the central concavity and the convex lateral and medial outlines of this location is required to maintain midfacial symmetry. OBJECTIVE: This is a retrospective study of our use of the melolabial rotation flap for reconstruction of surgical defects of the apical triangle. METHODS AND MATERIALS: Eighty-six surgical defects involving the apical triangle that were repaired with melolabial rotation flaps were included. All tumors were treated with Mohs micrographic surgery before reconstruction. Preoperative, intraoperative, and postoperative details of each case were analyzed. RESULTS: Of the 86 defects included in the study, 68 (79%) were evaluated postoperatively. The apical triangle was preserved in all cases. Clinical asymmetry was noted in 3 patients (3.4%). No major complications were noted, and no patient required surgical revision. CONCLUSION: Melolabial rotation flaps may be considered for single-stage reconstruction of surgical defects involving the apical triangle.

Toluidine Blue and Hematoxylin and Eosin Stains are Comparable in Evaluating Squamous Cell Carcinoma During Mohs.

BACKGROUND: Histologic examination of tissue is the foundation of Mohs micrographic surgery because determination of surgical margins influences whether additional tissue will be taken. Currently, there is no large focused study comparing toluidine blue (TB) and hematoxylin and eosin (H&E) stains in the evaluation of squamous cell carcinoma (SCC). OBJECTIVE: This study evaluates whether TB and H&E are comparable in assessing the presence of tumor in frozen sections of SCC. MATERIALS AND METHODS: One hundred eighty-six randomized slides representing 93 tissue pieces from 36 tumors were examined by 3 Mohs surgeons (1 Accreditation Council for Graduate Medical Education fellow and 2 fellowship-trained surgeons) and compared using a template that documented the presence and location of tumor on the slides. RESULTS: The evaluation of SCC with H&E and TB stains was highly concordant, with concordant identification of SCC in 96%, 96%, and 94% of tissue layers among the 3 Mohs surgeons ARS, LHG, and AK-A, respectively. CONCLUSION: Toluidine blue and H&E stains are statistically similar in their ability to detect SCC and guide Mohs surgical decision-making.