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BACKGROUND The patient consent process traditionally relies on conversations between the physician and the patient and rarely utilizes supplemental multimedia aids. OBJECTIVE To determine whether the addition of an educational video on Mohs micrographic surgery (MMS) can improve patient satisfaction with the consent process. MATERIALS AND METHODS This prospective observational quality improvement study compared the outcomes of traditional patient consent alone versus standard consent plus an educational video among patients undergoing their first MMS for a primary skin cancer. End points were patient satisfaction and preferences measured by postprocedure questionnaires. RESULTS The addition of a supplemental video to the consent process did not affect overall patient satisfaction, which was very high in both video and control groups. However, specific components of patient satisfaction were improved such as patient perception of the opportunity to ask questions and understand the procedure. CONCLUSION Multimedia aids can be effective tools in the patient consent process.

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.

BACKGROUND There are numerous blades available for use in dermatologic procedures. There are different advantages that are inhere.nt to different blades due to their shape and size. One aspect of the blade that is instrumental to its performance, but is not objectively defined, is sharpness. This information could be useful when choosing a blade for a particular procedure. OBJECTIVE This study aims to objectively define the sharpness of blades used in dermatologic surgery. METHODS AND MATERIALS The Sharpness Tester (Cutlery and Allied Trades Research Association, Sheffield, UK) was used to test the force in Newtons a blade requires to cut through a silicone cylinder. New blades were used to determine a standard for the sharpness of new blades. Blades used for surgery were tested to determine the sharpness after use. RESULTS The sharpest blade is the double-edged razor blade (0.395 N) followed by the dermablade (0.46 N), plastic handled #15 (0.541 N), #15c (0.575 N), #10 (0.647 N), and the #15 blade (0.664 N). CONCLUSION The sharpness of a blade is an important factor in its ability to perform a task and should be taken into account when choosing a particular blade for a particular procedure.

A higher and increasing incidence of skin cancer has been noted in younger women as compared with men.To assess the relative gender burden of basal cell carcinoma, squamous cell carcinoma, and malignant melanoma in various age groups, particularly in young adult women.A total of 16,994 biopsy-proven skin cancers in 9,376 patients in a single private dermatologic surgery practice was included in this study.Men constituted the majority (63.7%, p.0001) of patients, accounting for 68.7% of squamous cell carcinomas (p.0001), 60.8% of basal cell carcinomas (p.0001), and 57.5% of malignant melanomas (p.0001). However, a statistically significant majority of melanomas (67.3%, p.0001) and basal cell carcinomas (60.4%, p.0001) were seen in women in patients aged 10 to 49 years. There was also a statistically significant increase in the female representation in patients aged 10 to 49 years as compared with those aged 50 to 99 years with respect to squamous cell carcinoma.Women comprise a statistically significant majority of patients with melanoma and basal cell carcinoma in the younger (10-49 years) age groups. This raises a concern regarding an increased future incidence of skin cancer in this population group and a demographic shift to increased female representation among patients with skin cancer.

Steatocystoma multiplex (SM) is a rare condition characterized by multiple, small, asymptomatic dermal cysts. Treatment options are limited, with varying degrees of success; these include oral isotretinoin, surgical excision or drainage, and liquid nitrogen cryotherapy. The most effective method is excision, but cosmetic considerations, time, overall cost, and pain must be considered, because patients tend to have multiple cysts. Lasers, especially nonablative devices, have not frequently been used to treat SM. Herein, we present the case of a patient with isolated steatocystoma multiplex on the abdomen and lower chest with substantial clearance after two laser treatment sessions using two complementary lasers: a 1,450-nm diode laser to target the abnormal sebaceous glands and a 1,550-nm fractionated erbium-doped fiber laser to target the dermal cysts.

BACKGROUND Ontario is one of the most underserved provinces in Canada for providing Mohs micrographic surgery (MMS). A new MMS clinic was opened in Ottawa, Ontario, in June 2009 to help combat the increasing incidence of nonmelanoma skin cancer (NMSC) in this region. OBJECTIVE To prospectively compare MMS cases completed in Ottawa with cases completed in Houston, Texas, and examine the differences in tumor characteristics. MATERIALS AND METHODS The first 150 cases performed in Ottawa were prospectively compared with 150 consecutive cases performed at a Mohs surgery clinic in Houston, Texas. Patient demographics, tumor diagnosis, primary or recurrent disease, tumor dimension, number of surgical stages, defect size, complexity of the procedure, and closure method were compared. RESULTS The average preoperative tumor area was three times as great in Ottawa as in Houston. Almost one entire additional stage was required to clear the tumors treated in Ottawa. Postoperative defects were 87% larger in Ottawa. The number of advanced reconstructive repairs was significantly higher in Ottawa (93%) than Houston (14%). CONCLUSIONS A significantly higher NMSC disease burden and greater surgical complexity was observed in the tumors treated in Ottawa than in Houston. The authors have indicated no significant interest with commercial supporters.

BACKGROUND Pigmented lesions include solar lentigines, seborrheic keratoses, dermatosis papulosa nigra, ephelides, cafe-au-lait macules, nevus spilus, Becker's nevus, postinflammatory hyperpigmentation, melasma, nevocellular nevi, congenital nevi, junctional and compound melanocytic nevi, nevus of Ota and Ito, Hori's nevus, and blue nevi. Advances in laser technology have resulted in the ability to treat pigmented lesions with greater safety and efficacy. OBJECTIVE To review the literature on the use of cutaneous laser treatments for pigmented lesions using Medline. RESULTS The literature cited the use of various lasers to treat pigmented lesions, including argon, carbon dioxide, erbium-doped yttrium aluminum garnet, Q-switched, long-pulsed ruby, alexandrite, diode, and fractional lasers. For each lesion, we describe the efficacy of laser treatments, treatment intervals, and settings used for a variety of diagnoses. CONCLUSION The treatment of pigmented lesions continues to evolve as new laser technology emerges and improvements in existing devices are made. The ability to treat pigmented lesions with greater efficacy and safety has resulted from recent advances in laser technology.

BACKGROUND Defects of the scalp often pose a reconstructive challenge in dermatologic surgery. OBJECTIVE We report our experience with the H-plasty type of bilateral advancement flap for the closure of small to medium-sized scalp defects that cannot be closed primarily. METHODS In this case series study, 69 scalp defects 1.5 to 3.0 cm in diameter that could not be closed primarily were repaired using the H-plasty type of bilateral advancement flap. RESULTS Sixty-nine 1.5- to 3.0-cm-diameter scalp defects resulting from Mohs micrographic surgery that could not be closed primarily were identified over the 2-year study period. All 69 defects were closed entirely with the bilateral advancement flap, and there were no significant complications. CONCLUSIONS The H-plasty type of bilateral advancement flap allows appropriately selected scalp defects that might not be readily closed primarily to be repaired easily using local skin, providing an attractive alternative to other flap techniques, skin grafting, and healing via secondary intention. The limitations of this study are that the results are based on a retrospective single-surgeon experience and that there was no long-term follow-up scheduled to evaluate the final cosmetic outcome of the repair. The authors have indicated no significant interest with commercial supporters.

These changes often occur gradually asa person ages but can develop earlier if extensive UVexposure and photodamage have taken place. Whenpatients present early with photodamage, their con-cerns are often cosmetic, inquiring about treatmentsfor rhytides, skin roughness, laxity, and mottledappearance.

Background Immunohistochemical staining has been used to help detect malignant melanoma on Mohs surgery frozen sections. Previous investigators have developed protocols for reliable MART-1 immunostaining of frozen sections, but these protocols are time-consuming. Objective The objective was to report a rapid 20-minute MART-1 immunostaining protocol for frozen sections. Methods The protocol was utilized on 30 melanomas treated with Mohs micrographic surgery. Results The stain clearly highlighted normal background melanocytes, as well as melanocytic hyperplasia and malignant melanoma. Conclusions The 20-minute protocol provides a rapid and reliable method for immunostaining of malignant melanoma. The availability of more rapid immunostaining methods improves efficiency of the Mohs laboratory and significantly reduces patient and physician waiting time. The authors have indicated no significant interest with commercial supporters.

BACKGROUND The standard treatment for cutaneous melanoma in situ is surgical excision followed by standard pathologic evaluation. Serial cross-sectioning (bread-loafing) may result in false negative margin examination and higher local recurrence rates than Mohs micrographic surgery, which histologically evaluates the entire surgical margin. OBJECTIVE To estimate the sensitivity of bread-loafing in detecting residual melanoma in situ at surgical margins. METHODS A retrospective study was performed including 36 cases of melanoma in situ treated with Mohs surgery with positive margins after initial excision with 5 mm margins. The length of the margin involved with melanoma was measured. The ability of bread-loafing to detect residual tumor was calculated. RESULTS The average linear extent of tumor at the surgical margin was 1.4 mm. Bread-loafing at 1, 2, 4, and 10 mm intervals would have a 58, 37, 19, and 7% chance of detecting positive margins, respectively. In order to detect 100% of positive margins, bread-loafing would have to be performed every 0.1 mm. CONCLUSION Bread-loaf cross-sections through excised melanoma specimens are inherently unreliable for detecting residual melanoma at the surgical margins. We recommend complete histologic margin control of the entire surgical margin using en-face tissue orientation (Mohs technique) to reduce the risk of recurrence.

Unlike selective photothermolysis, which produces bulk thermal injury to specific targets in the skin, fractional photothermolysis (Fraxel, Reliant Technologies, Inc., Mountain View, CA) creates hundreds of microthermal treatment zones (MTZs) while sparing the surrounding tissue. We report marked improvement of postinflammatory erythema after the resolution of inflammatory acne vulgaris in two patients after one treatment session with fractional photothermolysis.

BACKGROUND Treatments for hypopigmented scars have shown limited efficacy and variable safety profiles. OBJECTIVE This study evaluated the safety and efficacy of fractional resurfacing (1,550-nm Fraxel SR laser, Reliant Technologies, Mountain View, CA) for the treatment of hypopigmented scars on the face in seven patients. MATERIALS AND METHODS Seven patients with hypopigmented scars on the face received between two and four successive treatments at 4-week intervals with the 1,550-nm Fraxel SR laser. Energy settings ranged from 7 to 20 mJ and a total density of 1,000 to 2,500 microthermal zones per square centimeter. Digital photographs were taken before each treatment and at 4 weeks after the last treatment. Independent physician clinical assessments were performed. RESULTS Independent physician clinical assessment 4 weeks after the final Fraxel SR laser treatment revealed improvements of 51% to 75% in hypopigmentation in six of seven patients. One patient had only 26% to 50% improvement in hypopigmentation. Additionally, clinical improvements were noted in the overall texture of the treated skin. The patient's degree of satisfaction paralleled the physician's assessment of improvement. All patients reported improvement in hypopigmentation lasting greater than 3 months after the last treatment. Side effects were limited to mild pain during the treatment and mild posttreatment erythema and edema, which resolved in 2 to 4 days. CONCLUSION Fractional resurfacing is a potentially effective modality for the treatment of hypopigmented scarring on the face. No adverse effects were observed.

BACKGROUND There are many closure techniques and suture types available to cutaneous surgeons. Evidence-based data are not available regarding the frequency of use of these techniques by experienced practitioners. OBJECTIVE To quantify, by anatomic site, the frequency of use of common closure techniques and suture types by cutaneous surgeons. METHOD A prospective survey of the members of the Association of Academic Dermatologic Surgeons that used length-calibrated visual-analog scales to elicit the frequency of use of specific suture techniques. RESULTS A response rate of 60% (61/101) indicated reliability of the received data. Epidermal layers were closed most often, in descending order, by simple interrupted sutures (38–50%), simple running sutures (37–42%), and vertical mattress sutures (3–8%), with subcuticular sutures used more often on the trunk and extremities (28%). The most commonly used superficial sutures were nylon (51%) and polypropylene (44%), and the most common absorbable suture was polyglactin 910 (73%). Bilayered closures, undermining, and electrocoagulation were used, on average, in 90% or more sutured repairs. The median diameters (defined as longest extent along any axis) of most final wound defects were 1.1 to 2.0 cm (56%) or 2.1 to 3.0 cm (37%). Fifty-four percent of wounds were repaired by primary closure, 20% with local flaps, and 10% with skin grafting, with the remaining 15% left to heal by second intent (10%) or referred for repair (5%). Experience-related differences were detected in defect size and closure technique: defects less than 2 cm in diameter were seen by less experienced surgeons, and defects greater than 2 cm by more experienced surgeons (Wilcoxon's rank-sum test: p=.02). But more experienced surgeons were less likely to use bilayered closures (r=−0.28, p=.036) and undermining (r=−0.28, p=.035). CONCLUSIONS There is widespread consensus among cutaneous surgeons regarding optimal suture selection and closure technique by anatomic location. More experienced surgeons tend to repair larger defects but, possibly because of their increased confidence and skill, rely on less complicated repairs.

Background. The occurrence of basal cell carcinoma within a port-wine stain or nevus flammeus is rare. Sixteen cases of basal cell carcinoma which developed in a port-wine stain or nevus flammeus have been reported. Objective. The objective was to demonstrate a rare case of basal cell carcinoma occurring in a port-wine stain successfully treated with Mohs micrographic surgery. Methods. This is a case report and literature review. Results. An 87-year-old man presented with a basal cell carcinoma on the margin of a previously untreated port-wine stain on the left cheek. Histologic examination showed a nodular basal cell carcinoma. The basal cell carcinoma was completely excised with Mohs micrographic surgery and complex linear closure was used to repair the wound in layers. The postoperative course was complicated by a hematoma, which developed 24 hr postoperatively. The hematoma was drained and there was no further bleeding or evidence of recurrence of the tumor after 12 months. Conclusion. Basal cell carcinoma should be included in the differential diagnosis of a skin lesion occurring in a port-wine stain.

BACKGROUND. Increases in complications resulting from the nonphysician practice of dermatologic procedures have been reported nationally. This investigation was initiated owing to growing concern regarding the nonphysician practice of medicine in Texas. OBJECTIVE. The objective was to survey dermatologists in Texas to determine the number of patients seeking corrective treatment owing to complications from dermatologic procedures performed by nonphysicians. METHODS. A total of 488 dermatologists in Texas were surveyed and seven patients who experienced complications were interviewed by phone. RESULTS. Nearly 53% of responding physicians noted increased complications resulting from nonphysician practice of medicine. Approximately 33% of responding physicians reported that complications were known to have occurred in the absence of an on-site supervising physician. CONCLUSION. The increase in the number of complications owing to nonphysician practice of medicine in Texas mirrors the increases that have been reported nationally. The serious complications reported underscore the need for improved awareness and regulatory changes by state boards of medicine.

Reconstruction of cutaneous eyebrow defects is a challenge, as eyebrow positioning provides an important role in communication, cosmesis, and signaling age, gender, and emotional status. Special consideration must be paid in order to maintain eyebrow symmetry and to avoid distortion of the hairline.To demonstrate reconstructive options for the eyebrow that preserve maximal function and cosmesis.The anatomy and function of the eyebrow are reviewed. Descriptions of five techniques of eyebrow reconstruction are then presented, including specific limitations and benefits of each closure option. Pertinent details regarding flap mechanics, design, and patient selection are also included.There are several options available for reconstruction of the eyebrow. Each closure method has advantages and disadvantages. The selection must be individualized, depending on the extent and location of the eyebrow defect relationship to other structures, gender, and age of patients. Each of the five closure options aid to maintain the function and aesthetic appearance of the eyebrow.Understanding the unique anatomy and function of the eyebrow, including its movement in facial expression, is useful in achieving good reconstructive outcomes while maintaining normal eyebrow function.

Background. The 1450-nm diode laser has been found to damage sebaceous glands selectively and to be effective for the treatment of inflammatory acne on the back. Objective. To evaluate the efficacy and safety of the 1450-nm diode laser in the treatment of inflammatory facial acne vulgaris. Methods. Nineteen patients with inflammatory facial acne were treated with the 1450-nm diode laser at 4- to 6-week intervals. There was no control group. Clinical photographs and lesion counts were obtained at baseline and after each treatment. Subjective evaluation of response to treatment and pain was assessed using a questionnaire. Results. All patients had a reduction in acne lesions. Lesion counts decreased 37% after one treatment (p

Background. Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. Objective. To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Methods. Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. Results. Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or “slits” are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 μm (53.9%) and less frequently at 4 μm (21.9%). Conclusion. There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.

background. Antithrombotic medications may increase perioperative bleeding during cutaneous surgery. Whether to discontinue these medications before surgery is controversial. objective. To evaluate the available evidence in order to generate preliminary guidelines regarding the perioperative use of antithrombotics. methods. Presentation of two cases of adverse events after preoperative discontinuation of antithrombotics, review of current anticoagulant and antiplatelet drugs, and review of the literature concerning perioperative antithrombotics in cutaneous surgery. results. Perioperative withholding of antithrombotics in cutaneous surgery may be associated with serious adverse vascular events. Continuing antithrombotics in these circumstances does not appear to significantly increase bleeding complications. The complexity of available antithrombotics makes case-by-case determinations regarding their use difficult. conclusion. Cutaneous surgeons should strongly consider perioperative continuation of patients' antithrombotic drugs. The final determination should be made by the surgeon after evaluation of the circumstances and, if necessary, consultation with other experts.

Background. Primary basal cell carcinoma (BCC) in the axilla has rarely been reported in the literature. No systematic review has yet been conducted. Objective. To present a case of basal cell carcinoma of the axilla. This is a rare presentation of a common disease in a non-sun-exposed part of the body. Methods. An extensive literature search for axillary BCCs was performed. An additional case is reported. Results. Only 14 cases of primary axillary BCC have been reported in the literature. Metastatic axillary BCC is also rarely reported. Conclusion. BCC in the axilla is extremely uncommon. Factors other than sun exposure are likely involved in tumorigenesis.

Background. Granular cell tumors are uncommon soft tissue neoplasms of neural origin that most often arise in the oral cavity. Penile lesions are distinctly uncommon. Mohs micrographic surgery (MMS) is a highly effective treatment for several cutaneous neoplasms when tissue conservation is crucial. Objective. To examine the use of MMS for this soft tissue malignancy. Methods. We report only the eighth granular cell tumor of the penis. The literature was reviewed regarding the use of MMS for these neoplasms. Results. MMS was performed to minimize the destruction of normal tissue in treating this patient's granular cell tumor. Only one previous article documented the use of MMS for this soft tissue tumor. Conclusion. Although utilized infrequently to treat granular cell tumors, MMS may prove beneficial when lesion location or size render tissue conservation or assuredness of cure paramount.

Chordomas are rare neoplasms that arise from the notochord remnant. They develop in the sacrococcygeal (50%) or cervical (15%) region and are generally regarded as a locally aggressive tumor with a slow progressive growth rate and a metastatic incidence ranging from 3 to 48%. Skin involvement by chordoma is rare, but can occur by direct extension, by local recurrence and by metastases.To illustrate by a case report the clinical presentation and management of this disease.We present a case of sacral chordoma with metastases over a 10-year period to the lungs, the soft tissue of the chest wall, the triceps tendon, and distant cutaneous metastases to the back and the nose.The cutaneous metastases were treated by excision.Chordoma is a slow growing tumor of the notochord remnant that may metastasize to the skin. Physicians and pathologists should be aware of this entity.

Objective. This article describes a new subtype of actinic keratosis that exhibits proliferative characteristics both histologically and clinically. We describe three representative cases occuring in the presence of infiltrative squamous cell carcinoma (SCC) and/or basal cell carcinoma (BCC). Methods. Histories of each lesion in the three cases discussed were obtained. The lesions were removed by Mohs micrographic surgery. Permanent sections, stained with hematoxylin and eosin, were examined and studied under light microscopy. Results. All three lesions had failed conventional treatment with liquid nitrogen and/or 5-fluorouracil (5-FU). Histologic examination of the lesions revealed sheets of dysplastic cells growing along the basal layer of the epidermis and migrating down hair follicles and sweat ducts. An associated infiltrative SCC and/or BCC was found in each case. Conclusions. Proliferative actinic keratosis is resistant to standard therapies because of deep migration of abnormal cells along hair follicles and sweat ducts. It has a strong propensity to develop infiltrative SCC and may occur concomitantly with BCC.

Amelanotic melanomas comprise only 2% of melanomas and are commonly a difficult clinical diagnosis, due to the lack of melanin pigment typically found in melanomas. Even rarer is the amelanotic lentigo maligna, which may have an unusual clinical presentation, such as erythema, pruritus, or edema. Biopsy is the key to diagnosis. Multiple therapies for amelanotic lentigo malignas have been tried, but excision, with margin control (Mohs micrographic surgery-frozen or paraffin sections), remains the treatment of choice.

Background. Merkel cell carcinoma (MCC) is a rare, aggressive, cutaneous neoplasm. The primary form of initial treatment is wide surgical excision. The use of Mohs micrographic surgery as the primary form of treatment in MCC has been controversial. The course of MCC is often aggressive, with early metastasis, widespread disease, and death. Despite the poor prognosis, spontaneous regression has occasionally been reported. Objective. We describe the clinical course of two patients with Merkel cell carcinoma who underwent treatment with Mohs micrographic surgery for the primary MCC. Metastases were excised in the first case and spontaneously regressed in the second. Both patients are without clinical disease at the time of this report. Methods. Histopathology, clinical records, and the current literature are reviewed. Results. One patients was without recurrence of MCC for 13 years of follow-up. The other patient experienced clinical spontaneous remission after nodal spread of the disease, with no recurrence for 18 months after clinical remission and 24 months after surgery. Conclusion. The treatment of Merkel cell carcinoma with Mohs micrographic surgery (MMS) has been successful for the control of primary skin disease, and is at least comparable to wide excision. Spontaneous regression may occur in the course of this usually relentless and aggressive disease. The explanation for spontaneous regression of MCC is unknown.

background. Reconstruction of defects of the distal nose/colu-mella region present a challenge both esthetically and functionally. objective. To describe the use of nasal floor tissue as an inferiorly based transposition flap for closure of distal nose/columella defects. methods. Mohs micrographic surgery for excision of basal cell carcinoma was performed on the distal nose/columella area of a patient. The resultant defect was closed using an inferiorly based transposition flap elevated from the nasal floor. Other closure options for this region are discussed. conclusion. The nasal floor flap allowed the reconstruction of a properly contoured columella and distal nose.

background. Cancer of the skin may be difficult to diagnose clinically if there are minimal skin findings on examination. objective. To remind physicians that the symptoms of squamous cell carcinoma (SCO may precede physical signs of the tumor. methods. Perineural invasion of SCC was confirmed by histologic examination of surgical specimens. results. We present two patients whose initial presentation of SCC was facial pain due to extensive perineural invasion. Their diagnoses were delayed until skin lesions eventually became evident months later. conclusion. Early detection can be lifesaving, thus emphasizing the importance of including skin cancer in the differential for facial pain or paresthesia.

BACKGROUND One option for the treatment of cutaneous tumors in the vent elderly has been simple observation. However, the combination of an increasing elderly population and a concomitant high incidence of skin cancer will make this problem more common. OBJECTIVE To assess the suitability of Mohs micrographic surgery as a treatment modality for skin cancer in the 90 years and older age group. METHODS A group of patients who underwent Mohs surgery from January 1988 to August 1996 aged 90 years and older was identified, and tumor type, site, comorbid medical conditions, medications, and surgical complications were recorded. RESULTS A total of106 basal cell carcinomas (BCCs), 33 squamous cell carcinomas (SCC) six melanomas, and one basosquamous carcinoma were resected from 115 patients with an average age of 92.4 years. The overall ratio of BCC/SCC was 3.2 BCCs occurred most commonly on the face; SCCs were found more frequently on the cheeks. Patients had an average of 1.9 comorbid medical conditions and took an average of 2.3 regular medications. One complication occurred. CONCLUSION . Mohs surgery is a safe and effective therapy for those over 90 years of age.

BACKGROUND Alar defects present a reconstructive challenge. OBJECTIVE To define closure options for alar defects of variable thickness and location. METHODS The repair options for closure of alar defects are reviewed and discussed with regard to depth of defect and complexity of reconstruction. CONCLUSION Surgeons repairing defects of the nose should develop a variety of reconstructive approaches for the ala including but not limited to those presented here. © 1997 by the American Society for Dermatologic Surgery, Inc. Dermatol Surg 1997;23:335–349. LEARNING OBJECTIVES After studying this article, participant should be able to: 1Understand the anatomy of the nasal ala. 2Develop a logical reconstructive approach to alar defects based on location and depth. 3Understand the advantages and disadvantages of commonly used reconstructive techniques.

background Hematoxylin and Eosin (H&E) is the most common stain used for Mohs frozen sections. Toluidine blue (T-blue) is a metachromatic stain that has been frequently utilized for this purpose. objective To compare the cytologic and stromal staining patterns of each stain for Mohs frozen sections of squamous cell carcinoma (SCC and basal cell carcinoma (BCC), and to identify the advantages and disadvantages of each technique. results T-blue revealed stromal change associated with the presence of BCC and SCC. H&E provided more prominent visibility of individual cell keratinization and necrosis, which are common features seen in SCC. conclusion We found T-blue to be fast and effective in identifying mucopolysaccharides in stroma associated with basal cell carcinoma. For this reason, T-blue is our preferred stain for BCCs, while H&E can provide greater ease of identification of histologic features of SCCs.

BACKGROUND. In our Mohs surgery practice, a large number of basal cell carcinomas (BCCs) occurring on the neck were noted to be of the superficial type. OBJECTIVE. Our purpose was to examine a series of consecutive cases of BCC on the neck. METHODS. We reviewed all cases of BCC on the neck that were treated in our Mohs surgery unit from 1988 to 1993. Permanent histologic sections of the BCCs, obtained by excisional debulking of the tumors, were examined and the BCCs were typed histologically. Each histologic type was correlated with the patient's age, race, sex, its location on the neck, and its status as either a primary or recurrent lesion. RESULTS. In total, 97 BCCs on the neck from 93 patients were examined. All patients were Caucasians with an average age of 62.7 years. A peak incidence in the fifth decade occurred in males while this peak occurred in the eighth decade for females. Males outnumbered females 3.4 :1. The type and incidence of each BCC was studied with the following results : superficial (38.1%), mixed-superficial (30.0%), nodular (15.5%), infiltrative (7.2%), morpheaform (5.1%), adenoid (2.1%), keratotic (1.0%), and metatypical (1.0%). Fifty-one percent of the tumors were primary and 49% were recurrent. The most common location on the neck was the skin overlying the superior aspect of the sternocleidomastoid muscles. CONCLUSION. BCCs occurring on the neck were most commonly of the superficial type.

BACKGROUND Few satisfactory closure options exist for large anterior auricular defects. OBJECTIVE To describe the use of the postauricular (revolving door) island pedicle flap for closure of large defects on the scapha, antihelix, and helix. METHODS Mohs micrographic surgery for excision of basal cell carcinoma was performed on the anterior auricular surface of two patients. Both defects were closed using a posterior auricular island flap that was advanced through cartilage with excellent cosmetic results. Other closure options are discussed for this region. CONCLUSION The postauricular (revolving door) island pedicle flap is a good closure option for large anterior auricular defects lacking perichondrium and not easily repaired by other methods.

background Due to the ear's complicated anatomy and closely adherent anterior skin, repairing ear rim defects is often difficult. objective We describe a simple postauricular cutaneous advancement flap for correcting ear rim defects of varying sizes. methods Skin tumors involving the ear rims of 12 patients were excised. A postauricular cutaneous advancement flap was designed to correct the resulting defects. results The postauricular cutaneous advancement flap provided excellent cosmetic results in our 12 patients. Minimal superficial necrosis of the flap was observed in one patient. conclusion Utilizing relatively loose postauricular skin, this postauricular advancement flap can cover helical rim defects of varying sizes with excellent cosmetic results and low complication rates.

BACKGROUND Basal cell carcinoma (BCC) is the most common malignancy in whites, but it rarely occurs in dark persons. OBJECTIVE To report a BCC on the hairy scalp of an Asian Indian female with no obvious risk factors except previous scalp trauma. METHODS We review the English literature concerning BCC in Indians, and compare this with data for North American blacks and whites; and reports of BCC arising in areas of prior trauma. RESULTS/CONCLUSION Skin cancer accounts for 1–2% of malignancies in blacks and Indians, compared with one-third of neoplasms in whites. BCC comprises 75% of skin cancers in whites, but squamous cell carcinoma represents 60–65% of skin cancers in blacks and Indians. Although most BCCs occur in sun-exposed areas in whites, blacks, and Indians, a significant percentage also develop in photoprotected areas. Trauma may be a significant risk factor for BCC, either with actinic damage or alone, as in our case.