Search

ObjectiveTo analyse the treatment results of bilobed flap reconstruction performed for skin defects after parotid carcinoma surgery.MethodTen patients who underwent bilobed flap reconstruction for skin defects after parotid carcinoma surgery in our hospital, from 2014 to 2020, were retrospectively enrolled.ResultsAll patients underwent bilobed flap reconstruction for skin defects after parotid carcinoma surgery. The size of the skin defect was 2.7 × 2.2 cm in the smallest dimension and 9.0 × 6.3 cm in the largest dimension. All bilobed flaps except one healed without any problems. One patient developed partial flap necrosis in the retroauricular region, and was treated with skin grafts after removal of the necrotic tissue under local anaesthesia. All bilobed flaps, including the cases in which skin grafts were performed, survived after post-operative radiotherapy or chemotherapy.ConclusionA bilobed flap is a good reconstruction option for skin defects after parotid carcinoma surgery in some cases.

Background: Venous malformations (VMs) are congenital vascular malformations that grow progressively and never resolve on their own. Cutaneous VMs are difficult to treat due to risk of injury and d...

BACKGROUND/AIM This study evaluated the incidence of perioperative complications in jejunal flap compared with the free tissue flap approach. PATIENTS AND METHODS This study included 75 patients who underwent free flap reconstruction for hypopharyngeal carcinoma. The primary outcome was the incidence of pharyngocutaneous fistula, and the secondary outcomes were perioperative complications. RESULTS Pharyngocutaneous fistula developed in 7% of patients who underwent jejunal flap procedures and 6% of patients who underwent free tissue flap procedure. Flap sampling site complications occurred in 23% of patients who underwent jejunal flap procedures and in none of the patients who underwent free tissue flap procedure. CONCLUSION No significant difference was observed in the incidence of pharyngocutaneous fistula between the two groups (p=0.99), but complications at the flap sampling site were significantly more common in jejunal flap procedures than in free tissue flap procedures (p=0.03). Free tissue flap procedures are potential reconstruction methods superior to jejunal flap methods.

Background Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. Objective To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. Materials and methods Multi-center, prospective discrete choice experiment (DCE). Results Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. Conclusion Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

The management of complex diabetic foot wounds with large skin defects poses a challenge for surgeons. We presented a simple skin stretching system and negative pressure wound therapy for the repair of complex diabetic foot wounds to examine the effectiveness and safety.A total of 16 patients with diabetic foot ulcers were retrospectively reviewed between January 2015 and October 2020. All patients underwent the treatment by 3 stages. In stage 2, these difficult-to-close wounds of diabetes foot were residual. This method was applied to the wounds with a median defect size of 20.42 cm2 (range, 4.71–66.76 cm2).The median time for closure of complex diabetic foot wounds was 14 days ranging from 8 to 19 days. With respect to the absolute rates of reduction, it was observed with a median of 1.86 cm2/day, ranging from 0.29 cm2/day to 8.35 cm2/day. In accordance with the localization of the defect, the patients were divided into 3 groups: side of the foot (37.5%), dorsum of the foot (50.0%), and others (12.5%). There was no statistical difference between side of the foot and dorsum of the foot in terms of the median defect size with P = 0.069 (Kruskal–Wallis test). Otherwise, there were statistically significant differences regarding the median time and the median absolute rates (P < 0.05; Kruskal–Wallis test). No severe complications were encountered in this study.In summary, our results show that application of the simple skin stretching system and NPWT is an effective and safe approach to complex diabetic foot wounds. Nevertheless, more attention should be paid to the appropriate patient selection and intraoperative judgment to ensure wound closure and avoid undue complications.

Introduction We evaluate a single center’s, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). Study design Patients undergoing keloid treatment were identified (2008–2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. Results 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1–53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6–30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p Conclusions MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

Introduction Basal cell carcinoma is the most common cancer. Excisional surgery is associated with a high clearance rate, at the expense of significant functional and aesthetic morbidity, especially within the T-zone or for extensive lesions. We report five-year follow-up outcomes for carbon dioxide laser extirpation of cutaneous basal cell carcinoma, assisted by immediate methyl aminolevulinate photodynamic therapy and cost–benefit considerations. Materials and methods Retrospective cohort database analysis of adult patients with biopsy-proven primary cutaneous basal cell carcinoma, completing five years of follow-up. Direct per-lesion cost was compared with conventional wide local excision. Patients with morphoeic basal cell carcinoma were excluded. Results Treated lesions were up to 1% total body surface area and up to 3.8mm (1.38 ± 0.695cm, mean ± standard deviation) in biopsy-proven depth. At the five-year follow-up mark, 93.6% of treated areas remained free of recurrence. Nodular basal cell carcinoma was the most common subtype (41.5%). A mean tumour depth greater than 2 ± 0.872mm was significantly associated with recurrence (Mann–Whitney, p = 0.0487). For a service delivered through the NHS at 2015 prices, we report a 43% saving, equating to a saving of £235 per basal cell carcinoma or a national annualised saving of £70 million by 2025 for the NHS. Conclusion Our results suggest that CO2-assisted photodynamic therapy is non-inferior to excision but may offer better functional and cosmetic preservation at a fraction of the direct like for like cost of operative surgery. Investigation of this method by randomised controlled methodology is warranted.

BACKGROUND Glomus tumors are benign neurovascular neoplasms, most commonly located in the subungual region. These subcutaneous nodules are characterized by intense pain and temperature sensitivity. Although surgical excision is the curative treatment, permanent nail deformity and recurrence are not uncommon after conventional surgery. OBJECTIVE This study evaluated the long-term efficacy of a modified transungual approach with nail preservation for removing subungual glomus tumors. MATERIAL AND METHODS Thirty-nine patients with clinically diagnosed and histopathologically proven glomus tumors treated at a medical center over a 13-year period (2007-2019) were retrospectively evaluated. RESULTS The 39 patients included 28 women and 11 men (ratio, 2.5:1), with a mean age of 48.9 years. Thirty-four tumors were located in the fingers and 5 in the toes. All patients returned to normal activity soon after the surgery. At a mean follow-up of 28.8 months, all were pain free or experienced minimal pain and were satisfied with treatment outcomes. One patient (2.6%) experienced recurrence. No nail deformity was observed. CONCLUSION The transungual approach with nail plate preservation is a novel and effective method for removing subungual glomus tumors with reduced postoperative pain and rapid healing, while preserving or improving the configuration of the nail.

Objective: New technologies are being developed to optimise healing of surgical incisions. BandGrip (US) is a micro-anchor skin closure device that replaces the need for subcuticular suturing and further dressing. The purpose of this study is to perform a matched cohort analysis comparing time to closure of surgical incisions between sutures and the novel skin closure device. Method: Patients undergoing orthopaedic surgery in 2019 underwent skin closure with either conventional sutures or the novel skin closure device. Patients were divided into three groups according to their procedural incisions: anterior cruciate ligament reconstruction (ACLR); simple arthroscopy; and general incisions. Patients who underwent closure of their surgical incision with the novel skin closure device were matched with patients undergoing superficial closure with sutures. Statistical analysis was performed to compare time to closure per centimetre of skin incision between the groups. Results: A total of 86 patients were included in the study. Overall mean time to closure using the novel skin closure device was less than with sutures (8.6 seconds/cm versus 42.8 seconds/cm, respectively, pConclusion: BandGrip is a novel skin closure device that allows for efficient surgical incision closure. Time to surgical skin incision closure is significantly less with the use of the novel skin closure device when compared with conventional sutures.

Cranial and cervical nerve (CCN) injury is recognized as a possible complication after carotid endarterectomy (CEA), which may result in minor local neurologic deficiencies and significant discomfort for the patient. The aim of this study is to investigate the effect of a mini-skin incision (5 cm) on the CCN injury after CEA in comparison to standard longitudinal incision of 12-15 cm in a high volume center, and to evaluate health-related quality of life (HRQOL) outcomes in those patients who had undergone both types of the skin incision.From January 2013 to December 2019, 446 CEAs (47.3%) were performed through a standard neck incision of 12-15 cm (group A), while 496 (52.7%) were performed through a mini-skin incision (5 cm) (group B). Sixty-two patients underwent standard neck incision on one side and mini-skin incision on the other side (subgroup B). The main outcome measures were stroke, death, CCN injuries, cervical hematoma rates, and reinterventions. The HRQOL was assessed at baseline and after 30 days using Medical Outcomes Study Short-Form 36 and 6 disease-specific modified Likert scales.The stroke and death rate at 30 days was 1.12% in group A and 1% in group B (P = 1). The incidence of CCN deficits was significantly lower in group B (5.1%) in comparison to group A (13.4%) (P 0.001). The cervical hematoma was more common after standard incision (4.9% vs. 1.2%, P = 0.02). HRQOL at 1 month showed that the outcomes after mini-skin incision were significantly better for less difficulty with eating/swallowing and neck pain (P 0.01).CEA through a small incision (5 cm) may reduce CCN complications without additional perioperative neurologic risks. As validated by patients with bilateral disease who experienced both surgical techniques, mini-skin incision is also associated with better HRQOL at 1 month, particularly with regard to eating/swallowing and neck pain.

Background Merkel cell carcinoma (MCC) management typically includes surgery with or without adjuvant radiation therapy (aRT). Major challenges include determining surgical margin size and whether aRT is indicated. Objective To assess the association of aRT, surgical margin size, and MCC local recurrence. Methods Analysis of 188 MCC cases presenting without clinical nodal involvement. Results aRT-treated patients tended to have higher-risk tumors (larger diameter, positive microscopic margins, immunosuppression) yet had fewer local recurrences (LRs) than patients treated with surgery only (1% vs 15%; P = .001). For patients who underwent surgery alone, 7 of 35 (20%) treated with narrow margins (defined as ≤1.0 cm) developed LR, whereas 0 of 13 patients treated with surgical margins greater than 1.0 cm developed LR (P = .049). For aRT-treated patients, local control was excellent regardless of surgical margin size; only 1% experienced recurrence in each group (1 of 70 with narrow margins ≤1 cm and 1 of 70 with margins >1 cm; P = .56). Limitations This was a retrospective study. Conclusions Among patients treated with aRT, local control was superb even if significant risk factors were present and margins were narrow. We propose an algorithm for managing primary MCC that integrates risk factors and optimizes local control while minimizing morbidity.

Melasma is a complex pigmentary disorder with challenging management.Evaluation of efficacy of topical tranexamic acid (TXA) versus Vitamin C (Vit C) with microneedling (MN) in melasma therapy.In 30 females with melasma, after 4 weeks of using Modified Kligman's formula, the right side of the face was treated with MN + TXA and the left with MN + Vit C for five biweekly sessions. Wood's light, dermoscopy, Melasma Area and Severity Index (MASI), MASI malar right and malar left (MASIBoth MASIMN followed by Vit C or TXA is successful in melasma management, the latter being advantageous vis-a-vis dermal vascularity and epidermal pigmentation. Dermoscopic evaluation appears crucial in choosing optimum treatment in each patient.

OBJECTIVE Various skin incision methods have been reported for reduction mammoplasty and mastopexy. This report describes a new incision method that may improve on conventional methods, particularly with respect to prevention of hypertrophic scars. METHODS We developed a comma-shaped incision method that results in fewer scars and less strain on the suture line. We then applied this new method to two cases, namely, one case of breast reduction and one case of breast fixation. RESULTS In both cases, we achieved good results. There was no scar at the inframammary fold, and no hypertrophic scar formation. All scars were within the breast area and were not in contact with the brassiere wire; hence, there was less pain after the operation. CONCLUSIONS We developed a new incision method for reduction mammoplasty and mastopexy.

Objective To demonstrate the efficacy of a protocol combining surgical excision and high-dose-rate brachytherapy for treatment of keloids. Methods The authors performed a unicentric retrospective cohort study between 2013 and 2018. The minimum follow-up was 12 months. All patients treated for keloids at the authors' institution were included. Extralesional excision was performed with placement of a brachytherapy sheath under the skin. The total dose of irradiation was 18 Gy. The postoperative results were evaluated for aesthetic and functional outcomes with a validated scale, as well as the presence or absence of recurrence. Results Fifteen patients were lost to follow-up. Thirty-eight patients with 67 keloids were included. The control rate was 94%. The aesthetic and functional outcomes were considered good in 62% of cases. The main limitation of the study was the small patient population. Conclusions Extralesional excision combined with postoperative high-dose-rate brachytherapy seems to be one of the most effective invasive protocols to treat and prevent keloids.

Objective The aim of the study was to identify the effectiveness of the combination of tissue stabilized guided subcision, microfocused ultrasound, and minimally invasive calcium hydroxylapatite injections in various sequences for treating skin surface irregularities of the buttocks and thighs. Material and methods 61 females (body mass index: 22.6 p 2.4 kg/ms, age: 37.2 p 6.8 years) were enrolled in this randomized interventional prospective study. Treatment arms included a variable combination and sequence of three treatment modalities: (1) Tissue-stabilized guided subcision, (2) microfocused ultrasound, and (3) calcium hydroxylapatite injections. Six months after the final intervention skin laxity and skin dimpling severity scores were assessed by the study participants, the treating physicians and by eleven blinded independent board-certified experts. Results No adverse events were observed during the study that required intervention outside the standard of care treatment protocol. The combination of three treatment modalities was shown to provide greater improvement in skin laxity 1.88 (95% CI, 0.66n5.37) and skin dimpling 1.31 (95% CI, 0.61n2.81) scores as compared to any combination of two modalities. The combination of concomitant microfocused ultrasound and calcium hydroxylapatite injections followed three months later by tissue stabilized guided subcision yielded the greatest improvement in skin laxity 2.23 (95% CI, 0.51n9.82) and skin dimpling 1.79 (95% CI, 0.67n4.78) at 9-month follow-up. Conclusion This study provides evidence for the effectiveness of combination therapies for the improvement of skin surface irregularities on the buttocks and thighs. J Drugs Dermatol. 2020;19(11): 1030-1038. doi:10.36849/JDD.2020.5117.

Different treatment modalities have been applied for nonmelanoma skin cancers (NMSCs) of the head and neck area. One of the most important points after surgical treatment is the selection of appropriate reconstruction methods. The aim of this study is to investigate the efficacy and feasibility of the use of both defect size reduction with sutures and secondary healing with delayed reconstruction with full-thickness skin grafts in NMSC patients. In total, 18 (42.8%) male and 24 (57.2%) female patients with NMSC were operated. Defect size was measured both after excision and just before repair, and the approximate defect area was calculated with ImageJ software. Reconstruction was performed after 14 days in all patients in the second session, using free skin grafts. There were 18 (42.8%) male and 24 (57.2%) female patients. The mean age was 70.5 (45–82) years. The mean follow-up period was 40.3 (16–68) months. The mean defect area measured after excision was 8.44 ± 1.91 cm2. After 14 days of delay, the mean defect area was 5.51 ± 1.28 cm2 (34.8% reduction) (p

Background Treatment practices vary for lentigo maligna (LM). Staged excision with circumferential margin control (SECMC) has the potential to achieve low recurrence rates. Objectives To evaluate the clinical outcomes of SECMC using permanent, paraffin-embedded sections and delayed reconstruction. Methods We conducted a retrospective, uncontrolled, observational cohort study involving patients who underwent staged excision for LM of the head and neck at Women’s College Hospital in Toronto, Canada, from September 2010 to March 2013. Recurrence and infection rates were ascertained from patient charts and postal surveys. Results One hundred and two patients (45 female, 57 male) were included with a median follow-up time of 1410.5 (IQR 260-1756) days. The median age was 69 (IQR 61-79) years. Approximately one-fifth (21%, 21/102) of patients required greater than 0.5 cm margins to achieve histological clearance. One patient (1/102) upstaged to invasive melanoma based on the initial stage of excision. The infection rate was 6% (6/102) and the 5-year cumulative recurrence rate was 1.4% (95% CI 0.2-9.6%). Conclusion SECMC using permanent sections and delayed reconstruction appears to be a safe and effective treatment method for LM on the head and neck. Randomized trials are needed to help define the optimal treatment.

Background Cutaneous angiosarcoma (CAS) is a rare, malignant tumor of vascular mesenchymal origin accounting for less than 1% of all sarcomas. Objective To examine epidemiologic trends and outcomes in CAS. Methods In this retrospective, population-based study, patients with CAS were identified from the Surveillance Epidemiology and End Results database. Age, sex, and race-standardized incidence rates (IRs) were calculated. Survival was assessed with Kaplan-Meier curves and Cox proportional hazards models. Results Of 811 patients with CAS, 43% had a prior primary cancer. CAS IR for patients without prior primary cancers dropped from 5.88 per 100,000 in 1973 to 1984 to 2.87 per 100,000 in 2005 to 2014. In those with prior primary cancers, IR rose from 0.03 per 100,000 in 1973 to 1984 to 2.25 per 100,000 in 2005 to 2014. On multivariate analysis, patients older than 70 years of age had a higher risk of death compared with those younger than 50 years (hazard ratio, 2.16; 95% confidence interval 1.33-3.57; P = .002), and distant disease was associated with increased risk of death compared with localized disease (hazard ratio, 1.50; 95% confidence interval, 1.11-2.03; P = .008). Receipt of surgery and/or radiation therapy was not associated with survival. Limitations Potential selection and miscoding bias, retrospective nature. Conclusion CAS rates are rising among those with other prior primary cancers. Survival is not affected by current therapeutic strategies, highlighting the need for additional treatment options.

Background It is unknown whether all thick melanomas share the same prognostic features. We present a large, multi-institutional study on thick melanoma, evaluating for factors prognostic of survival. Methods We queried the database of the Sentinel Lymph Node Working Group for patients with thick melanoma (>4 mm) who had a sentinel lymph node biopsy from 1993 to 2018. Clinicopathologic characteristics were correlated with overall survival. Results There were 1,235 patients with a median follow-up of 28 months. Median thickness was 5.9 mm, with 713, 356, and 166 cases having a thickness of >4 to 6, >6 to 10, and >10 mm, respectively. Ulceration was seen in 51.2% of cases, while sentinel lymph node metastases were seen in 439 of 1,235 (35.5%) cases. For melanomas >4 to 6 mm, age, thickness, ulceration, lymphovascular invasion, and sentinel lymph node metastasis were correlated with overall survival (all P 6 to 10 mm, only sex and sentinel lymph node metastasis were prognostic of overall survival (both P 10 mm, only sentinel lymph node metastasis predicted overall survival on multivariable analyses (P Conclusion Prognostic markers of overall survival for thick melanoma include thickness, ulceration, and sentinel lymph node metastasis, but also include other unique factors such as lymphovascular invasion. Moreover, certain prognostic markers for survival are associated with different subgroups of thick melanoma, which vary based on thickness group.

Basal cell carcinoma (BCC) is the most common skin cancer. While Mohs micrographic surgery is commonly accepted for BCC treatment, surgical excision with free margins is widely considered the best treatment modality for BCCs in Japan. However, little is known about the predictors of the invasion levels of BCCs.To investigate the optimization of deep surgical margins by identifying factors significantly influencing the invasion levels of facial BCCs.The tumor invasion level was defined as the deepest part of a tumor. Tumor thickness was measured from the top of the granular layer to the deepest extension of the tumor or from the ulcer base overlying the deepest point of invasion in ulcerated lesions. Factors independently associated with tumor thickness and invasion level were identified by multivariate analysis. Six variables were tested: age, sex, anatomical region (nose, orbit, others), histologic pattern (aggressive, non-aggressive), presence of pigmentation, and diameter.We included 718 cases of facial BCCs involving 705 Japanese patients. The most frequent anatomical region and histologic pattern were the nose and nodular pattern, respectively. Only tumor diameter showed a correlation with tumor thickness (β = 0.377, P0.001). Tumor diameter (AOR = 71.189, 95 % CI: 11.420-430.931, P = 0.01) and the following anatomical regions showed correlations with the invasion level: nose/others: AOR=2.769, 95 % CI: 1.235-6.493, P = 0.01; orbit/others: AOR=6.369, 95 % CI: 2.728-15.429, P0.001; orbit/nose: AOR=2.300, 95 % CI: 1.056-4.984, P = 0.04.This study serves as a guide for optimizing deep surgical margins and planning surgery for facial BCCs considering independently associated factors.

Longer time from diagnosis to definitive surgery (TTDS) is associated with increased melanoma-specific mortality. Although black patients present with later-stage melanoma and have worse survival than non-Hispanic white patients, the association between race and TTDS is unknown.To investigate racial differences in time to melanoma treatment.Retrospective review of the National Cancer Database (2004-2015). Multivariable logistic regression was used to evaluate the association of race with TTDS, controlling for sociodemographic/disease characteristics.Of the 233,982 patients with melanoma identified, 1221 (0.52%) were black. Black patients had longer TTDS for stage I to III melanoma (P .001) and time to immunotherapy (P = .01), but not for TTDS for stage IV melanoma or time to chemotherapy (P .05 for both). When sociodemographic characteristics were controlled for, black patients had over twice the odds of having a TTDS between 41 and 60 days, over 3 times the odds of having a TTDS between 61 and 90 days, and over 5 times the odds of having a TTDS over 90 days. Racial differences in TTDS persisted within each insurance type. Patients with Medicaid had the longest TTDS (mean, 60.4 days), and those with private insurance had the shortest TTDS (mean, 44.6 days; P .001 for both).Targeted approaches to improve TTDS for black patients are integral in reducing racial disparities in melanoma outcomes.

Background Topical anesthetics are used in noninvasive transdermal anesthesia to decrease the superficial pain sensation threshold during dermatologic surgery. Combined pain relief and sensitivity loss can avoid discomfort during the surgery. Objective The aim of this placebo-controlled study was to compare the efficacy of 3 commonly used topical agents by collating loss of sensitivity over time. Materials and methods Three topical anesthetic creams, a topical anti-inflammatory cream, and a moisturizing cream were applied on the left volar forearm of each of the 48 healthy Caucasian participants. Sensitivity was assessed with the dynamic 2-point discrimination and the Semmes-Weinstein test at 0, 60, 90, 120, 150, and 180 minutes after cream application. Results After 180 minutes, benzocaine showed a significantly lower 2-point discrimination reduction than lidocaine alone and a lidocaine and prilocaine mixture. Sensory threshold measurements by the Semmes-Weinstein test after 60 minutes revealed a significantly higher effect with lidocaine alone and with the lidocaine and prilocaine mixture than with benzocaine. Conclusion The authors found a stronger skin sensitivity reduction by the eutectic lidocaine and prilocaine mixture and lidocaine alone compared with benzocaine. We suggest increased discomfort reduction in topical anesthetic supported dermatologic surgery by the eutectic mixture and lidocaine alone.

Supplemental Digital Content is Available in the Text., BACKGROUND Dermatologic surgery services are largely absent in Africa and in Afro-Caribbean counties. In the USA, studies of people of African ancestry have demonstrated health care gaps, but there are no data for Africa nor a Afro-Caribbean country. Dermatology surgery has been largely absent from global health because there are few data to demonstrate the need. We sought to determine skin cancer tumor types, and local knowledge and perception in an Afro-Caribbean country. OBJECTIVE We sought to determine whether there exist knowledge gaps and whether a dermatology surgery medical missions program would improve the health of Afro-Caribbean people. METHODS First, we conducted a survey of knowledge and behaviors related to skin cancer. Second, we analyzed the number and types of tumors treated during a multi-year surgical dermatology project. RESULTS In the survey, 62% did not know what melanoma was. Eighty-one percent did not think skin cancer is preventable. Of 163 surgical specimens, 64 were malignancies with 91% related to UV exposure. CONCLUSION There is a need for a skin cancer treatment and education program in a country of mostly African-ancestry people.

Background Perioperative anxiety can negatively impact patient satisfaction and can complicate outpatient dermatologic procedures. Objective Evaluate adverse events associated with oral midazolam as a perioperative anxiolytic during dermatologic surgery and assess whether an enhanced monitoring approach is associated with an increased detection rate. Materials and methods Five hundred cases (250 before and after change in monitoring) where patients were administered oral midazolam between July 2015 and May 2017 were retrospectively reviewed. The number of procedures, type of procedures, dose in milligrams, number of doses, major and minor adverse events, and vital signs were recorded. Results The difference in number of treatment sites, types of procedures, and total dose administered was not significant. There were minor but significant differences in the mean change in blood pressure, heart rate, respiratory rate, and Richmond Agitation and Sedation Scale score before and after the procedure but not oxygen saturation. These vital sign changes were not clinically significant. There were zero major adverse events in both groups. There were 2 patients who became transiently hypoxic. Conclusion Oral midazolam administration was not associated with major adverse events including in the more intensively monitored group. This supports its use as an anxiolytic for outpatient dermatologic procedures.

Summary Background: In most breast reduction techniques, the pedicle of the nipple–areola complex (NAC) is de-epithelialized to preserve the subdermal plexus, thereby decreasing the risk of NAC necrosis. However, deskinning the pedicle is faster and makes it more pliable, which potentially improves the aesthetic outcome. There is no scientific evidence regarding the beneficial effects of de-epithelialization. In this study, we present data from patients undergoing breast reduction with deskinning of a superomedial pedicle. Methods: In the period June 2013 to March 2019, a single surgeon performed all breast reductions using a superomedial glandular pedicle. The patients were included retrospectively and data were collected by reviewing the medical records. The NAC necrosis rate was compared with data from the literature through a systematic review. Results: The cohort consisted of 142 consecutive patients. The median resection weight was 287 g (interquartile range (IQR), 197–399) per breast. No complete NAC necroses occurred during the follow-up period, but two patients (1.4%) developed partial NAC necrosis. In the literature, the rate of NAC necrosis (complete or partial) was 1.5% of patients undergoing breast reduction with de-epithelialization. Conclusion: The rate of NAC necrosis after breast reduction with deskinning of the pedicle was comparable with breast reductions with de-epithelialization that has been reported in the literature. Our findings support that the pedicle in breast reduction surgery can be deskinned safely in patients with low resection weights.

Background The purpose of the present study is to investigate the therapeutic effect of fasciotomy through multiple small skin incisions for the treatment of early osteofascial compartment syndrome in children. Methods From January 2009 to May 2017, 56 pediatric patients with early osteofascial compartment syndrome in their limbs were admitted into our department and treated with multiple small skin incisions for decompression at the early stage. The skin incisions, function, and sensation of the limbs were followed up. Results The osteofascial compartment syndrome was diagnosed at 7.4 ± 2.1 h after injury, and then fasciotomy was performed at 1.4 ± 0.4 h later. The average procedure time of fasciotomy was 12.7 ± 4.8 min. No postoperative incision infections or neurovascular injuries were observed in all the patients. The incisions completely healed in 7–10 days with an average healing time of 8 days without secondary suture. The patients were followed up for an average of 5.1 years. No Volkmann’s contractures in the injured limbs were found. The appearance, electromyography, and nerve conduction velocity of the affected limbs were not significantly different from that of the contralateral limbs. All the patients were free of symptoms and were fully recovered of sensation and function, being an “excellent” outcome at the latest follow-up. Conclusion Fasciotomy through multiple small skin incisions, which can be useful to decompress the compartment pressure with fewer complications, is a simple and effective strategy for the treatment of early osteofascial compartment syndrome in children.

Use of anticoagulants is common and practice regarding continuation or discontinuation of the medication peri-operatively for cutaneous surgery lacks evidence-based consensus. Therefore, we aimed to do a prospective observational study with patients who were referred to cutaneous surgery and needed full thickness or split skin grafting and using antitrombotic or non-antitrombotic therapies. Data on patients characteristics, diagnosis, location of surgery and surgery performed, antithrombotic medication and complications in skin grafts were collected. Skin grafts were traced on a transparent film and areas of unhealed skin graft were marked. All patients were routinely followed-up on days 5–7 postoperative. Chi-square test, Fisher’s exact test or Mann-Whitney U-test were used to compare patients taking antitrombotic medication with patients receiving no antitrombotic therapy. In addition, associations were calculated for treatment with the different antithrombotic therapies. No severe bleeding requiring blood transfusion or re-operation was observed in this study. The results showed no statistically significant difference between patients who continued treatment with antithrombotic therapy compared with patients having no antithrombotic treatment regarding sub graft hematomas or graft take. Continuing antithrombotic monotheraphy with acetylsalicylic, clopidogrel, warfarin or fish oil in relations to cutaneous surgery do not seem to increase risk of haematoma or graft lost.

BACKGROUND AND OBJECTIVES: Leiomyosarcoma of skin (LMS) can be sub-classified on pathology appearances as Dermal or Subcutaneous. The aim of this study was to provide treatment recommendations for these uncommon tumours. METHODS: A retrospective review of all patients with dermal and subcutaneous leiomyosarcoma managed at the Peter MacCallum Cancer Centre, Australia from January 2003 to December 2018 was performed. Eighty-three patients were identified (64 dermal leiomyosarcoma, 19 subcutaneous leiomyosarcoma). RESULTS: Subcutaneous leiomyosarcoma were larger (median size 14 mm dermal, 49 mm subcutaneous, P = 0.01). No patient with a dermal leiomyosarcoma developed metastatic disease compared to 4 of the 19 subcutaneous leiomyosarcoma (5-year overall survivals, 98% and 88%, respectively, P = 0.03). The most common site of metastasis was to the lung. No difference in risk of local recurrence was apparent (5-year recurrence-free survivals were 85% and 78%, respectively, P = 0.17). Adjuvant radiotherapy was used in 16 (25%) dermal leiomyosarcoma patients and 13 (68%) subcutaneous leiomyosarcoma patients (P

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique to obtain symmetry of the breast shape and a level inframammary line and nipple-areola, which achieved excellent results. Six Japanese patients with early breast cancer located on the upper area of the breast were enrolled into this study. A triangle-shaped area of skin was removed together with cancerous and healthy-surrounding breast tissue. Two crescents were designed and de-epithelialized in the directions of 9 o'clock and 3 o'clock. The width of the crescent was decided to be the same as a half or the length of the base of a triangle to be removed. After partial mastectomy, the inner and outer glandular flaps were horizontally sutured. The operations were simple to perform and were not associated with any postoperative complications. Oncoplastic breast surgery combining partial mastectomy with triangular skin resection and re-centralization of the nipple-areola was useful for patients with breast cancer on the upper quadrant area of non-ptotic breasts.

Background Mohs micrographic surgery (MMS) is a cost-effective treatment for nonmelanoma skin cancer that bundles costs for surgical excision, tissue processing, and histopathological interpretation. A comprehensive MMS bundle would include all aspects of an episode of care (EOC), including costs of reconstruction, preoperative, and postoperative care. Objective To assess the feasibility of an alternative payment model for MMS and reconstruction. Methods Retrospective chart review and payment analysis for 848 consecutive patients with 1,056 tumors treated with MMS. Average Medicare payment of an EOC was compared with bundles based on specific repair types. Results The bundle for a flap/graft repair averaged $1,028.08 (confidence interval [CI] 95% $951.37-1,104.79), whereas the bundle for a linear closure (LC) averaged $585.07 (CI 95% $558.75-611.38). The average bundle including all repairs was $730.05 (CI 95% $692.31-767.79), which was statistically significant from both the flap/graft and LC bundles. Conclusion Bundling surgical repairs with MMS based on an average payment does not represent the heterogeneity of the care provided and results in either underpayment or overpayment for a substantial portion of cases. Consequently, EOC payments bundling MMS and surgical repairs would inaccurately reimburse physicians for work completed. Current payment methodology allows for accurate payment for this already cost-effective therapy.

Current guidelines recommend local excision margin (EM) with 1 to 2 cm on primary Merkel cell carcinoma (MCC) sites.We compared survival outcomes of patients with MCC who were treated with different surgical interventions.A retrospective analysis of MCC cases in the Surveillance, Epidemiology, and End Results database was performed using the Kaplan-Meier, competing risk, and Cox proportional hazards regression model analyses. Influence of age, T stage, American Joint Committee on Cancer stage, adjuvant radiotherapy, and other subgroups were also analyzed by pairwise log rank test.Our results indicated a significant association between local destruction method and inferior survival, while an EM2 cm showed significantly higher overall survival. In addition, the competing risk analysis depicted a similar trend as the Kaplan-Meier analysis, and considerably reduced estimated cumulative incidence. Further subgroup pairwise analysis demonstrated that the EM2 cm method had better survival in patients who were60 years of age, having smaller tumor diameters (T1 and T2) or having undergone adjuvant radiotherapy (P .05). In contrast, different EMs did not show any significant association with survival rate in patients ≥75 years of age or stage III tumors.This study was not prospectively randomized without relapse data.It is challenging to make optimal EM recommendations, because surgical options may depend on individual case situations. Further prospective randomized studies are warranted.

Summary Background Cell-assisted lipotransfer (CAL) promotes the survival of fat grafts with high vascular density and improves skin quality by increasing collagen content. However, no study has quantified the changes on the skin surface, and rigorous methodological evaluations are still lacking. Design Fifty patients were recruited and randomly divided into two groups: an experimental group (n = 25) that underwent a stromal vascular fraction (SVF)-assisted fat graft and a control group (n = 25) that underwent fat graft only. Methods The SVF cells were counted, tested in terms of viability, and characterized. The volumes of whole faces were determined by using a 3D scanner and Geomagic software preoperation, immediately after surgery, and 6 months postoperation. Facial skin qualities, including spots, wrinkles, texture, pores, UV spots, brown spots, red areas, and porphyrins, were detected by a VISIA skin detector preoperation and 6 months postoperation. A visual analog scale was used for clinical evaluation. Results The cell pellet contained 1–3 × 107/mL of fresh SVF cells. The cell viability exceeded 98%. The immunophenotyping characteristics and stemness were consistent with the features of adipose- derived stem cells (ADSCs). The survival rate of SVF-enriched fat grafts was significantly higher than that of control grafts: 77.6%±11.6% versus 56.2%±9.5% (p Conclusions Our results demonstrated the positive outcomes of autologous SVF-assisted fat graft in improving facial skin quality and its promising application potential in clinical settings. This study is registered at www. ClinicalTrials.gov, number NCT02923219.

Shave excision is a simple and cost-effective technique for the removal of suitable skin lesions. We performed a prospective study over six months, collecting data from pigmented lesions that were treated with shave excision by dermatologists. Only shave excisions with the intent to remove the lesion in toto were included. A total of 349 lesions were included in this study, 50 (14%) of these were melanomas and no melanoma diagnosed had deep margin involvement, while 13 (26%) had lateral margin involvement.

Basal cell carcinoma (BCC) are the commonest cutaneous malignancy and incidence continues to increase. There is a need to expand the therapeutic toolbox to increase options for patients that are unsuitable for or unwilling to undergo the current therapies. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief pulsed electrical field and combined with low dose chemotherapeutics to ablate malignancies. It is a simple technique causing minimal damage to the surrounding healthy tissue and has the potential to avoid the need for complex reconstruction. ECT is an established treatment for skin metastases but its role as a primary treatment modality is not demonstrated. A prospective randomised control trial evaluating ECT against the gold standard of treatment, Surgery, was performed for patients with primary BCC and patients followed for 5 years. All lesions treated with ECT (n = 69) responded although 8/69 (12%) needed a second treatment to ensure a complete response. All surgical lesions (n = 48) showed histological evidence of complete excision with 2/48 (4%) undergoing a second excision. At 5 years, in the surgical arm there was no evidence of recurrence in 39/40 (97.5%) lesions with 1/40 (2.5%) confirmed recurrence. In the ECT arm there was no evidence of recurrence in 42/48 lesions (87.5%). There was 5 confirmed recurrences. These groups show statistical equivalence in this non inferiority study design (p = 0.33). ECT is an effective and durable treatment option for primary BCC and should be considered as part of the armamentarium of options available.

Summary Background Breast reconstruction is routinely used to alleviate the psychological adverse effects of mastectomy. Nipple preservation further improves the cosmetic result, and causes less trauma on the body surface. Nipple-sparing mastectomy, however, comes with challenges, especially in the case of large, ptotic breasts to the degree that large-sized breasts have conventionally been a contraindication for nipple preservation. In this report, we describe a novel technique for nipple preservation in immediate reconstruction of large, ptotic breasts. Methods From 2013 to 2018, 24 patients (30 breasts) with large, ptotic breasts were treated with mastectomy and immediate reconstruction with nipple preservation. Median BMI was 28 and 8 patients were smokers. The technique involves the de-epithelialisation of a large area of the breast skin, the mastectomy through a lateral full-thickness incision within the de-epithelialised area, imbrication of the de-epithelialised skin, lifting of the nipple to a higher position and finally closure of wound. Results There were no full, 4 partial nipple necroses and 3 re-operations were done under local anaesthetic to correct partial peripheral necrosis of the areola. Six patients needed seroma aspiration and 4 presented with cellulitis. No implants were lost and there were no delays to adjuvant treatment. Conclusions The proposed technique has significant advantages and may be ideal when large skin reductions are necessary in immediate breast reconstruction with nipple preservation. The low complication rate makes the method ideal when adjuvant treatment is to follow and/or patients are of high risk for surgical complications.

Background Postacne scars have significant psychosocial distress among patients. Subcision is a well-known treatment modality specially for rolling type of acne scars, but is a crude mechanical process, which carries a risk of hematoma formation. Aims To compare the efficacy and safety of radiofrequency-assisted subcision (rSubcision) with conventional subcision in postacne scars. Methods In this randomized, split-face study, adult patients with postacne scars were randomized to receive either conventional subcision or rSubcision in 2 sessions, 4 weeks apart and followed up for 2 months. Outcome was measured using Goodman and Baron score (GBS), investigator global assessment (IGA) by two blinded dermatologists, and patient global assessment (PGA). Results Seventeen out of 21 patients completed the treatment. Statistical analysis of the results was performed using SPSS 15.0 statistical software (SPSS). Patients in both the groups had significant improvement from baseline according to quantitative scoring (P = .0001), number of scars (P = .0001), IGA, and PGA. The improvement was comparable in both the groups according to GBS and IGA but better on rSubcision side in terms of PGA. Two patients developed small entry point burn during rSubcision which healed in one month and one developed persistent hematoma with conventional subcision. Conclusions Both modalities were comparable in terms of assessment scores and investigator assessment, but patients found improvement better on rSubcision side.