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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.

BACKGROUND Lower eyelid margin defects can be a reconstructive challenge. A possible alternative is second intention healing of the lower eyelid margin. OBJECTIVE To determine the cosmetic outcomes and patient satisfaction of second intention healing of the lower eyelid margin after Mohs micrographic surgery (MMS). MATERIALS AND METHODS A retrospective chart review was performed on patients who underwent MMS of the lower eyelid margin. Patient information was gathered on age, sex, diagnosis, postoperative size, number of Mohs stages, thickness of defect, and clinical photographs. The preoperative and postoperative photographs were evaluated with a physician assessment scale and patients completed a satisfaction survey. RESULTS In all 17 patients (100%), the cosmetic results obtained were considered good to excellent. The objective outcomes were graded as excellent, very good, good, satisfactory, unsatisfactory, and poor. The patient satisfaction survey was divided into excellent, good, satisfied, and unsatisfied. Patient satisfaction ranged from satisfied to excellent. The incidence of complications was low with one report of trichiasis. CONCLUSION Second intention healing of the lower eyelid margin can produce good cosmetic results and patients are generally satisfied with their outcomes.

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 The incidence of basal cell carcinoma (BCC) in younger individuals has increased in recent decades. However, the characteristics of BCCs in this population, especially in Ibero-Latin American countries, have not been completely defined. Objective To describe the demographic, clinical, and histopathological characteristics of BCCs in patients younger than 40 treated with Mohs Micrographic Surgery (MMS). Materials and methods A multicenter, retrospective study conducted between January 2009 and December 2014, in five Ibero-American countries, included biopsy-proven BCCs in patients younger than 40 that were treated with MMS. Demographic, clinical, histopathological, and surgical characteristics were described. Results The study included 301 tumors in 241 patients, of whom 61% were female. The most common Fitzpatrick phototype was III. The most common histological subtypes were nodular (37.5%) and infiltrative (18.9%). Perineural invasion was encountered in 1.7%, and tumor clearance was achieved in 87.4% within two stages of MMS. Conclusions This is the first Ibero-Latin American transnational study describing the characteristics of BCCs in young patients treated with MMS. Despite darker skin phototypes in this population, BCCs can occur in early ages and may present with aggressive features. Therefore, MMS may be considered an appropriate first-line treatment option in this population.

Background The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. Objective We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. Methods A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. Results Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. Limitations Specific causes of death were not accessible. Conclusion This growing section of the population may safely undergo MMS.

Background Patients may delay treatment for skin cancer for various reasons. Prior research on treatment delay has focused on melanoma rather than nonmelanoma skin cancer (NMSC), which is much more common. Objective We sought to clarify the reasons for delay in the presentation for diagnosis and treatment of NMSC. Methods This was a prospective cohort study in a Mohs micrographic surgery private practice in an urban setting. Eligible subjects were 982 consecutive patients presenting for Mohs micrographic surgery for NMSC between March and December 2005. No enrolled subjects were withdrawn for adverse effects. The survey was a 4-page written self-administered questionnaire, eliciting patient medical history, skin cancer history, demographic information, initial and subsequent lesion size, and reasons for delay in presentation for evaluation and management. Outcome analyses addressed the: (1) frequency of specific reasons for delayed presentation, as provided by self-report; (2) association between reasons for delay with demographic or other patient-specific factors; and (3) change in lesion diameter from the time of detection by the patient to the time of presentation to the doctor. Results Among the reasons for waiting, denial (including: thought it would go away, thought it wasn't important, too busy, thought they could self-treat, afraid it might be something dangerous) was the most frequent, accounting for 71% of cases; difficulty scheduling was associated with 10% of the instances of delay. Older patients (age >64 years) were more likely to wait to seek care than younger patients (odd ratio [OR] = 0.5; 95% confidence interval [CI] 0.4-0.7). Patients with a prior skin cancer were more likely to wait (OR = 1.4; 95% CI 1.1-2.0), as were patients with major life problems (OR = 2.6; 95% CI 1.6-4.3) and patients with a history of any cancer (OR = 1.8; 95% CI 1.3-2.4). Weighted kappa analysis comparing tumor size at the two time points yielded a kappa of 0.72 (SE = .02; 95% CI 0.68-0.77). When the data were separated into two groups, one including those tumors that had decreased in size or remained the same (698 patients), and those that had increased in size (120 patients), the median delay-to-presentation intervals associated with these two groups (2.5 vs 6.0 months, respectively) were found to be significantly different ( P Limitations This study may have limited generalizability to the extent that it reflects the characteristics only of the subpopulation of patients with skin cancer who eventually received treatment at a referral-based, urban, dermatology private practice. Overall, these patients may have been better insured and be more affluent than the general population. Conclusions Denial is the most common patient-specific factor accounting for delayed presentation for NMSC diagnosis and treatment. Patients younger than 65 years, with a skin cancer history, with major life problems, and with a history of any cancer were most likely to wait to see a doctor. There was a significant increase in tumor size from the time when tumors were noticed by patients to the time when patients presented to a physician. Increased delay was associated with increased tumor growth.

Actinic keratoses (AKs) are in situ epidermal tumors that may progress to invasive squamous cell carcinomas. Liquid nitrogen is used during cryotherapy to freeze the epidermis and upper dermis and is the standard treatment for individual AKs.To evaluate the efficacy of a cryosurgery device incorporating an infrared sensor to measure the temperature at the skin surface while spraying liquid nitrogen on the surface of the skin during the treatment of AKs.Thirty-six patients with 180 thin AKs were treated with liquid nitrogen spray to a temperature of -5°C using the sensor to control the temperature at the skin surface. Patients were evaluated for cure rate, side effects, and healing time.At the 1-week follow-up, 66.7% of the lesions were cleared. By the 6-week follow-up, there was a 100% cure rate. Side effects were limited to redness, blistering, crusting, oozing, and ulceration at the 1-week follow-up and were resolved by the 6-week follow-up. No recurrence of AK, scarring, or hypopigmentation was noted.Cryotherapy with an integrated sensor for temperature control is an effective, safe, and precise treatment, allowing for a 100% short-term cure rate of AKs.

Background Several specialties and textbooks continue to advocate that local anesthesia using epinephrine should not be used during surgery involving the digits. Objective We sought to assess the association between local anesthesia (buffered 0.5% lidocaine and 1:200,000 epinephrine) injected into digits, comorbid patient conditions, and postoperative complications including ischemia or necrosis. Methods A retrospective review of all patients presenting for Mohs micrographic surgery in a private practice ambulatory surgery center was performed between October 2002 and January 2009. Patient factors including amount of anesthesia injected; preoperative vitals; history of hypertension, stroke, or circulatory disorders; and presence of anticoagulation were assessed. Results Three Mohs surgeons' patients were included in the study. No digital blocks were performed; local anesthesia was infiltrated directly into the tumor site. Patients received buffered 0.5% lidocaine plus epinephrine 1:200,000. Of 63 patients presenting for surgery (59 fingers and 4 toes), there were no cases of digital ischemia or necrosis. Approximately one-third had a circulatory disorder or diabetes, and more than half had a diagnosis of hypertension or were taking anticoagulation. The average amount of anesthesia injected was 6.92 mL, with the greatest amount being 25 mL. Limitations This was a retrospective review with possible overestimation of adverse effects as a result of referral bias of complicated patients to an ambulatory surgery center for treatment. Conclusion There is no evidence that buffered 0.5% lidocaine with epinephrine 1:200,000 causes ischemia or necrosis when injected into digits. This is true despite a history of circulatory disorders, thrombosis, diabetes, smoking, anticoagulation, or significant preoperative hypertension.

Background A 15-year-old Caucasian male presented with 9-month history of a recurrent nodule on the nasal columella. The previous biopsy was reported as a neurofibroma. Methods Frozen sections revealed a spindle cell neoplasm. Permanent section immunohistochemistry sections stained positive for vimentin and smooth muscle actin and negative for S100 and CD34, confirming the diagnosis of leiomyosarcoma. Results The tumor was removed using Mohs micrographic surgery. Radiological work-up revealed no distant metastasis. There has been no local recurrence to date. Conclusions Leiomyosarcoma is a difficult diagnosis to make clinically and requires histological confirmation. Re-biopsy of a “benign” growth may be necessary if clinicopathological correlation does not match with the clinical behavior of the tumor in question. Finally, Mohs micrographic surgery is a useful treatment modality for leiomyosarcomas, particularly those located in cosmetically-sensitive regions of the body such as the nose.

The UV radiation-mimetic chemical 4-nitroquinoline-1-oxide (4-NQO) is thought to induce squamous cell carcinoma (SCC) similar to those induced by UV radiation in animals. Therefore, we tested the hypothesis that cellular sensitivity to 4-NQO is associated with risk of developing skin cancer in a case-control study of 191 patients with nonmelanoma skin cancer (NMSC; 81 SCC and 110 basal cell carcinoma (BCC)) and 176 cancer-free controls. Short-term blood cultures were treated with 4-NQO at a final concentration of 10 microM for 24 hours and scored for chromatid breaks in 50 well-spread metaphases. We found that the mean frequency of chromatid breaks per cell (b/c) was significantly higher in the cases (mean+/-SD, 0.46+/-0.43 for SCC and 0.43+/-0.38 for BCC) than in the controls (0.25+/-0.25; P0.001 for both comparisons) and were associated with more-than-twofold increased risk for both SCC and BCC after adjustment for known risk factors. Therefore, our findings support the notion that sensitivity to 4-NQO reflects susceptibility to UV-induced NMSC. However, there is a lack of correlation between UVB-induced b/c and 4-NQO-induced b/c in this study population. Therefore, these findings need to be verified by additional studies.

The 1450-nm diode laser has been known to thermally alter sebaceous glands and has been found to be effective for the treatment of inflammatory facial acne.Our aim was to evaluate the dose response of a 1450-nm diode laser for treatment of facial acne, sebum production, and acne scarring utilizing two laser fluences and to determine long-term remission after laser treatment.Twenty patients (Fitzpatrick skin phototypes II-VI) received 3 treatments using the 1450 nm diode laser (3-4 week intervals). Split face comparisons were performed by randomizing patients to one of two fluences (14 or 16 J/cm(2)) on the right or left side of the face. Clinical photographs, lesion counts, and sebum measurements were obtained at baseline and after each treatment. Investigators' and patients' subjective evaluations of response to treatment were assessed.Percentage reductions in mean acne lesion counts from baseline were 42.9% (14 J/cm(2)) and 33.9% (16 J/cm(2)) after one treatment and 75.1% (14 J/cm(2)) and 70.6% (16 J/cm(2)) after 3 treatments. There was persistent reduction of 76.1% (14 J/cm(2)) and 70.5% (16 J/cm(2)) at the 12-month follow-up (P.01). Both objective and subjective improvements in acne scarring and sebum production were noted. Treatment-related pain was well tolerated, and adverse effects were limited to transient erythema and edema at treatment sites.This was a small study and comparison was limited to two laser fluences.The 1450-nm diode laser reduced inflammatory facial acne lesions even in Fitzpatrick skin phototypes IV-VI with minimal side effects. Significant improvement in acne lesion counts were noted after the first treatment and was maintained 12 months after the third treatment, indicating significant long-term clinical remission after laser treatment.

BACKGROUND: Mutagen sensitivity, measured as mutagen-induced chromatid breaks per cell in primary lymphocytes in vitro, has been used to study susceptibility to various epithelial cancers. Patients with xeroderma pigmentosum are highly sensitive to ultraviolet (UV) light due to inherited defects in DNA repair and have a 1000-fold higher risk of UV-induced skin cancer than the general population. However, an association between UV-induced chromosomal aberrations and risk of skin cancer in the general population has not been established. METHODS: We assessed in vitro UVB-induced chromatid breaks in a hospital-based case-control study. The study included 469 patients with skin cancer (231 with nonmelanoma skin cancer [NMSC] and 238 with cutaneous malignant melanoma [CMM]) and 329 cancer-free control subjects. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). All statistical tests were two-sided. RESULTS: Compared with the frequency of UVB-induced chromatid breaks per cell in control subjects (mean = 0.28 breaks per cell, 95% CI = 0.27 to 0.30), that in NMSC patients (basal cell carcinoma [BCC], n = 143, mean = 0.36 breaks per cell, 95% CI = 0.33 to 0.39 and squamous cell carcinoma [SCC], n = 88, mean = 0.35 breaks per cell, 95% CI = 0.32 to 0.38) was higher (P = .001 and P < .001, respectively), but that in CMM case patients (mean = 0.30 breaks per cell, 95% CI = 0.28 to 0.33) was not (P = .22). A frequency of chromatid breaks per cell above the median of control subjects was associated with nearly threefold increased risks for BCC (OR = 2.78, 95% CI = 1.79 to 4.30) and SCC (OR = 2.62, 95% CI = 1.50 to 4.60), but not with an increased risk of CMM. A dose-response relationship was evident between mutagen sensitivity and risk for both BCC (Ptrend < .001) and SCC (Ptrend < .001). Multiplicative interactions between mutagen sensitivity and sun exposure variables on risk, particularly for sunburn in BCC and hair color, tanning ability, and family history of skin cancer in SCC, were seen for NMSC but not CMM. CONCLUSIONS: UVB-induced mutagen sensitivity may play a role in susceptibility to NMSC but not to CMM.

Background Squamous cell carcinoma (SCC) of the ear compared with SCC occurring at other skin sites has an increased incidence of recurrence following treatment. Objective To determine the following variables: patient age and gender, life status, tumor location, and recurrence rate following Mohs micrographic surgery (MMS). Methods The charts of 117 patients with 144 invasive SCCs of the auricle were reviewed. The patients were contacted by telephone to confirm tumor recurrence and patients' life status. The range of follow-up was 7 to 67 months (average 34.6 months) after MMS. Results The patients' ages ranged from 34 to 90 years (mean age 71 years). The male to female ratio was 22:1. The helix was the most common site of occurrence (50.7%). Local recurrence after MMS was found in four patients (five tumors). MMS was performed on these five recurrent tumors, with no further recurrences. Telephone confirmation was obtained on 91 patients (26 patients could not be contacted) with 122 tumors, which included the 4 patients with 5 recurrent tumors. There were no additional recurrences. Of these 122 tumors, 35 were followed for less than 2 years (average 16.6 months), and 87 were followed for 2 years or more (average 41.8 months). From the chart review and telephone contact, the 2-year local recurrence rate was 5.7% (5 of 87 tumors) after MMS. The average size of these 87 tumors was 3.5 cm2. Twelve of 91 patients had died with evidence of active disease from causes unrelated to SCC. Conclusion Invasive SCC of the ear was once a formidable disease with a severe prognosis. The course of this disease has been appreciably improved by early diagnosis and treatment with MMS.

Background There has been no previously published study on skin cancers on the scalp of women. Objectives To better elucidate the characteristics of skin cancers that develop on the female scalp. Methods A retrospective review of 13,885 biopsy-proven skin cancers treated by Mohs micrographic surgery was performed. We identified 197 tumors on the scalp of women. Demographic features and tumor characteristics were compiled and analyzed. Results The average age of women with scalp tumors was 61.8 ± 16.9, which was significantly lower than that of men with scalp tumors. The age followed a bimodal distribution with peaks in the fifth and eighth decades. Overall, 77% of female scalp tumors were basal cell carcinomas (BCCs), 17% were squamous cell carcinomas (SCCs), and 6% were a variety of other tumors. This contrasts with men in whom 53% of tumors were squamous cell carcinomas. Basal cell carcinomas were significantly more common in women under age 50. Conclusion Skin cancers of the female scalp tend to be basal cell carcinomas, many of which occur at a relatively young age as compared to other skin cancers. The exact role of ultraviolet radiation in the development of some of these tumors is unclear.

Background. There are a number of reports in the literature of patients developing thrombotic events after stopping medically necessary antiplatelet and antithrombotic agents. Objective. The objective was to determine whether discontinuation of aspirin taken for primary prophylaxis contributes to the development of thrombotic complications in patients undergoing dermatologic surgery. Methods. A case is reported and the literature is reviewed. Results. We present the first reported case of a postoperative thrombotic event following dermatologic surgery in a patient withholding aspirin that was taken for primary prophylaxis. Conclusion. We believe that the available data make it difficult to implicate aspirin discontinuation in the development of each thrombotic event, given the high baseline risk of thrombotic events in the Mohs surgery patient population and the low risk of developing such events when medications are withheld perioperatively.

Background. Elliptical excision is a standard form of treatment for cutaneous neoplasms, but routine pathologic sectioning results in incomplete histologic control of surgical margins. Objective. The objective was to describe a technique of complete histologic margin control for tumors removed by excision as an ellipse. Methods. A retrospective study of 100 consecutive nonmelanoma skin cancers of the head and neck removed using elliptical excisions with complete histologic margin control was performed. The technique is described and depicted in detail. Results. Seventy-one tumors were removed in one excision, and 29 required additional excisions for complete histologic tumor clearance. Linear repairs were used for 93 tumors. Conclusion. Elliptical excision, combined with our technique of complete histologic margin control, provides a simple, efficient, and effective method for surgical removal and repair of nonmelanoma skin cancers and provides an alternative variation of performing Mohs micrographic surgery for selected tumors.

Background. Granular cell tumors, also known as granular cell myoblastomas, are uncommon neoplasms of unknown etiology. Most granular cell tumors are benign and present as solitary, painless dermal nodules of the head and neck. Few of these tumors are reported on the lower extremities and only eight cases of granular cell tumor of the foot have been reported. Of these eight, only two clinically benign granular cell tumors occurred on the heel. Objective. The objective was to describe the first reported case of malignant granular cell tumor of the heel. Methods. All reported cases of granular cell tumor of the foot are reviewed and clinical details of a malignant granular cell tumor of the heel are provided. Results. The malignant granular cell tumor of the heel was extirpated with two stages of Mohs microscopic surgery. No recurrence was noted at 22 months. Conclusion. malignant granular cell tumor of the heel is among the rarest of malignancies. In this case, the tumor appears to have been successfully treated with Mohs micrographic surgery.

Background Keratoacanthomas usually occur spontaneously as a single rapidly growing tumor on sun-exposed skin. Multiple keratoacanthomas are rarely seen. Keratoacanthomas may also develop after trauma, laser resurfacing, radiation therapy, and at the donor site after skin grafting. Objective We report 6 cases of keratoacanthomas that developed in and around healing and healed surgical sites after treatment of skin cancer. These tumors developed 1 to 3 months after surgery and were sometimes multiple. Methods We performed follow-up examinations of patients' wounds after the treatment of skin cancer. Histological examination of nodules developing in the margins of healing wound sites and in the scars of healed wound sites after Mohs micrographic surgery revealed keratoacanthomas. Results The tumors presented as a rapidly growing nodule or nodules, with the typical morphology and pathology of keratoacanthoma. One patient developed multiple keratoacanthomas at surgical and nonsurgical sites. These nodules were treated by a combination of excision, curettage and electrodesiccation, and oral isotretinoin, 4 mg/d. Conclusion Keratoacanthoma must be considered in the differential diagnosis of a rapidly growing nodule within or around the surgical site after skin cancer surgery.

Background. Advancements in nonablative laser technology necessitate concurrent developments in topical anesthesia, as patients have reported varying degrees of discomfort during these procedures. Although topical anesthetics have proven efficacious, they possess inherent limitations related to ease of use. Objective. To evaluate the efficacy of the S-Caine Peel (ZARS Inc., Salt Lake City, UT), a novel topical anesthetic that dries to form a flexible membrane, for induction of anesthesia after only a 30-minute application period. Method. Twenty patients received concurrent 30-minute applications of both the S-Caine Peel and a placebo cream randomized to the right and left cheeks in a double-blinded manner. After one pass of the 1450-nm diode laser (Smoothbeam, Candela Corp., Wayland, MA), patients' pain levels were recorded on a visual analog scale (VAS). Both the investigator and an independent observer rated perceived discomfort and immediate skin reaction based on a numerical scale. Results. Differences in VAS scores between active sites (average rating of 15 mm) and placebo sites (average rating of 47 mm) were statistically significant (P

background. Laser eye protection has been designed to protect operators and patients from severe eye injuries. objective. To describe two cases in which lasers used for cutaneous therapy may have been associated with the induction of vitreous floaters, a subacute eye injury, in physicians operating these devices, and to review the theoretical feasibility of such injuries, prior reports of the same, and strategies for minimizing risk. methods. Report of two cases and review of the literature. results. Given the circumstantial evidence, it is possible that subacute vitreous injuries may be sustained by the operators of dermatologic lasers. Ex vivo experiments and previous case reports have demonstrated the possibility of laser-induced vitreous injury, including changes in vitreous conformation and vitreous hemorrhage, in the absence of permanent retinal deficits. It may be speculated that vitreous floaters are a milder manifestation of such subacute injuries. conclusion. To the extent that vitreous floaters can multiply and presage the onset of severe retinal injury, the risk of their induction by dermatologic lasers should be minimized. Simple strategies and further research can help achieve this goal.

background. Surgical defects of the eyebrow region routinely present a cosmetic challenge to the reconstructive surgeon. objective. To present the use of a commonly employed reconstructive technique for an uncommon location. methods. Defects and repairs are demonstrated to illustrate techniques and document outcomes. The biomechanical influences on flap choice are explored. results. The subcutaneous island pedicle flap yielded excellent functional and cosmetic results when medium or larger defects were confronted in the eyebrow region. A centrally based pedicle enhanced cosmetic outcome, while rendering an uncompromised vascular supply. conclusion. The subcutaneous island pedicle flap provides a competitive repair alternative when reconstructing substantial defects of the eyebrow region.

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.

Background Vismodegib is approved for treatment of advanced basal cell carcinoma. Objective We sought to characterize vismodegib efficacy and safety in operable basal cell carcinoma. Methods Patients with new, operable, nodular basal cell carcinoma received vismodegib (150 mg/d) followed by excision and Mohs micrographic surgery to ensure clear margins. Cohort 1 received vismodegib for 12 weeks; cohort 2 received vismodegib for 12 weeks, then 24 weeks of observation before excision; and cohort 3 received vismodegib for 8 weeks on/4 weeks off/8 weeks on. Results In all, 24 patients enrolled in cohort 1, and 25 in cohorts 2 and 3. Complete histologic clearance was achieved by 42%, 16%, and 44% of patients in cohorts 1, 2, and 3, respectively. Muscle spasms (76%), alopecia (58%), and dysgeusia (50%) were the most frequent adverse events (AEs). Five (7%) patients discontinued treatment because of an AE. AE reversibility was evaluated in cohort 2 with 24 weeks of observation after treatment discontinuation. Limitations Nonrandomized, small cohort sizes, and short observation durations for some patients are limitations. Conclusion Primary efficacy end points were not met (predefined complete histologic clearance rate: >50% in cohorts 1 and 3; >30% in cohort 2). Safety was comparable when dosed continuously versus intermittently. Posttreatment reversibility of vismodegib-related AEs was demonstrated.

Background. Basal cell carcinoma may present as a discrete skin-colored papule, which may mimic other common skin tumors. Objectives. We present pigmented speckling as a clinical sign for basal cell carcinoma. Methods. Twenty cases of basal cell carcinoma with pigmented speckling were collected and their clinical and histologic features were reviewed. Results. There were 12 men and 5 women. The patients' average age was 70.5 years (range 33–90 years). Fifteen of the 17 tumors were on the head and neck, and 2 tumors were on the shoulders and back. Clinical examination revealed a “speckled appearance” of brown-black pigmentation within and/or at the border of the tumors. Histopathology showed basal cell carcinoma with melanin pigment (positive for Fontana-Masson stain and negative for Perl's stain) within nests of tumor cells. Conclusion. The speckled pigmentation of a basal cell carcinoma is a distinguishing feature, which may be useful in the differential diagnosis of this tumor from other discrete skin tumors.

The effect of a low-fat diet on occurrence of non-melanoma skin cancer was examined in a 2-year dietary intervention trial. A total of 101 skin-cancer patients were randomized either to a control group that consumed, on average, 38% of caloric intake as fat, and in which no changes in dietary habits were introduced, or to a low-fat dietary-intervention group, in which patients were instructed to limit their calories from fat to 20% of total caloric intake. Patients were examined at 4-month intervals by dermatologists blinded to their dietary assignments. Nutrient analyses, conducted at each of the 4-month follow-up visits, indicated that the % calories of fat consumed in the intervention group had been reduced to 21% at 4 months and remained below this level throughout the 2-year period. There were no significant differences in total calories consumed, or in mean body weights, between the control and the intervention groups. Nor were there significant group differences in P/S ratios until month 24. Numbers of new skin cancers treated at each examination were analyzed in 8-month periods of the 2-year study. Comparisons of skin-cancer occurrences revealed no significant changes in the control group from baseline values. However, cancer occurrence in the low-fat intervention group declined after the first 8-month period and reached statistical significance by the last 8-month period. Patients in this group had significantly fewer cancers in the last 8-month period than did patients in the control group. In addition, there was a significant reduction in the number of patients developing skin cancer in the last 8-month period, as compared with the first 8-month period, within the low-fat intervention group. There were no significant changes in the control group. These data indicate that a low-fat diet can significantly reduce occurrence of a highly prevalent form of cancer.

Basal cell nevus syndrome is a genetically determined disease characterized by 5 major manifestations (multiple basal cell carcinomas, jaw cysts, skeletal abnormalities, pits of the hands and feet, and ectopic calcification) and a variety of developmental anomalies. We present a case of basal cell nevus syndrome in which the patient had adenoid cystic carcinoma of the minor salivary glands develop in the soft palate resulting in distant pulmonary metastases. The patient died at the age of 44 years of respiratory complications. To our knowledge, this is the first simultaneous occurrence of basal cell nevus syndrome with adenoid cystic carcinoma of salivary gland. (J Am Acad Dermatol 2003;48:S64-6.)

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.

This study presents data relative to the efficacy and safety following the continuous use of oral acyclovir in the treatment of genital herpes over a 5-year period. In this study, 1,146 patients (53% males; 47% females) were originally enrolled. These included patients with a history of frequently recurring genital herpes (mean12 episodes per year). During the first year, patients were randomized between those receiving 400 mg of acyclovir twice daily and an equal number receiving placebo. Additionally, acyclovir was utilized for episodic treatment (ES) in both groups. Thereafter, patients received open-label acyclovir suppressive therapy for the remainder of the study period. Complete data are available on 389 patients who completed the fifth year of therapy. All the participants who completed the fifty year of the study had completed either 4 or 5 years of daily suppressive acyclovir therapy. During the first year, a significant decrease in the frequency of recurrences in patients receiving continuous acyclovir (SS) was noted as compared to the placebo group (1.7 vs. 12.5 recurrences; P0.0001). From year one to the end of year three, a progressive decrease in the frequency of recurrences was noted in both groups. Yet, those patients who had received SS for the full 3 years had significantly fewer recurrences than those who had received ES in the first year (P = 0.05). During years four and five, the decrease in frequency of recurrences between the ES and SS groups was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

background. Microcystic adnexal carcinoma is a slow-growing, nondescript, locally aggressive, deeply infiltrating neoplasm histologically characterized by an infiltrative pattern of basaloid or squamous cells, a desmoplastic stromal reaction, keratin-filled cysts, and glandular structures. objective. Microcystic adnexal carcinoma is uncommon and may be mistaken microscopically for other benign and malignant entities. Perineural or intraneural involvement by tumor cells is characteristic and extension into underlying structures including muscle, fat, and bone are frequently encountered. Although local recurrences are common after standard surgical excision, metastases have not been reported. Extensive resections of lesions may be necessary to extirpate widespread tumor, particularly those that are long standing or recurrent. Because significantly increased morbidity is associated with recurrent disease, surgical and histopathologic techniques that stress examination of all margins are advantageous. methods. We review the course of 10 patients with microcystic adnexal carcinoma of the face (six primary and four recurrent lesions) and their treatment by Mohs micrographic surgery.

Pain characteristics and analgesia in patients undergoing Mohs micrographic surgery have not been systematically studied. It is important to know about pain after Mohs micrographic surgery to better serve patient needs.We sought to measure pain in patients after Mohs micrographic surgery, and to investigate the relationship among postoperative pain, surgical characteristics, patient characteristics, and analgesics used.The Wong-Baker 0-to-10 pain scale was prospectively administered postoperatively to all patients presenting for Mohs micrographic surgery in a private practice setting between October 1, 2007, and December 31, 2008. Patients recorded their pain level from the day of surgery through postoperative day 4. The age, sex, location of surgery, number of lesions operated on, postoperative size, type of repair, severity of pain, and oral analgesics consumed and dosages used were recorded.A total of 433 patients were included in the final analysis. The highest pain scores were found on the day of surgery and steadily declined until postoperative day 4 (P.000). In all, 52% of patients took pain medication on the day of surgery, which declined successively with each postoperative day. The highest mean pain scores were statistically significantly associated with repair type (flaps), age (66 years), number of lesions, and consumption of narcotics for pain relief. No statistically significant differences existed for sex or postoperative defect size.The instrument used to measure pain relied on patient self-report in a private practice surgery center. Only the validated Wong-Baker pain scale was used to assess pain in this study.Approximately half of the patients after Mohs micrographic surgery take medication for pain control. Type of closure, location of surgery, age, and type of pain medication taken were significantly associated with postoperative pain.

The presence of human papillomaviruses (HPV) has been shown to be associated with the development and progression of invasive cancers of the genital tract, skin, and head and neck. In this study we analyzed 37 human nonmelanoma skin cancers (21 squamous cell carcinomas and 16 basal cell carcinomas) for the presence of HPV sequences. The polymerase chain reaction (PCR) was employed using primers designed to amplify DNA encoding the E6-E7 region of HPV types 6b/11, 16, and 18. HPV type 6b/11 and 18 sequences were absent from the DNA of all 37 tumors examined. However, HPV type 16 sequences were detected in four of 21 squamous cell carcinomas (SCC) (19%) and three of 16 basal cell carcinomas (BCC) (19%) as indicated on agarose gel electrophoresis by the presence of a single specific DNA band of predicted length. Furthermore, HPV type 16 sequences were absent in the DNA of normal skin from these seven skin cancer patients. The presence of HPV type 16 sequences in the seven skin tumors was confirmed by dot blot hybridization of PCR-amplified material to 32P-labeled HPV type 16, but not to HPV type 6/11 or 18-specific probes. These data indicate that HPV type 16, but not 6b/11 or 18 , is associated with development of some human nonmelanoma skin cancers.

Our previous studies have shown that human skin cancers occurring on sun-exposed body sites frequently contain activated Ha-ras oncogenes capable of inducing morphologic and tumorigenic transformation of NIH 3T3 cells. In this study, we analyzed human primary squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs) occurring on sun-exposed body sites for mutations in codons 12, 13, and 61 of Ha-ras, Ki-ras, and N-ras oncogenes by amplification of genomic tumor DNAs by the polymerase chain reaction, followed by dot-blot hybridization to synthetic oligonucleotide probes designed to detect single base-pair mutations. In addition to the primary human skin cancers, we also analyzed Ha-ras-positive NIH 3T3 transformants for mutations in the Ha-ras oncogene. The results indicated that all three NIH 3T3 transformants, 11 of 24 (46%) SCCs, and 5 of 16 (31%) BCCs contained mutations at the second position of Ha-ras codon 12 (GGC----GTC), predicting a glycine-to-valine amino acid substitution, whereas only 1 of 40 skin cancers (an SCC) displayed a mutation in the first position of Ki-ras codon 12 (GGT----AGT), predicting a glycine-to-serine amino acid change. In addition, three of the SCCs contained highly amplified copies of the N-ras oncogene in their genomic DNA. Interestingly, two of the SCCs containing amplified N-ras sequences also had G----T mutations in codon 12 of the Ha-ras oncogene. These studies demonstrate that mutations in codon 12 of the Ha-ras oncogene occurred at a high frequency in human skin cancers originating on sun-exposed body sites, whereas mutation in codon 12 of Ki-ras or amplification of N-ras occurred at a low frequency. Since the mutations in the Ha-ras and Ki-ras oncogenes were located opposite potential pyrimidine dimer sites (C-C), it is likely that these mutations were induced by ultraviolet radiation present in sunlight.

Purpose: To examine the role of suboptimal DNA repair capacity (DRC) for UV light–induced DNA damage in the development of nonmelanoma skin cancer (NMSC) and tumor progression.Experimental Design: We conducted a hospital-based case-control study of 255 patients with newly diagnosed NMSC [146 with basal cell carcinoma (BCC) and 109 with squamous cell carcinoma (SCC)] and 333 cancer-free controls. We collected information on demographic variables and risk factors from questionnaires, tumor characteristics from medical records, and lymphocytic DRC phenotype by the host-cell reactivation assay. Multivariable logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (95% CI).Results: Overall, there was a relative 16% reduction in DRC in NMSC patients compared with controls (P < 0.001 for BCC and for SCC, respectively). DRC below the controls' median value was associated with increased risk significantly for BCC (OR, 1.62; 95% CI, 1.07-2.45) but borderline for SCC (OR, 1.63; 95% CI, 0.95-2.79) after adjustment for age, sex, and other assay-related covariates. When the highest tertile of controls' DRC was used as the reference, the intermediate and low DRC were associated with a statistically significant trend for increasing risk for both BCC (Ptrend = 0.007) and SCC (Ptrend = 0.020). However, patients with aggressive or multiple SCC tended to have a higher DRC than those with nonaggressive or single SCC.Conclusions: Reduced DRC is an independent risk factor for BCC and single or nonaggressive SCC but not for multiple primaries, local aggressiveness, or recurrence of NMSC.