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Background Reconstruction of nasal alar defects is difficult because of the complex anatomy of the region. A frequent challenge in this area is repair of small cutaneous defects involving the lateral nasal supratip and the superior alar groove. Observations An oblique advancement flap that uses laxity from the nasal sidewall is described. Its benefits and limitations are compared with those of alternative closures. Overall, the oblique advancement flap preserves the superior alar groove, while minimizing tissue contortion. It is technically similar to a primary closure but functionally and aesthetically superior. Conclusions For selected small lateral nasal supratip defects impinging on the superior alar groove, the oblique advancement flap offers a simple, visually pleasing repair that preserves the alar architecture.

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

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

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

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

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

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

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

We present a case report of a patient with basal cell nevus syndrome (BCNS) who developed multiple polypoid basal cell carcinomas (PBCC) in the perineum. PBCC is a rare variant of nodular BCCs. Clinically, PBCCs mimic acrochordons. We recommend that the perineum, perianal, and genital areas should be included in the routine exam of patients with BCNS.

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

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

Background Controversy exists over the rate of malignant transformation of actinic keratoses (AKs) and, therefore, which treatment is indicated. Furthermore, it is not known to what degree each of the separate clinical subtypes of AKs become malignant. Objective Our purpose was to examine clinically diagnosed hyperkeratotic AKs and classify them histologically. Methods Fifty papular hyperkeratotic AKs on the dorsum of the hand, wrist, and arm, less than 1 cm in diameter, were identified in 43 patients. Histologic evaluation was conducted in a blinded fashion by two observers. Results Histologic examination showed 18 lesions (36%) to be invasive squamous cell carcinoma, whereas another seven (14%) were squamous cell carcinoma in situ. Proliferative AKs were the next most common lesion identified (26%), followed by hypertrophic (10%) and lichenoid (4%) AKs. Basal cell carcinomas (4%) and other benign lesions (6%) comprised the rest of the biopsy specimens. Conclusion It is possible to predict clinically, with greater certainty than previously realized, which AKs have a greater tendency toward malignant change. Clinical hyperkeratotic AKs less than 1 cm in diameter on the dorsum of the hand, wrist, or forearms of white patients have a malignancy rate of 50%. Lesions with this clinical description should be removed by shave biopsy, then by 35% trichloroacetic acid, then liquid nitrogen to a width and depth of 3 mm.

A randomised, placebo-controlled, multi-centre trial of intracellular subunit herpes simplex virus (HSV) type 1 vaccine NFU.Ac.HSV-1(S–)MRC (Skinner vaccine) was conducted at three medical centres in the United States. Subjects with documented herpes genitalis of at least 1-year duration and a history of six or more genital HSV recurrences in the 12 months prior to study entry were randomised to receive vaccine or placebo at 0, 1 and 2 months. Vaccination induced significant neutralising, enzyme-linked immunosorbent assay and lymphocyte transformation response to HSV-1 antigen. The frequency of recurrences was reduced in the vaccinated female patients at both 3 and 6 months following vaccination with an overall reduction in patients of both sexes which did not reach statistical significance. Recurrence severity was reduced as measured by decreased number of lesions and associated symptoms per recurrence (P = 0.04). The data suggest that clinical manifestations of latent HSV genital infection may be modified by therapeutic immunisation.

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

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

Importance Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. Objectives To quantify adverse events associated with MMS and detect differences relevant to safety. Design, Setting, and Participants Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. Exposure Mohs micrographic surgery. Main Outcomes and Measures Intraoperative and postoperative minor and serious adverse events. Results Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. Conclusions and Relevance Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

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

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

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

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

I ssues pertaining to the disposal of surgical waste are seldom discussed in the dermatologic surgery literature. Management of surgical waste as pertaining to the surgeon includes proper disposal of sharps in appropriate containers as well as proper handling and disposal of infectious nonsharp materials. Attention should be paid to two particular issues. First and foremost is to minimize the risk of exposure of patients, health care workers, office or operating room staff, and employees collecting or processing surgical waste to infectious materials through proper disposal of sharp and infectious waste. Although one may assume that these procedures are routinely adhered to in clinical practice, one study in New Zealand discovered that 56% of dental practices disposed of bloody swabs into the waste paper bin, and 24% disposed of contaminated sharp items into the general household refuse collection.1 Second is to minimize aberrant introduction of non-sharp waste into sharp waste disposal containers or of non-infectious waste into infectious waste bags. This is to minimize the financial and environmental costs associated with the processing of sharp and infectious waste. One study of university sharp boxes discovered that the full boxes contained only 14% appropriate sharps by weight and less than 50% appropriate sharps by volume.2 Moreover, the implementation of a waste segregation program in one hospital resulted in a 65% reduction in infectious

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

I n most dermatologic surgery, hematomas and infection can be avoided by careful patient selection, hemostatic control, and meticulous surgical technique. On rare occasions, postoperative hematomas or abscesses require drainage. Herein, we describe an alternative to the Penrose drain commonly used in such situations. Penrose1 first reported placing a common rubber condom to drain excess fluid collection after abdominal surgery. Today, with millions used yearly, the Penrose drain is the most widely used drain.2 Whereas the cost of the Penrose drain is not prohibitive, it is not routinely used by all dermatologic surgeons nor kept in supply in the office. However, all dermatology offices do have sterile surgical gloves that can be modified and used as a surgical drain. To make this drain, first cut the appropriate length finger from a nonpowdered, sterile glove (Fig 1). This “finger” can then be fenestrated to allow greater drainage along the lateral aspects of the wound that need fluid removal (Fig 2). The fenestrations are discarded, and the drain is placed within the wound bed with the exposed portion allowed to drain inferiorly. The length of drain required will dictate the size of glove needed and which digit to remove from the body of the

Background. The appearance of squamous cell carcinoma (SCC) in chronic scar lesions of various etiologies has been reported. Here we present a case of SCC developing in a Leishmania scar after 59 years. Observations. An Iranian female presented with a SCC that arose when she was 3 years of age in a scar that was secondary to cutaneous Leishmania. Conclusions. SCC should be included as a rare but late sequela of cutaneous Leishmania.

Background Odontogenic keratocysts of the jaw are a central feature of basal cell nevus syndrome (BCNS) and arise from the basal cell layer of the surface epithelium. Although they are benign, they tend to be aggressive, with local invasion of bony structures, extensive growth, and potential for substantial disfigurement and speech dysfunction. Complete surgical resection is the current standard of care; however, the procedures are often technically challenging and are followed by high recurrence rates. Observations We report the case of a 55-year-old man with a long-standing history of BCNS. Over a 25-year period, this patient had been treated for many basal cell carcinomas (BCCs). He also had multiple large odontogenic keratocysts in the mandible that had previously been treated using surgical, chemotherapeutic, and radiation treatment techniques. He had also undergone a right inguinal lymph node dissection after BCC metastasis was diagnosed within a lymph node. Owing to the recalcitrant nature of his condition and his history of BCC metastasis, the patient was started on a daily regimen of a new oral drug, GDC-0449, which inhibits the hedgehog signaling pathway, a key genetic contributor in the oncogenesis of BCCs. In addition to complete resolution of all his BCCs at 12-week follow-up, nearly complete resolution of 3 odontogenic keratocysts was documented by serial dental radiographs after 2 years of therapy. Conclusions We report the nearly complete regression of multiple BCNS-associated odontogenic keratocysts following nonsurgical treatment with GDC-0449. This novel drug, useful for the treatment of BCC, also appears to be effective for treatment of odontogenic keratocysts.

background. The best cosmetic results are obtained if certain “skin lines” are followed. However, which “skin lines” are the correct ones has been controversial. objective: To review the histo y of skin lines, the physiological basis of skin tension lines, and the factors that govern them. method: Twenty-seven individuals were observed, 15 greater than 65 years of age, and 12 less than 30 years of age. Patients were placed at 0″ and 90″ and the shift in skin tension lines was observed. result: In older patients there was a significant shift in the skin lines with changes in positioning that was not present in the younger patients. In the older group of patients the shift in skin lines appeared to follow the direction of gravity's effect on the skin. conclusions: Skin tension lines in older patients may become movable with position changes and are not static as previously stated.

Leonard H. Goldberg, MD, FRCP, has indicated no significant interest with commercial supporters.

Xanthelasma of the eyelid is an asymptomatic and not uncommon disease with cosmetic consequences that drive the patient to seek medical treatment. tic acid cauterization, carbon dioxide laser ablation, erbium :YAG laser treatment, pulsed-dye laser treatment, and Q-switched Nd:YAG laser treatment. 1-7 .

One prominent lesion induced in DNA by ultraviolet (UV) radiation is the cyclobutyl pyrimidine dimer formed between adjacent pyrimidines on the same DNA strand. We investigated whether people who have developed basal cell carcinoma on sun-exposed skin have an altered ability to repair UV-induced pyrimidine dimers in DNA. Twenty-two patients with at least one basal cell carcinoma, aged 31-84 years, and 19 healthy volunteers, aged 25-61 years, took part in the study. Both groups were given one minimal erythema dose (MED) of simulated solar radiation on the lower back. DNA was extracted from the irradiated skin 0 to 6 h later, and the number of UV-induced pyrimidine dimers was determined using a dimer-specific endonuclease. At time 0, the average number of dimers per unit of DNA was similar in the two groups. After 6 h, an average of 22 +/- 4% of the dimers were removed in the group with basal cell carcinoma compared to 33 +/- 4% in the cancer-free group. In the basal cell carcinoma group, only 23% of the patients repaired more than 30% of the dimers after 6 h, compared with 53% of the cancer-free subjects (p less than 0.05). We conclude that patients who develop basal cell carcinoma on sun-exposed skin may have a decreased ability to repair pyrimidine dimers induced in skin exposed to simulated solar radiation.