Faculty Bibliography

Knowledge of the indications, techniques, donor site considerations, and complications of all types of skin grafting is invaluable for the dermatologic surgeon who performs soft tissue reconstruction on a regular basis. With proper defect assessment, reconstructive planning, and attention to detail pre-, intra-, and postoperatively, optimal cosmetic and functional results using skin grafting techniques can be achieved.

BACKGROUND:Curettage may be helpful as a preliminary step to outline the gross subclinical extensions of high-risk basal cell carcinomas (BCCs) before the first stage of Mohs micrographic surgery. Although many Mohs surgeons use curettage in the Mohs surgical setting, no prospective studies have as yet been performed that demonstrate the efficacy of curettage in delineating tumor margins before Mohs surgery. OBJECTIVE:To document the efficacy of curettage in delineating BCC margins before Mohs micrographic surgery. METHODS:This was a prospective evaluation of 599 patients with biopsy-proven BCCs treated with Mohs surgery. The preoperative dimensions of each tumor, the curetted dimensions before the first surgical stage, the proposed excisional margins before each surgical stage, and the final defect dimensions after each surgical stage were measured. The maximum curetted margin around each tumor was calculated and compared with typical Mohs excisional margins of 1, 2, 3, and 4 mm. A hypothetical 1-, 2-, 3-, or 4-mm excisional margin was added to the preoperative X and Y dimensions of each tumor, and the actual final defect sizes were compared with the hypothetical final defect sizes to determine whether an additional surgical stage would have been needed had curettage not been performed. The amount of tissue stretch occurring after specimen removal was calculated to determine whether tissue stretch falsely elevated the number of instances in which an additional surgical stage would have been needed had curettage not been performed. RESULTS:The curetted margin around the observed extent of each tumor exceeded 1 mm in 87.6% of cases, 2 mm in 47.1% of cases, 3 mm in 19.7% of cases, and 4 mm in 5.7% of cases. The mean curetted margin was 1.7 mm. Taking a 1-mm margin in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.2% of cases, whereas taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 93.0%, 88.1%, and 49.4% of cases, respectively. After calculating and eliminating the effects of tissue stretch, it was found that a 1-mm excisional margin taken in the first stage of Mohs surgery without first performing curettage would have necessitated an extra surgical stage in 99.0% of the cases. Taking a 2-, 3-, or 4-mm margin would have necessitated an extra surgical stage in 87.5%, 57.9%, and 29.5% of cases, respectively. CONCLUSION/CONCLUSIONS:Careful debulking and palpation with the curette significantly reduce the number of Mohs surgical stages required for BCC clearance. Even after taking the effects of tissue stretch into consideration, a significant proportion of tumors would still require an additional stage for tumor clearance without aggressive presurgical curettage.

BACKGROUND: Human papillomavirus (HPV) type 2 is generally considered to be a benign viral infection associated with common warts. Other HPV types have been associated with the development of squamous cell carcinomas (SCCs). OBJECTIVE: To describe a case of HPV type 2 identified in a SCC of the finger in an immunocompetent patient. To our knowledge, this is the first such case reported in the literature. METHODS: This is a case report and review of the literature. RESULTS: Mohs micrographic surgery performed in two stages effectively removed the tumor. CONCLUSION: HPV type 2 may play a role in the development of cutaneous SCC. Further epidemiologic and molecular studies of HPV and SCCs will be helpful in determining the role of HPV type 2 in cutaneous oncogenesis.