Faculty Bibliography

Defects of the central face can pose significant reconstructive challenges and are some of the most frequently encountered defects in facial reconstructive surgery. Familiarity with the repair of such defects is essential. At our institution, we have found that a systematic approach to central facial defects allows for superior results. We present that approach here using several cases to demonstrate the intraoperative planning involved. The cosmetic units and subunits within the defect must be identified. The defect must then be assessed for structural defects and deep soft tissue defects, which can be repaired utilizing cartilage grafts and hinge flaps respectively. Superficial defects of the cheek, lip, and nasal sidewall can then be assessed and repaired, taking advantage of the available tissue reservoirs using adjacent sliding flaps. The remaining distal nasal defect can then be repaired, depending on size, with a full-thickness skin graft, a cheek interpolation flap, or if necessary, a paramedian forehead flap. This systematic approach to reconstructing central facial defects simplifies seemingly complex reconstructive challenges and optimizes results.

BACKGROUND:No established standard of care exists for aggressive cutaneous squamous cell carcinoma (CSCC). OBJECTIVE:We sought to establish an aggressive CSCC management protocol by reviewing high-risk CSCC (HCSCC) and very high-risk CSCC (VCSCC) cases at our institution. METHODS:This was a retrospective review of all CSCC cases treated at our institution. RESULTS:A total of 27 patients were identified of 1591 cases treated between 2000 and 2011. Four patients with HCSCC received surgery alone and 1 received surgery and radiation. All remain disease free (median follow-up 5 years). Among patients with VCSCC, 4 received surgery alone: 1 (25%) showing a complete response and 3 (75%) showing disease progression. Eleven received surgery and radiation: 4 (36.4%) with complete response (median follow-up 3 years) and 7 (63.6%) with disease progression (median time to recurrence 6 months). Six received surgery and cetuximab: 3 (50%) had a complete response (median follow-up 3 years), 2 (33%) had disease progression, and 1 (14%) could not be assessed because of inability to tolerate infusions. One patient received surgery, cetuximab, and radiation, and remains disease-free after 4 years. LIMITATIONS/CONCLUSIONS:Lack of randomization, blinding, a true control arm, or standardization of treatment protocols are limitations. CONCLUSIONS:Patients with very HCSCC may have improved outcomes with surgery and adjuvant cetuximab.

BACKGROUND: There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair. OBJECTIVE: To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics. METHODS: Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons. RESULTS: The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99). CONCLUSIONS: Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages.

Evaluation of suspicious skin lesions by dermatologists is usually accomplished using white light examination and direct punch or surgical biopsy. However, these techniques can be imprecise for estimating a lesion's margin or level of dermal invasion when planning surgical resection. Laminar optical tomography (LOT) is an imaging technique capable of acquiring depth-sensitive information within scattering tissues. Here, we explore whether LOT data can be used to predict the depth and thickness of pigmented lesions using a range of simulations and phantom models. We then compare these results to LOT data acquired on normal and malignant skin lesions in vivo.

BACKGROUND: The apical triangle is the superior portion of the cutaneous upper lip lying between the medial cheek and alar margin. Defects involving this subunit are often repaired without taking into consideration the aesthetic implications of its potential loss or reduction. We present a simple option for repair of apical triangle defects to address this concern. METHODS: We collected a series of 69 patients with apical triangle defects treated from 2002 to 2008 with Mohs micrographic surgery. Their defects were reconstructed using various flaps (advancement, rotation, island pedicle, or M-plasty). A subset of 27 patients was identified who had undergone a standard cheek advancement flap or a modified flap. The modified design introduces an incision extending from the alar crease onto the nasal sill along the cutaneous upper lip, creating a second sliding flap to assist in recreating the apical triangle. RESULTS: A modified flap design introduced the ability to transfer adjacent tissue of the cutaneous upper lip to reconstruct the apical triangle subunit. CONCLUSION: This flap modification is a simple and efficient method of repairing peri-alar defects that restores the apical subunit, preserving facial symmetry.

BACKGROUND:Immunotherapy for cutaneous malignancy involves manipulating the immune system to treat and prevent skin cancer. Although initial efforts were fraught with low success rates and technical challenges, more-recent endeavors have yielded response rates approaching 50% for treating metastatic melanoma. Many of these advances are a result of increasing knowledge of the immune system's intricacies and continued progress in laboratory techniques. OBJECTIVE:To review our current understanding of the skin immune system and discuss how these factors contribute to the host response to malignancy and to report the current state of immunotherapeutic techniques. MATERIALS AND METHODS/METHODS:An extensive PubMed literature search was conducted in topics involving immunotherapy with specific relevance to cutaneous malignancy using the MeSH terms "immunotherapy" and "skin cancer." RESULTS:Despite initially poor patient responses to these treatment modalities, recent gains in scientific knowledge and clinical intervention protocols have brought immunotherapy to the forefront of prospective skin cancer therapeutics, particularly for advanced melanoma. CONCLUSIONS:Current treatment options for advanced cutaneous malignancies such as melanoma are low in efficacy. Immunotherapies have the potential to provide novel approaches to address this, particularly when used in combination. The authors have indicated no significant interest with commercial supporters.