Management of stage I malignant melanoma.
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Humans↗
Biomedical subjects
J A Zitelli
Publications and source records attributed to J A Zitelli.
Full-thickness skin grafts. Clinical observations on the impact of using epinephrine in local anesthesia of the donor site.
BACKGROUND AND DESIGN: A recent animal study indicated that epinephrine in local anesthesia adversely affects the survival of full-thickness skin grafts. Because animal models do not always correlate to humans, we performed a prospective observational study to elucidate the clinical outcome of using epinephrine in local anesthesia of the donor site. Seventy-two patients had cutaneous tumors excised by the Mohs micrographic technique. The resultant surgical defects were repaired using full-thickness skin grafts. Patients were randomly divided into two groups based on the local anesthetic used at the donor site: (1) 1% lidocaine (Xylocaine) (n = 33) or (2) 1% lidocaine with 1:100,000 epinephrine (n = 39). RESULTS: Assessment of the skin grafts at 1 week revealed a significantly increased risk of developing graft complications in the lidocaine with epinephrine group compared with the plain lidocaine group. The overall cosmetic outcome of the grafted site at 6 weeks revealed no significant difference between the two groups. CONCLUSIONS: Because there was only a minimal clinical effect of epinephrine on graft survival observed at 1 week and there was no effect on the 6-week cosmetic outcome, we do not recommend harvesting all full-thickness skin grafts with plain lidocaine. In certain clinical circumstances with compromised vascular supply or poor oxygenation, the use of plain lidocaine may be advantageous.
Aged↗
Surgical margins for excision of dermatofibrosarcoma protuberans.
BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) commonly recurs after standard surgical excision with a wide margin. No studies have been undertaken to objectively determine the appropriate surgical margins by measuring the extension of the subclinical tumor. OBJECTIVE: Our purpose was to measure the subclinical extent of tumor in 20 patients with DFSP to determine appropriate surgical margins. METHODS: We mapped the subclinical tumor extension with Mohs micrographic surgery and measured the surgical margins required to clear the tumor completely. RESULTS: We found that a 2.5 cm surgical margin through the deep fascia (nonscalp) or periosteum (scalp) cleared all of the tumors. DFSP tumors that measured less than 2 cm were completely cleared with a 1.5 cm surgical margin. None of our patients had a recurrence of the tumor, and in 16 of 20 patients repairs were possible. CONCLUSION: Our data support the use of Mohs surgery to excise DFSP with maximum conservation of tissue and a high cure rate.
Adult↗
The prognosis and treatment of true local cutaneous recurrent malignant melanoma.
BACKGROUND: The prognosis and treatment of true local cutaneous recurrent malignant melanoma is presently unknown. We define this entity as melanoma bearing an in situ component that recurs contiguous with the scar of the primary excision. Although previously uncommon, the incidence of true local recurrent melanoma may rise due to the recent use of more narrow margins for excision of thin primary melanoma. OBJECTIVE: We hypothesized that there is a difference in prognosis between true local cutaneous recurrent melanoma versus local recurrence from satellite or in-transit metastases. Also, we defined guidelines for the surgical management of true local cutaneous recurrent melanoma. METHODS: We calculated the surgical margin necessary to reach a tumor-free plane using Mohs surgery in 50 patients with true local recurrent melanoma. Patient survival was determined by the Kaplan-Meier method. RESULTS: Seventy-six percent of the tumors were completely excised using a margin of less than 1 cm. However, a margin of up to 2 cm was required to successfully treat all 50 patients. Thicker tumors did require significantly larger margins. The Kaplan-Meier 5-year overall and melanoma survival rates were 89% and 98%, respectively. The 5-year disease-free survival rate was 66%. CONCLUSION: The prognosis of true local recurrent melanoma is related to tumor thickness. We recommend full-thickness excision of the entire old scar including a 2-cm margin or Mohs surgery if a narrower margin of resection is desired.
Adult↗
Choice of wound dressings and ointments.
Over the last several decades, methods for wound dressing have dramatically changed. This article reviews the effects of wound dressing, antiseptics, and antimicrobials on the process of wound healing and on the incidence of wound infection. A set of guidelines is provided to help the surgeon decide what to apply topically to wounds and which dressing to select to achieve the best possible outcome in wound healing.
Anti-Infective Agents, Local↗
Repair of the soft triangle of the nose.
BACKGROUND: Notching of the soft triangle is a complication of excisional and some reconstructive surgery that is difficult to repair. OBJECTIVE: This article provides a simple single-stage procedure to correct the complication of notching of the soft triangle. METHODS: A detailed description of a turnover flap from the inferior tip covered with a full-thickness skin graft is provided. RESULTS: The method described has provided uniformly satisfactorily results based on the author's experience. CONCLUSION: This simple method is the treatment of choice for a one-stage repair of a soft triangle notch.
Dermatologic Surgical Procedures↗
A review of topical agents for wounds and methods of wounding. Guidelines for wound management.
This article reviews the effects of antiseptics, antimicrobials, hemostatic agents and surgical methods on the incidence of wound infection and the process of wound healing. A set of guidelines is provided to help decide what to apply topically to wounds and which method of wounding to select in order to achieve the best possible outcome in wound healing.
Administration, Cutaneous↗
New primary nonmelanoma skin cancer in patients with a history of squamous cell carcinoma of the skin. Implications and recommendations for follow-up.
BACKGROUND: Rational follow-up guidelines for skin cancer patients should be based on the risk of three separate events: cancer recurrence, cancer metastasis, and the development of subsequent skin cancers. However, currently no guidelines exist for follow-up of patients with squamous cell carcinoma of the skin (SCC), which take into account all three of these risks. OBJECTIVE: The purpose of this study is to establish rational minimum guidelines for follow-up of patients with SCC. To do this, we first must determine the risk of SCC patients for the development of subsequent skin cancers. Combining these data with previously published data on SCC recurrence and SCC metastasis, we then propose guidelines for follow-up of patients with SCC. METHODS: We followed up 101 SCC patients on a yearly basis for 5 years after treatment and recorded the date and site of subsequent nonmelanoma skin cancers (NMSCs). RESULTS: Thirty percent of SCC patients developed additional SCCs and 52% developed subsequent NMSCs within 5 years of therapy for their first SCC. Patients showing the highest risk of subsequent NMSC were those presenting with multiple SCC, SCC greater than 1 cm in diameter, SCC requiring more than 1 Mohs surgery layer to remove, or SCC occurring on the scalp, ear, nose, or extremities. One hundred percent of subsequent NMSCs were detected by the fourth year of follow-up; 54% of these occurred within the first year of follow-up. CONCLUSION: After combining our data with previously published studies of SCC recurrence and metastasis, we recommend that all patients with SCC be followed up for at least 4 years after treatment. Moreover, because most subsequent NMSCs, SCC recurrences, and SCC metastases developed early in the follow-up period, we recommend that patients be reexamined at least every 3 months during the first year of follow-up and every 6 months thereafter. It must be stressed that these are meant as minimum follow-up guidelines.
Carcinoma, Squamous Cell↗
Mechanisms of metastasis.
The role of dermatologists in the diagnosis and treatment of skin cancer continues to increase. Consequently, they will more frequently be involved in the diagnosis, treatment, and management of patients with metastatic or potentially metastatic tumors. Squamous cell carcinomas and malignant melanomas are frequently seen in dermatologic practices and have the capability to metastasize. Metastases are the result of a complex process that is characterized by a sequence of steps, each of which requires acquisition by the malignant cell of key biologic properties. The metastatic sequence can be conceptualized as detachment from the primary tumor followed by invasion, intravasation into a vessel, circulation, stasis within a vessel, extravasation, invasion of the recipient tissue bed, and ultimately proliferation. The basic steps of the metastatic sequence are described as well as how these steps and other tumor cell adaptations can affect the clinical patterns of metastasis. Finally, practical applications of the understanding of these principles of metastasis are discussed.
Cell Aggregation↗
Surgical margins for excision of primary cutaneous squamous cell carcinoma.
BACKGROUND: No guidelines for the margin of resection of cutaneous squamous cell carcinoma have been based on data measuring subclinical tumor extension, as have been formulated for basal cell carcinoma. OBJECTIVE AND METHODS: Guidelines for appropriate margins of excision of primary cutaneous squamous cell carcinoma were formulated on the basis of a prospective study of subclinical microscopic tumor extension. RESULTS: Four millimeter margins were adequate for most squamous cell carcinomas. However, certain tumor characteristics were associated with a greater risk of subclinical tumor extension and included size of 2 cm or larger, histologic grade 2 or higher, invasion of the subcutaneous tissue, and location in high-risk areas. CONCLUSION: Minimal margins of excision of 4 mm around the clinical borders of the squamous cell carcinoma are proposed for all but the high-risk tumors, in which at least a 6 mm margin is recommended.
Aged↗
Cryosurgery for skin cancer.
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Cryosurgery↗
The reliability of frozen sections in the evaluation of surgical margins for melanoma.
As the width of surgical margins declines, histologic evaluation of the margins is needed to assess the completeness of excision of a malignant melanoma. We studied 221 specimens in 59 patients and compared the interpretations of frozen and paraffin sections from the same block. Frozen sections had a sensitivity of 100% in detecting melanoma when present and a specificity of 90%.
False Positive Reactions↗
Syringoid eccrine carcinoma.
Eccrine carcinomas are locally aggressive and have an infiltrative growth pattern. They have a variable clinical appearance and a diversity of histologic findings that often make the diagnosis difficult. The histologic findings, together with immunoperoxidase and enzyme histochemical studies, usually allow differentiation between eccrine carcinomas, other cutaneous neoplasms, and visceral adenocarcinomas with skin metastases. Provided there is no evidence of distant metastases, surgical excision is the treatment of choice. We report a case of syringoid eccrine carcinoma that was treated with Mohs micrographic surgery.
Adenocarcinoma↗
A regional approach to reconstruction of the upper lip.
Treatment of upper lip wounds by second intention, full-thickness skin grafts, and local flaps is discussed. The location, size, depth, and type of closure for each defect in 200 cases involving defects of the upper lip are reviewed. The percentages of wounds treated by each modality were 20, 6, 74% for second intention, grafts, and local flaps, respectively. Of wound treatment by local flaps, 80% used advancement flaps, 10% used transposition flaps, and 10% used island-pedicle flaps. Advancement flaps, island-pedicle flaps, possible complications, and post-operative care are reviewed.
Humans↗
Reconstruction of the nose with local flaps.
The author presents the results of a study of 200 patients with surgical defects of the nose following excision of skin malignancies. The location, size, depth, and quality of the adjacent skin, the reconstruction choice, and the cosmetic result were recorded. Healing by second intention was most useful for wounds in concave areas. Full-thickness skin grafts were used for defects too large for local flaps, or for defects on the nasal tip or alar surface. Local flaps were the most useful choice for nasal reconstruction. Transposition flaps, in particular, were most useful for each cosmetic sub unit of the nose.
Humans↗
Mohs surgery for lentigo maligna.
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Humans↗
TIPS for a better ellipse.
The ellipse or fusiform closure is the simplest and most common type of excisional surgery and repair. Textbooks and review articles repeat similar traditional principles for excision and closure. In this article four additional ideas are reviewed to improve the final cosmetic result of the ellipse.
Dermatologic Surgical Procedures↗
Systemic isotretinoin: effects on dermal wound healing in a rabbit ear model in vivo.
Clinical observations have suggested that wound healing may be altered in patients treated with systemic isotretinoin. In this study, we examined the effects of systemic isotretinoin on dermal wound healing and connective tissue metabolism in a rabbit ear model. Forty 6-mm punch-biopsy wounds were created in the ears of two control rabbits as well as two experimental animals fed isotretinoin, 4 mg/kg per day. Clinical inspection and histologic examination revealed no difference between the control and isotretinoin-treated rabbits in terms of the time required for complete wound healing or the appearance of the final scar. The tissue removed from the wound site at days 0, 7, 14, and 21 after wounding was subjected to analysis of a collagen production and collagen gene expression. Collagen production, determined by the synthesis of [3H]hydroxyproline after incubation of tissue slices with [3H]proline in vitro or by the measurement of the steady-state levels of types I and III procollagen mRNAs, was not significantly different between the two groups. The results indicate that systemic administration of isotretinoin does not affect collagen synthesis in the rabbit ear model of wound healing.
Animals↗