The development of the circle technique for determining the optimum line of tumour excision.

The healing of skin wounds is markedly influenced by their relationship to the tensional forces in the skin. Directional variations in skin extensibility which give rise to the cleavage line phenomenon and the skin tension lines are easily visualized by a recently developed skin marking technique. This technique makes it possible to plan accurately the optimum line of excision of skin tumours, including malignant melanomata, so as to allow primary linear wound closure without the necessity of undermining or grafting. The technique is particularly applicable to the excision of tumours of the back and limbs, and in addition, provides a warning if the local skin tensional state makes primary closure hazardous.     

A simple technique for successful primary closure after excision of pilonidal sinus disease.

Primary closure after excision of postanal pilonidal sinus disease frequently has been complicated by wound break-downs. Healing by second intention takes many weeks and requires supervised wound care. A simple technique has been developed which has resulted in primary healing in 28 of 31 patients treated in a 5-year period. Sepsis and haematoma formation, the causes of wound breakdown after pilonidal sinus excision, have been prevented by preoperative preparation, prophylactic antibiotic administration, wound irrigation with povidone-iodine and simple skin closure over a Redivac suction drain for at least 4 days. This series suggests that primary closure can be successful using the technique described.     

The skin overlying the sentinel lymph node: a full thickness skin graft donor site after local excision for cutaneous melanoma

Wound defects resulting from wide local excision for cutaneous melanoma, can require the use of skin graft for closure. Harvesting the skin graft can result in an additional morbidity. The increasing use of sentinel lymph node biopsy in cutaneous melanoma allows us the development of an alternative technique for obtaining donor skin. This method utilizes the skin overlying the sentinel lymph node as the skin graft donor site. Sixteen patients with cutaneous melanoma over than 1 mm of Breslow index, underwent wide local excision with sentinel lymph node biopsy and full thickness skin graft harvested from the node biopsy site. After a median follow-up of 18 months, there were no graft failure, one case of lymph swelling was relieved in the donor site. There were no melanoma recurrence and no metastasis. One case of in transit metastasis was treated by local excision and suture. In cases were primary closure is not feasible or cosmetically unfavourable, the use of the sentinel lymph node site as a skin graft donor, provides an alternative technique sparing the patient an additional skin graft donor site defect.     

The keystone design perforator island flap. Part II: clinical applications.

BACKGROUND: This curvilinear- and trapezoidal-shaped flap essentially consists of two conjoined V-Y flaps end to side. The vascular supply is supported by the subcutaneous vascular network and is dependent on fascial and muscular perforators. A review of 15 clinical cases was performed to assess the reliability and versatility of the flap. METHODS: Twelve keystone flaps were performed following excision of skin tumours or post-traumatic defects in various locations, from the head and neck region, the trunk and the limbs. RESULTS: No flap necrosis, even partial, was observed regardless of the site and the type of keystone used. Patients were almost pain free in the postoperative course. The aesthetic results are quite satisfactory, as the flap is aligned locally without evidence of the 'pincushioning' appearance sometimes seen around island reconstructions. DISCUSSION: Elevation of the flap seems to evenly distribute the tensional forces without undermining. The flap is particularly useful in the repair of defects following skin cancer removal. Bulk is not a problem and good skin cover is achieved. CONCLUSION: The presence of perforators and subcutaneous network distributed throughout the body create an environment which makes this flap universally applicable and extremely reliable.     

ISLAND FLAPS INCLUDING THE BEZIER TYPE IN THE TREATMENT OF MALIGNANT MELANOMA

Despite the trend in current surgical practice in the treatment of melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a fascial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the derma-tomes, which act as an aid memoire upon which the flaps are marked.     

Burn wound excision and local flap closure

Eleven circumscribed, full-thickness burns were treated in 9 patients with immediate excision and primary closure of the defect or by using a variety of local random cutaneous and musculocutaneous flaps. The burns were located on the face, trunk, and extremities. In 2 patients this technique was used in the management of smaller burns on one surface of the body, thus facilitating skin grafting of larger wounds on the opposite surface. The cutaneous flaps utilized included advancement flaps, V-Y flaps, Moberg flaps, and S-plasties. The timing of the excision and closure varied from 2 hours to 2 weeks following thermal injury, with no postoperative wound infections. In selected cases primary excision of deep burns and closure by use of local tissue approach ideal treatment. With certainty of the depth of destruction, this procedure should be carried out regardless of locality when technically and anatomically feasible.     

Repeat pilonidal operations

Radical excision of pilonidal disease is unwarranted. The unhealed wound which may follow such surgery can be salvaged by the technique of cleft closure. Should repeat operation become necessary, the technique of cleft closure should be performed. It is simple, causes little disability, results in primary wound healing, and requires minimal postoperative care. The operation is directed against the cause of both pilonidal disease and the unhealed wound, which appears to be skin pulling away from bone, and not against the abscess in fat, which is a secondary effect.     

Technical aspects of war wound excision

Excision of war wounds may be performed by civilian surgeons with no previous experience of war surgery. The principles of complete excision of non-viable tissue with removal of foreign material, leaving the wound open, and delayed primary closure of skin are vitally important. A major part of the surgical approach is wound assessment and the formation of an operative plan. The extent and ease of the operation depends on the site, age and type of wound. Attention to the technique of wound excision avoids septic complications and permits skin closure when the first dressing is removed. Wounds may need re-excision at a later date. Modification of surgical management is necessary when certain difficult areas are wounded and when the patient presents after many days or has suffered inappropriate first aid.     

The use of suction curettage as adjunct to the management of lymphedema

This case report describes the use of suction curettage as an adjunct to the method of skin and subcutaneous tissue excision in the treatment of primary lymphedema. Pretreatment with high-vacuum cannula suction can provide three advantages over straightforward primary excision and closure; (1) larger volumes of skin and subcutaneous tissue can be resected at a single setting; (2) tensionless closure can be obtained without skin flap undermining; and (3) procedural blood loss is minimized.     

Skin malignancy and the reconstructive plastic surgeon.

Skin malignancy represents at least 25% of the plastic surgeon's workload. The commonest tumour, the basal cell carcinoma, usually arises in the skin of elderly patients who are frequently managed by surgery under local anaesthetic, often as outpatients. The recurrent basal cell carcinoma poses a difficult problem regardless of the primary therapy. Skin repair with direct closure or skin grafts is usually simple, but skin flaps will be needed when bone, cartilage or major neurovascular structures are exposed, or where tissue vascularity has been reduced by irradiation fibrosis. Squamous cell carcinomas of lip, ear and hand may recur as lymph node metastases despite clinical and histological clearance. Malignant melanoma continues to present as advanced disease (thick tumours) in this country, and this largely dictates prognosis, since tumour thickness is recognised as the single most important dominant prognostic variable. Incisional biopsy compromises histological microstaging and should be avoided. Indirect evidence from narrow margin excision of invasive head and neck cutaneous melanomas suggests no detriment, and narrow margin excision of melanomas is increasingly being practised.     

Techniques in blepharoplasty.

The technique for upper lid blepharoplasty is presented, which emphasizes the creation of a concave, high supratarsal fold by removal of existing preaponeurotic fat pads, excision of a strip of preseptal orbicularis fibers, and portion of the orbital septum. In additon, the skin edges are fixated to the levator aponeurosis just above the tarsus. With this technique, a pleasing result can be obtained, minimizing the amount of skin that is required to excised and introducing a safety factor in the prevention of postoperative lagophthalmos. A skin technique for lower led blepharoplasty is presented which reduces a tendency for "dog-ear" formation with skin closure and minimizes chances of postoperative ectropion. The technique consists of triangulation of the excision of skin from the lower lid to insure an equal-sided wound edge for precise closure and anchoring the lower lid skin flap to the lateral orbital rim. Although the above techniques introduce a safety factor reducing the problem of lagophthalmos in the upper lid and ectropion in the lower lid, they should be considered an "advanced technique" by the occasional blepharoplasty surgeon.     

MELANOMA OF THE FACE: THE SAFETY OF NARROW EXCISION MARGINS

Recent studies have shown that narrower excision margins may be safe, but the optimal or minimum margin for melanoma is unknown. Wide margins of excision are possible on the trunk and limbs, but functional and cosmetic constraints often limit the extent of excision on the face. A collaborative study from two continents (Cape Town, South Africa and Northwood, England) investigated the outcome of different excision margins of 106 patients with stage I melanoma of the face. The margin of excision was measured from the records of the pathological specimen. Thirty patients had margins of less than 1 cm, 64 had margins of between 1 and 2 cm, and 12 had margins greater than 2 cm. Primary apposition or flap closure was possible in 85 patients. Seven patients developed local recurrences and these were not influenced by the excision margin. This study supports the contention that the primary treatment of cutaneous melanoma on the face should be histologically confirmed complete excision, and that this can be achieved with margins of excision less than 1 cm. Local recurrence is not related to the margin of excision or to tumour thickness.     

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic, debilitating disease of apocrine gland-bearing skin. Its management must be individualized according to the site and extent of the disease. Initial conservative measures with antibiotics, local wound care, and limited incision and drainage can alleviate the acute symptoms, but more radical surgery will likely eventually be necessary in order to control and prevent recurrent disease. Options include unroofing and marsupialization, local excision, or more extensive operative excision with primary or secondary closure, skin grafting, or flap coverage of defects. Wide excision will offer the most definitive therapy, with the trade-off being a higher morbidity. Split-thickness skin grafts in the anal canal may contract and result in anal stenosis and should be avoided. Perianal disease is often best managed with local excision alone, with primary closure for small defects, and either unroofing or healing by secondary intention for larger wounds.     

MANAGEMENT OF INVASIVE PENILE CANCER BY SYNCHRONOUS PENILE LENGTHENING AND RADICAL TUMOUR EXCISION TO AVOID PERINEAL URETHROSTOMY

Background: Adequate excision of invasive penile carcinoma often results in penile stump of inadequate length to control the urinary stream. A simple technique to lengthen the stump and avoid urethrostomy is described here. Methods: Additional corporal length is gained by dividing the dorsal suspensory ligaments through transverse lower abdominal skin incision. Skin length is gained by vertical closure of this incision. Results: Conclusions: In selected cases this technique may avert the need for perineal urethrostomy after adequate excision of penile cancer.     

Serial Excision of a Large Facial Skin Cancer

BACKGROUND: In the management of large facial neoplasms, the dermatologic surgeon must consider local factors affecting the success of closures. OBJECTIVE: Large facial neoplasms can be removed serially with Mohs micrographic surgery. Serial excision facilitates recruitment of adjacent normal skin for replacement of lesional skin, minimizing the risks of necrosis. METHODS: A large morpheaform basal cell carcinoma was excised serially. The initial defect was closed with an O to L advancement flap. The final excision and repair 2 months later consisted of a combination of primary closure with marsupialization and pursestring closure. A full-thickness skin graft was used to close the final defect. RESULTS: The patient had optimal cosmesis at 2-year follow-up. CONCLUSION: Large facial neoplasms can be excised serially. This technique, performed in the setting of Mohs micrographic surgery, takes advantage of "mechanical and biologic creep," resulting in excellent cosmesis and function.     

Expanded scalping forehead flap for coverage of giant congenital nevi of the face: A report of three cases

Summary We present a technique using expanded forehead skin to allow excision and resurfacing of giant hairy nevi of the face. In each of three young patients an expanded scalping forehead flap provided pleasing coverage and permitted primary closure of the donor site. We believe that the superiority of this technique compared to other reconstructive options justifies the multiplicity of operative stages.     

皮肤伸展术在创伤修复重建外科中的应用

目的观察验证皮肤伸展器的可行性及临床应用效果。方法采用周黎安自行设计的针爪结合的皮肤伸展器,在皮肤缺损创缘行皮肤伸展术,治疗烧（创）伤肉芽创面、供皮瓣创面及肿瘤切除后的缺损共３４例。结果该装置使用时间为１５～７２０分钟,可分别在术前、术中及术后三个不同阶段使用。随访１６例,时间为６～１２个月,效果均满意。结论此种针爪结合的皮肤伸展器对创伤及其它原因造成的皮肤软组织缺损的创面闭合有积极意义,是一种行之有效的治疗方法。     

The role of soft tissue reconstruction after melanoma resection in the head and neck

INTRODUCTION: Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience. METHOD: We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting. RESULTS: The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm2. Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results. CONCLUSION: Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas.     

Reducing Opposed Multilobed Flap Repair, a New Technique for Managing Medium-Sized Low-Leg Defects Following Skin Cancer Surgery

BACKGROUND: Following skin cancer excision, skin defects on the low leg between 10 and 35 mm in diameter can be problematic. Direct closure of the wound risks excessive wound tension and wound dehiscence. Skin grafts heal slowly and often remain unsightly. Traditional skin flaps have a limited role. OBJECTIVE: The objective was to develop a random-pattern skin flap that offers significant advantages over traditional techniques including grafting. METHODS: The reducing opposed multilobed flap involves a series of semicircular lobes extending both cephalic and caudal from the defect. The technique involves lobes most distant from the primary defect being transposed in turn closer to the defect. The technique does not result in the unnecessary excision of Burrows triangle skin. RESULTS: The reducing opposed multilobed (ROM) flap reduces skin tension concerns, lowers the risk of flap necrosis, and allows for quicker and more aesthetic healing. After 20 cases, we have yet to experience dehiscence, infection, or delayed healing. The healing wound is resistant to contraction and invariably produces an acceptable aesthetic outcome. CONCLUSION: The ROM flap repair allows the dermatologic surgeon an additional option when faced with a medium-sized lower leg defect following skin cancer excision.     

Port-site Metastasis of Extrahepatic Bile Duct Carcinoma after Laparoscopic Cholecystectomy without Evidence of a Primary Tumour

A 75-year-old man suffering from symptomatic cholelithiasis underwent laparoscopic cholecystectomy using the four-port technique. No malignancy was observed in the resected gall-bladder and the patient exhibited a good postoperative course. Eleven months postoperatively he presented with two subcutaneous tumours: one at the port-site on the right anterior axillary line (at the position of the vacuum drain) and the other at the subumbilical port-site. The patient underwent an incisional biopsy, which revealed metastatic adenocarcinomas of the primary extrahepatic duct, with no evidence of a primary tumour or other distant metastasis. The patient underwent wide excision of the subcutaneous tumours. Six months later he again presented with subcutaneous tumours at the same positions. Magnetic resonance imaging of the abdomen revealed only the subcutaneous tumours. The patient again underwent wide excision of the subcutaneous tumours, followed by radiotherapy. At a 21-month follow-up the patient was symptom-free. Magnetic resonance imaging of the abdomen and magnetic resonance cholangiopancreatography results were normal, and there was no evidence of other metastasis. Four months later the patient died from metastatic disease of the abdomen.