The current status of curettage and electrodesiccation

Curettage and electrodesiccation (CE) is a technique widely used in the destruction of benign and selected malignant cutaneous neoplasms. CE is used mainly by dermatologists and family practice physicians, whereas plastic surgeons and other surgeons excise most benign and malignant lesions. The use of CE for the treatment of skin cancer has been widely extolled and also fervently criticized. Some practitioners treat most non-melanoma skin cancers (NMSC) with CE, and others have called for abandoning the technique in the treatment of such lesions. A thorough review of the literature reveals that CE has both virtues and flaws. In taking a rational approach to the treatment of benign and malignant cutaneous lesions it is essential to learn the basis for CE, the likely cure rates for given lesions, the proper technique, and the expected level of cosmesis. As the surgical treatment of skin cancer has become firmly entrenched in the field of dermatology, it is valuable to examine this technique in depth and to come to some thoughtful conclusions about its use for patients with skin cancer and assorted benign skin lesions. Last year a remarkably complete and exhaustive favorable review of curettage, electrosurgery, and skin cancer was published by Sheridan and Dawber. This article is a must read for anyone performing curettage; however, the author is writing with a slightly different perspective, that of a dermatologic surgeon. Although the author believes that CE has value and he uses this technique frequently, he disagrees with some of the truisms expressed in the literature about CE and attempts to define carefully what he believes are the strengths and limitations of this technique.     

Factors influencing skin cancer excision rates in Scottish primary care

Skin cancer incidence rates are rising in the UK, yet many areas are experiencing a shortage of dermatologists. We sought to compare skin cancer excision rates between general practice (GP) surgeons to identify factors associated with good practice, through a retrospective analysis of GP skin cancer histopathology reports in three Scottish Health Boards over a 4‐year period. Postal questionnaires were used to explore factors affecting surgeons’ excision rates. GPs excised 895 skin cancers (4.5% of the 19 853 regional total) during the period. Of the basal cell carcinomas, 308 would be classified as low‐risk by current National Institute for Health and Care Excellence criteria. Of the returned questionnaires, 58 accounted for 631 (70.5%) of the excised skin cancers. Analysing completeness of skin cancer excision, there was a statistically significant difference between GPs performing excision on ≥ 11 lesions/month compared with those performing excision on ≤ 10/month. Policymakers may wish to consider systems to facilitate low‐risk patients being treated by GPs who undertake frequent surgical procedures.     

Mohs surgery in Australia: a survey of work practices

Background: Mohs micrographic surgery is the preferred treatment for certain skin cancers. It had already been considerably refined prior to its introduction into Australia in 1978, refinement has continued since. Documenting the work practices of Australian Mohs surgeons serves to clarify the current role of Mohs surgery and may help tailor future Mohs fellowship programs. Methods: A survey was conducted to investigate the characteristics and clinical practices of Australian Mohs surgeons, particularly as they relate to skin cancer management and aesthetic dermatology. Results: The typical Australian Mohs surgeon is male (90%), works in a group private practice (70%), and is aged 40–44 years (37%). Mohs surgery is generally reserved for tumours that are located on the head, neck, digits or genitals (98%), and flap reconstructions are the commonest repair types performed (48%). Laser and cosmetic injectable treatments form part of many Mohs surgeon's repertoires. Conclusion: Australian Mohs surgeons make an important contribution to the management of skin cancer in Australia and many are skilled in laser and cosmetic procedures. The increasing number of cases performed annually and the familiarity with laser and cosmetic therapies reinforces Australian dermatologists as leaders in these important areas of dermatology.     

Surgical excision of skin cancer: the importance of training

Background Skin cancers are the most common malignancy in New Zealand and their treatment imparts a huge burden on the healthcare system both in terms of the cost of surgical intervention and in treatment delivery (estimates are in excess of NZ$33 million per annum for the year 2000). Currently in New Zealand, skin cancers are excised by dermatologists, general practitioners (GPs), GPs with a special interest in skin surgery (GPSIs) and specialist surgeons with diverse training backgrounds including ear, nose and throat, ophthalmic and general surgeons. To date there is scant literature evaluating complete excision rates following surgical treatment of skin cancer between these vocational groups. Objectives To review retrospectively pathology reports from all skin excisions sent to one private pathology laboratory over three consecutive months. The aim was to investigate the margins of excision and completeness of skin cancer surgery performed by each vocational group. Methods A retrospective analysis of skin pathology reports was undertaken for a 3‐month period between April and June 2007. Raw data obtained from the pathology reports included diagnosis, completeness of excision, size of specimens, body site and vocational group of the medical practitioner performing the surgery. Results In total, 1532 lesions were excised: 432 benign and 1100 malignant. Six hundred and seven were from the head and neck. Dermatologists excised 276 lesions of which 93% were malignant, 55% were from the head and neck, and 0% were incompletely excised. GPs excised 633 lesions: 63% malignant, 30% head and neck, 23% incomplete excision of malignant lesions. GPSIs excised 368 lesions: 71% malignant, 35% head and neck, 21·5% incomplete malignant excision. Specialist surgeons excised 255 lesions: 72% malignant, 53% head and neck, 20% incomplete malignant excision. Conclusion GPs and GPSIs excised more benign lesions and had higher incomplete excision rates of skin cancer surgery than dermatologists. Incomplete excision rates for the vocational groups ranged from 0% to 45% depending on site and pathology.     

Simple things that make a difference in nasal reconstruction

The nose is the most common location for nonmelanoma skin cancer. As a result, nasal reconstruction is a frequent challenge for Mohs surgeons. The esthetic outcome of each nasal repair can be improved by replacing nasal skin with the most similar match, restoring the intricate three-dimensional structure of the nose and applying the principle of cosmetic subunits. This article will present techniques and helpful hints, which are useful during nasal reconstruction to improve the selected repair and enhance the final result.     

Tissue expansion: update and prospects

This brief history of the development of the tissue expansion technique, from the initial intuitions of C.G. Neumann to the later applications by C. Radovan and subsequent uses, includes notes on the surgical techniques involved and the structural modifications of expanded skin. The author explains his preference for use of the external valve expander and presents data regarding use of high resolution ultrasound to monitor the thickness of expanded tissues. Dermatologists as well as surgeons should be familiar with the possible uses of this technique in the treatment of various wounds and skin lesions.     

The Use of the Cryostat for Histographic Surgery

Microscopically monitored excision for the treatment of skin cancer is becoming increasingly popular among dermatologists. One decision faced by beginning histographic surgeons involves the choice of apparatus for making the frozen sections. This paper compares the freezing microtome with the cryostat and gives details of the University of Iowa method, which employs the Slee© cryostat.     

Cowden's disease (multiple hamartoma syndrome) An underdiagnosed syndrome with increased risk of malignant development

Cowden's disease is so often followed by malignant diseases, such as cancer of the breast and thyroid, and different forms of gynaecological cancer, that surgeons should be made especially aware of those changes in skin and mucous membranes which, if multiple are pathognomic. It remains, however, an underdiagnosed syndrome. We believe a number of other conditions are also associated with Cowden's disease.     

Combination excision and liposuction in a single‐stage treatment of various skin disorders

Objectives The repair of skin defects resulting from the excision of large skin disorders is always challenging for surgeons as many methods have varied disadvantages. Therefore, we attempt to overcome frequent disadvantages of other surgical methods in repairing skin defects with the help of liposuction. Methods Before excision of skin disorders, liposuction was performed in regions where they were located followed by complete excision. The sliding flaps on both sides of the defect created by liposuction were pulled together to cover the defect. In our study, 40 skin disorders located on the upper arm, thigh, and trunk were treated by this technique. Results Forty skin disorders were excised and resulting skin defects were repaired in one stage by the surrounding sliding flaps without wound dehiscence, infection, incision edge necrosis, sensory deficit, or severe scar recurrence. The regions of liposuction presented a harmonious result and simultaneously the body contour was well‐balanced. Conclusion Some large skin disorders at sites rich in subcutaneous fat can be treated in one stage by combining excision and liposuction with good functional and esthetic outcomes with few complications. Although the indications for this technique are limited, it is really a good option for appropriate cases.     

Cancer of the scalp

Carcinomas on the scalp have a tendency to recur following traditional treatment. Their management is often difficult because of the extent of the tumor and the unique anatomy of the area. In order to maximize cure rates for complicated carcinomas, Mohs micrographic surgeons and other surgical specialists have formed interdisciplinary treatment teams. Resection of bone, parotid/facial nerve dissection, and neck dissection are often necessary. Interdisciplinary cooperation in the treatment of skin cancer leads to maximal utilization of expertise and is a major advance in cancer treatment.     

Mohs micrographic surgery: a review of indications,technique, outcomes,and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.     

Dermabrasive surgery state of the art

Except for refinements in equipment and instrumentation, the technique for dermabrasion essentially is unchanged from that described by Kurtin when he introduced the use of the wire brush in 1953.¹ Dermabrasive end pieces, usually a diamond fraise or the wire brush, rotating at high speeds from power-drive instruments, are surgically directed across skin that has been frozen to hardness with cryogenic spray. Both plastic surgeons and otolaryngologists with a plastic-surgery orientation have joined dermatologic surgeons in acknowledging the superior efficacy of this procedure as the profession's most versatile modality to resurface and recontour the skin successfully. From the early 1960s to the mid-1970s, dermabrasion was an innocent victim of unwarranted bad press. Most physicians and nearly all health insurance companies relegated its practicality to “cosmetic” enhancement of acne scars. Few training programs taught the procedure, and many physicians who attempted to perform it were inadequately prepared.     

MOHS micrographic surgery for head and neck nonmelanoma skin cancer: An approach for ENT surgeons

Surgery is the main approach for skin cancer, with Mohs micrographic surgery (MMS) allowing the highest cure rates, best esthetics and superior functional outcomes. Ear, nose, and throat (ENT) surgeons are often challenged with patients presenting skin cancer, needing appropriate expertise to its adequate management. This paper highlights the most important aspects of MMS, enabling ENT surgeons to become familiar with its fundamental aspects. A review of the literature was performed, concomitantly presenting the author's outcomes as an ENT surgeon. A total of 51 MMSs were performed in 41 patients, and 78.4% of the tumors were cutaneous basal cell carcinomas (cBCCs), 19.6% were cutaneous squamous cell carcinomas (cSCCs), and one case was a microcystic adnexal carcinoma. Most tumors were located in high‐risk areas (88.2%), and 84.3% of them were ≥10 mm in diameter. Most tumors (90.2%) required no more than two MMS excision steps to be completely removed. All cases were managed by reconstruction either using flaps or grafts. Recurrence occurred in only 2% of the cases. This study addressed the main issues of MMS, which may be important in ENT surgeons' daily practice.     

Motor nerves of the head and neck that are susceptible to damage during dermatological surgery

As the incidence of non melanoma skin cancer rises, dermatologists will increasingly be called upon to perform excisions in the head and neck region. Damage to the motor nerves of the head and neck represents an important adverse event for patients, and a source of litigation for surgeons. Understanding the anatomy of this region is key to counselling patients about the possibility of motor nerve injury associated with particular skin surgical procedures. We describe the anatomy of the motor nerves of the head and neck that are most vulnerable to injury during dermatological surgery. The consequences of injury are outlined, and the surface anatomy and anatomical landmarks that may be used to identify the relevant danger zones are described.     

Analysis of surgical treatment for nonmelanoma skin cancer performed by dermatologists in a public hospital: clinical-pathological correlation, use of hospital resources, and waiting list time from diagnosis

BackgroundNonmelanoma skin cancer is the most common form of cancer in humans. It can be treated by a variety of specialists and using different techniques, surgical excision being the procedure associated with the lowest rates of recurrence. No studies have been published addressing differences in the management of surgical treatment for nonmelanoma skin cancer according to the specialties involved.ObjectivesTo assess the preoperative diagnostic accuracy and the use of health care resources when surgical treatment of nonmelanoma skin cancer is done by dermatologists belonging to the Spanish national health service.MethodsA prospective observational study was carried out over a period of 36 months using data corresponding to all patients diagnosed with nonmelanoma skin cancer and treated surgically in the Dermatology Department of Complejo Hospitalario de Burgos, Spain. Data were analyzed for clinical-pathological correlation, complexity of the intervention, use of health care resources, and time elapsed between clinical diagnosis and surgery.ResultsThe study included 448 patients and 521 skin lesions suspected to be nonmelanoma skin cancer (basal cell carcinoma or squamous cell carcinoma). Diagnosis was exclusively clinical in 487 tumors and a clinicalpathological correlation of 84.39 % was observed. Surgery was performed with local anesthesia in 96.42 % of patients, although 111 (21.29 %) required complex surgical repair. In 349 patients (77.90 %) the procedure was performed on an outpatient basis, 73 (16.29 %) required a short stay in the surgical day care unit, and 26 (5.80 %) required hospital admission. The mean (SD) delay from clinical diagnosis to surgery was 68.44 (42.22) days, with a median delay of 60 days.ConclusionsDermatology specialists are highly qualified to diagnose malignant skin tumors and accurately identify those patients requiring surgery. Dermatological surgeons use minimal health care resources, shorten the overall length of the process, and help to control overall health care costs for cancer.     

Skin cancer prevention in the primary care setting: assessment using a standardized patient

Our objective was to utilize the standardized patient technique in assessing the ability of primary care physicians to identify and counsel primary prevention for patients at high risk for skin cancer. A secondary goal was to test the feasibility of this technique as a measure of actual physician behaviors in the outpatient setting. We used a convenience sample of 15 primary care physicians. The standardized patient was an 18-year-old woman with skin phototype I. She presented to physicians as needing a general physical examination for a summer lifeguard job at a beach. She stated a family history of skin cancer. Physician performances were rated using a standard checklist completed by the standardized patient following each visit. We found that none of the physicians asked questions specifically related to skin phototype or sun exposure habits such as childhood sunburns. Only 13% asked about mole changes. For counseling, 67% of physicians recommended sunscreen use; only 7% discussed sunscreen types or procedures for effective use. Only 13% counseled other skin protective behaviors. No significant differences by physician gender were found in these areas; however, female physicians counseled more global health behaviors than male physicians (p < or = 0.01). Our pilot data suggest that little skin cancer primary prevention counseling is performed for high-risk patients. The standardized patient technique worked well in obtaining outcome data for physicians' preventive practices.     

In vivo reflectance confocal microscopy for early diagnosis of nonmelanoma skin cancer

Reflectance confocal microscopy (RCM) is a novel tool for noninvasive in vivo diagnosis of nonmelanoma skin cancer at high resolution. Given the excellent correlation that has been demonstrated between RCM findings and routine histology, clinicians using this imaging technique can establish an immediate diagnosis. Multiple studies have evaluated the use of RCM in melanoma and nonmelanoma skin cancer and have demonstrated high sensitivity and specificity rates. We discuss the applicability of RCM for the early diagnosis of NMSC and discuss other clinical applications of this emerging technique.     

Cryosurgery of malignant and premalignant diseases of the skin: A simple approach

Cryosurgical treatment of skin cancer and premalignant conditions of the skin has been in widespread use for 20 years. Data accumulated over this period suggest that if attention is paid to the treatment technique and to lesion selection, then cure rates equivalent to radiotherapy, simple surgical excision, and curettage and cautery can be achieved reliably. Moh's micrographic surgery offers a higher cure rate for skin cancer, but is not suitable for the vast majority of lesions seen in clinical practice. The decision to use cryosurgery to treat any particular lesion will therefore be influenced by a number of other considerations. Cryosurgery competes well on morbidity and cosmetic outcome and is the quickest, easiest, cheapest and most readily available of the treatment options. As such it has earned its place among the recognized treatment modalities for skin cancers as well as premalignant conditions of the skin. Cryosurgery is commonly delivered empirically without record of the dose delivered and without audit of the outcome. The aim of this review is to describe in detail one standard technique of therapy that is easily reproduced and has been audited; the timed spot freeze technique. This technique can be used, even by those inexperienced in cryosurgery, to achieve predictable success rates. Many other techniques do exist, but either have not been audited or are unnecessarily cumbersome.     

In vivo confocal microscopy in dermatology

Confocal microscopy is an optical imaging tool that allows for high resolution, noninvasive imaging in vivo. Thin sections of human tissue can be imaged allowing visualization of cellular and nuclear detail without biopsy. This technique recently has been used to image benign and malignant pigmented skin lesions, nonmelanoma skin cancer, inflammatory skin conditions, and dynamic skin processes.     

Technique for histological control of surgical margins in lip cancer

To preserve oral function and achieve acceptable cosmetic results, intraoperative control of surgical margins with frozen section evaluation may help to determine surgical technique in lip cancer. However, frozen section analysis is usually limited to suspicious areas and has not been systematically performed among surgeons. The accuracy of such analysis for detecting histological surgical margins is highly dependent on the methods used to obtain and analyze the margins. Improving the pathodiagnostic reliability of conventional intraoperative frozen section evaluation is the most important goal of surgical management in our method. We describe the successful use of the “double‐blade method” in lip cancer treatment. The technique we describe has the advantage of histologically confirming clear margins in lip cancer. This method appears to be time‐saving and easy to apply with existing surgical systems. In addition, this method may be used as an alternative to complete evaluation of lateral surgical margins that is important in planning a suitable surgical reconstruction procedure in lip cancer at many institutions where Mohs micrographic surgery is difficult to perform.