Perineural invasion of cutaneous malignancies

BACKGROUND

Perineural invasion is an important mode of tumor spread and is associated with increased aggressiveness and a propensity for recurrence among cutaneous malignancies.

OBJECTIVE

To review the pathogenesis, diagnosis, and treatment of cutaneous tumors exhibiting perineural invasion.

METHODS

This article is based on a review of the medical literature concerning tumors with perineural involvement.

RESULTS

This article describes the clinical signs and histologic features of cutaneous malignancies exhibiting perineural involvement.

CONCLUSION

Appropriate patient care mandates consideration of perineural invasion in the evaluation of cutaneous tumors. As the majority of patients present without symptoms of neural involvement, physicians must be vigilant in the search for this type of tumor spread.

The structure and some molecular properties of acetone-picrylhydrazone

Various physical measurements and quantum-mechanical computations to characterize molecular 2-propanone(2,4,6-trinitrophenyl)hydrazone, alias acetone-picrylhydrazine (AH), are reported, including an X-ray diffraction structural determination, an1H and13C NMR study of its internal hindered reorientation, and a theoretical (SCF-MO) interpretation of these observations. The structure of AH was determined by X-ray crystallography. The space group is Pbar over 1, with a = 10.1768(9) Å, b = 7.7968(18) Å, c = 8.0018(5) Å, α = 92.102(6)°, β = 99.919(7)°, γ = 105.926(6)°, Z = 2, wR2(F2) = 0.1995 based on all 2748 unique reflections. The (picryl) proton NMR thermal work yielded a Gibbs activation energy ΔG‡= 46.9 ± 0.4 kJ mol-1in acetone-d6and 48.1 ± 0.2 kJ mol-1in chloroform-d, whereas13C NMR (two pairs in the picryl ring) yielded 46.6 ± 1.0 and 46.4 ± 1.0 kJ mol-1in acetone-d6. The SCF-MO computations yielded a detailed model of the conformerization path. Various model conformations and tautomers of AH have been considered, as has removal of H+or of H0from its hydrazinic linkage.Key words: dynamic NMR, picrylhydrazone, hindered rotation, activation parameters, SCF-MO model.

Malignant melanoma: a clinical review

The incidence of cutaneous malignant melanoma is increasing at an alarming rate. It is projected that Americans born in the year 2000 will have a 1 in 75 lifetime risk of developing melanoma. Long-term survival for patients with metastatic disease is only 5% and approximately 15% of patients diagnosed with melanoma eventually die from their disease. Conversely, the prognosis for early disease is excellent and often simple surgical excision is curative. It is therefore crucial that the practicing physician becomes familiar with all of the clinical and histologic presentations in order to ensure an accurate and prompt diagnosis. This, in turn, should lead to earlier detection and a more favorable prognosis.

Ocular melanoma

The eye is the second most common site for primary melanoma after the skin. An ophthalmologic evaluation should be an integral aspect of melanoma screening that is often not even considered by nonophthalmologists. Delays or failures to make an accurate and early diagnosis can have grave consequences. Early recognition and diagnosis, before the tumor has progressed into an advanced process with a poor prognosis, can often result in complete cures through early interventional treatments. It is imperative that physicians adequately understand and appropriately examine or refer patients for appropriate screening for ocular melanoma as a routine practice in screening for melanoma. This article is intended to raise the clinical awareness of the practicing physician regarding this disease.

Current therapy of cutaneous melanoma

We review the current therapy for cutaneous malignant melanoma. Early surgical resection offers the best likelihood of cure. The initial staging of melanoma patients determines subsequent therapeutic decisions and follow-up care. The prognosis and appropriate therapy for each stage of melanoma are discussed. We review the controversy over lymph node dissection, and recent recommendations for the use of lymphoscintigraphy. Interferon-alpha continues to be the only Food and Drug Administration-approved adjuvant therapy for high-risk patients. In addition, the follow-up care of melanoma patients will be discussed.

Mohs micrographic surgery for the treatment of dermatofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread

BACKGROUND

Dermatofibrosarcoma protuberans (DFSP) is an uncommon soft-tissue tumor of the skin; its microscopic extent of invasion beyond the grossly visible tumor is frequently difficult to appreciate. Although wide local excision has been the standard treatment of DFSP, recurrence rates range from 11% to 53%. Because Mohs micrographic surgery allows the extent of excision to be tailored to the microscopic extent of tumor, we evaluated this technique for the treatment of primary and recurrent DFSP.

OBJECTIVE

Our purpose was to determine the local recurrence rate and microscopic extent of spread of primary and recurrent DFSP after treatment with Mohs micrographic surgery.

METHODS

The records of 58 patients with primary and recurrent DFSP treated with Mohs micrographic surgery at three institutions were reviewed and the macroscopic and microscopic extents of tumor were recorded.

RESULTS

One patient with a twice-recurrent DFSP had another recurrence after Mohs micrographic surgery, for an overall local recurrence rate of 2% (zero for primary tumors and 4.8% for recurrent tumors). There were no cases of regional or distant metastases. Macroscopic tumor size ranged from 0.3 x 0.6 cm to 30 x 20 cm, whereas microscopic (postoperative) size ranged from 1.8 x 1.0 cm to 35 x 40 cm. We calculated the likelihood that a given width of excision around the macroscopic tumor would clear the entire microscopic extent of tumor. Standard wide excision with a width of 1 cm around the primary tumor would have left microscopic residual tumor in 70.7%; a width of 2 cm, 39.7%; 3 cm, 15.5%; and 5 cm, 5.2%. Even an excision width of 10 cm would not have cleared the microscopic extent of some tumors, despite taking a huge excess of normal tissue.

CONCLUSION

Treatment of primary and recurrent DFSP by Mohs micrographic surgery results in a low recurrence rate because of the ability of the technique to permit the detection and excision of microscopic tumor elements in even the most asymmetric tumors. Whatever type of surgery is chosen to treat DFSP, it is necessary to assess the entire perimeter of the tumor for microscopic extension and to achieve tumor-free margins in all directions.

Mohs' micrographic surgery for nonmelanoma skin cancers

The incidence of NMSC is increasing at a phenomenal rate, with a current estimated annual incidence in the United States of more than 600,000 cases. It is vitally important for all surgeons to become familiar with all modalities, surgical as well as nonsurgical, that are used to treat these skin cancers. This article was designed to inform the reader about the surgical technique called MMS (Figs. 9 and 10), and to present the facts regarding its historical evolution, actual technique, indications, and limitations. MMS has been modified and refined over a period spanning 60 years. During this time, tens of thousands of tumors have been treated, and the literature supports the fact that MMS provides the highest possible cure rates for the treatment of NMSCs.

The efficacy of dermabrasion in the treatment of nodular amyloidosis

Nodular amyloidosis is a rare entity that predominantly affects females in the sixth and seventh decades. Frequent cutaneous sites of involvement are the extremities, trunk, and genitalia. Numerous cosmetic procedures have been employed to treat the lesions of nodular amyloidosis. Dermabrasion, which was performed on the lesions of nodular amyloidosis on the chin after surgical debulking, proved successful in the treatment of localized nodular amyloidosis. Follow-up at 26 months showed no clinical evidence of recurrence. Dermabrasion offers another acceptable modality for cosmetic treatment of nodular amyloidosis.

A comparison of wire brush and diamond fraise superficial dermabrasion for photoaged skin. A clinical, immunohistologic, and biochemical study

BACKGROUND

Superficial dermabrasion has a proven beneficial effect on photoaged skin, but little is known about the differences between the two major modalities used in dermabrasion, the diamond fraise (DF) and the wire brush (WB).

OBJECTIVE

We compared the clinical, immunohistologic, and biochemical changes after superficial dermabrasion with DF and WB.

METHODS

Eight photoaged patients (mean age, 68 years; range, 49 to 80 years) underwent facial dermabrasion to the level of the papillary dermis. Clinical assessments were performed at baseline and at 3 and 12 weeks after dermabrasion. Biopsy specimens were taken from both dermabraded halves at the same time points and assessed by routine histologic and immunohistologic examinations, western blot analysis, and radioimmunoassay. Scoring of intracellular and extracellular transforming growth factor-beta 1 was based on a semiquantitative ordinal scale (0 = no staining to 4 = maximum staining) in half-unit increments. The score for each specimen represents the average of values obtained from four high-power fields.

RESULTS

Both methods of dermabrasion resulted in significant resolution of actinic keratoses, lentigines, and wrinkling. No statistical significance was noted between the two methods in regard to clinical efficacy. Significantly fewer milia occurred after DF than after WB. Solar elastosis decreased with both the WB and DF. Immunohistologic examination demonstrated a highly significant increase in papillary dermal fibroblast staining for amino terminal procollagen I (type I pN-collagen) at 3 weeks for both DF and WB compared to baseline. Staining at 12 weeks had decreased from the peak noted at week 3, but was still significantly increased from baseline. Western blotting of type I pN-collagen demonstrated a 5.4-fold (p = 0.01) increase from baseline at 3 weeks and a 4.9-fold (p = 0.002) increase at 12 weeks after dermabrasion with the WB. Similarly, the DF produced a 4.9-fold (p = 0.006) increase at 3 weeks and a 5.1-fold (p = 0.008) increase at 12 weeks after dermabrasion. Western blotting of amino terminal procollagen III (type III pN-collagen) showed a 6.1-fold (p = 0.07) increase from baseline at 3 weeks and a 3.9-fold (p = 0.04) increase at 12 weeks after dermabrasion with the DF. The WB showed a 3.8-fold (p = 0.07) increase from baseline at 3 weeks and a 5.1-fold (p = 0.05) increase at 12 weeks. Transforming growth factor-beta 1 demonstrated a significant increase in extracellular staining with DF (3.3 +/- 0.2) and WB (3.7 +/- 0.2) from baseline (1.2 +/- 0.2, p < 0.001) at 3 weeks.

CONCLUSION

Superficial dermabrasion with DF and WP appears to be similarly efficacious in the treatment of photoaged skin. Significant increases in type I pN-collagen, type III pN-collagen, and TGF-beta 1 occurred in the papillary dermis after both types of dermabrasion. These results suggest that increased fibroblast activity and consequent collagen I and III synthesis underlie the clinical improvement.

Sebaceous carcinoma

Sebaceous carcinoma is a rare, aggressive, malignant tumor derived from the adnexal epithelium of sebaceous glands. It may arise in ocular or extraocular sites and exhibits such a variety of histologic growth patterns and diverse clinical presentations that the diagnosis is often delayed for months to years. We discuss incidence as well as clinical, histologic, diagnostic, prognostic, and management issues of this aggressive neoplasm.

The Rieger flap for nasal reconstruction

OBJECTIVE

To repair surgical defects of the middle and distal third of the nose.

DESIGN

The anatomic and technical design of the Rieger (dorsonasal) flap is described.

CONCLUSION

When performed on properly selected patients, the Rieger flap is an aesthetically predictable, one-stage procedure.

The importance of maintaining the alar-facial sulcus in nasal reconstruction

The alar-facial sulcus is an important topographical region because it represents a junctional zone of three cosmetic units: the nasal base, the medial aspect of the cheek, and the upper lip. Too often, the sulcus is violated by transposition flaps that have been harvested from the cheek to reconstruct defects of the nasal-alar lobule. When the sulcus is violated by surgery, it is difficult to restore a completely natural appearance. For this reason, we suggest an alternative method of reconstructing the alar lobule through the use of an interpolated flap. When defects extend into the alar-facial sulcus, reconstruction of the sulcus is necessary and should be accomplished with a separate skin flap from that used to repair the nasal component of the defect. When a single flap is used to reconstruct both lobule and sulcus, restoration of a completely natural-appearing sulcus is rarely achieved and usually involves multiple surgical procedures often facilitated by aggressive flap contouring, secondary intention healing, and Z-plasty. We describe our methodology in restoring the alar-facial sulcus after nasal reconstruction.

Current therapy for cutaneous melanoma

We review the current therapy for melanoma. The diagnosis, prognostic variables, staging, treatment, and follow-up guidelines for cutaneous melanoma are reviewed from the earliest to the most advanced stages. New guidelines for margins are discussed. A new, evolving, innovative radiographic technique, positron emission tomography using 2-fluorine-18-fluoro-2-deoxy-D-glucose, may be useful to identify subclinical nodal and visceral disease. Recent advances with respect to tumor vaccines, gene therapy, immunotherapy, and interleukin 2 as well as current concepts regarding lymph node dissection are discussed.

The role of dermabrasion and chemical peels in the treatment of patients with xeroderma pigmentosum

We describe our experience with two patients with xeroderma pigmentosum who underwent periodic trichloroacetic acid chemical peels. One also received a full-face dermabrasion. The effect of chemical peeling was more transient than dermabrasion but was associated with less morbidity. Both chemical peeling and dermabrasion provided a prophylactic effect against the development of skin malignancies; the latter had a more pronounced effect.

Pilot histologic and ultrastructural study of the effects of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin

BACKGROUND

Chemical peels are employed for a variety of benign and premalignant skin disorders.

OBJECTIVE

We compared clinical and histologic features with ultrastructural changes that occur after medium-depth chemical facial peel.

METHODS

Three men with actinically damaged facial skin underwent a single 35% trichloroacetic acid peel. Biopsy specimens were taken before the peel, and 2 weeks and 3 months after the peel, for histologic examination, electron microscopy, and gel electrophoresis to assess total collagen type I content.

RESULTS

Clinical resolution of actinic damage corresponded with restoration of epidermal polarity. Collagen type I was markedly increased after the peel. Characteristic ultrastructural features of skin after peeling include markedly decreased epidermal intracytoplasmic vacuoles, decreased elastic fibers, and increased activated fibroblasts.

CONCLUSION

Electron microscopic studies after a medium-depth chemical peel of photodamaged skin reveal more profound changes than those seen histologically.

Increased expression of matrix metalloproteinase-3 (stromelysin-1) in cultured fibroblasts and basal cell carcinomas of nevoid basal cell carcinoma syndrome

Nevoid basal cell carcinoma syndrome (NBCCS), an autosomal dominant disorder, is characterized by the development of numerous cutaneous basal cell carcinomas (BCCs). To better characterize this disorder, we examined the expression of matrix metalloproteinase-3 (MMP-3; also known as stromelysin-1) in BCC tumor specimens, adjacent normal skin, and fibroblasts isolated from the normal-appearing skin of NBCCS patients. Three of three BCC tumors obtained from NBCCS patients overexpressed MMP-3 mRNA. In contrast, only 25% of BCC specimens in patients without NBCCS demonstrated overexpression of MMP-3 mRNA. Moreover, fibroblasts isolated and cultured from all nine uninvolved skin specimens of NBCCS patients overexpressed MMP-3 mRNA. MMP-3 mRNA was not detected or was detected at very low levels in normal skin and fibroblast cultures isolated from normal skin in nonsyndrome patients.

Clinical improvement following dermabrasion of photoaged skin correlates with synthesis of collagen I

BACKGROUND AND DESIGN

The ability of superficial dermabrasion to improve clinical features of photoaged skin is well known, but the specific biological mechanisms involved are poorly understood. The so-called repair zone, as visualized by routine histologic examination, has been attributed to new collagen formation within the papillary dermis and may be responsible for clinical improvement following dermabrasion. We investigated molecular and histologic events occurring in dermabraded skin and correlated them with clinical improvement. Ten photoaged patients (mean age, 59 years) underwent facial dermabrasion to the level of the papillary dermis. Clinical severity of photoaging was graded in a blinded manner at baseline and 12 weeks after dermabrasion. Biopsy specimens obtained at baseline and 3 and 12 weeks after dermabrasion were analyzed histologically and by in situ hybridization for fibroblast procollagen I mRNA, immunohistologically and by Western blotting with a monoclonal antibody specific for the aminoterminal cleavage site of procollagen I.

RESULTS

Masson's trichrome staining demonstrated an increase in collagen from baseline (as an upper dermal band in the dermabrasion "repair zone") at 3 and 12 weeks' postdermabrasion. Immunohistologic examination demonstrated papillary dermal fibroblast staining for procollagen I at baseline that increased by threefold at 3 weeks' postdermabrasion and by 1.5-fold at 12 weeks' postdermabrasion. Western blotting demonstrated an average-fold increase in pN collagen I of 4.2 +/- 1.5 at 3 weeks and of 2.7 +/- 0.7 at 12 weeks. By in situ hybridization, baseline levels of procollagen I mRNA in papillary dermal fibroblasts increased sixfold at weeks 3 and 12 postdermabrasion. Increase in procollagen I mRNA correlated with clinical improvement, ie, reduction in wrinkling.

CONCLUSION

Superficial dermabrasion clinically improves photoaged skin, and this improvement correlates strongly with increased collagen I gene expression.

Unusual basal cell carcinomas

The typical features of basal cell carcinoma are well recognized. However, manifestations of uncommon and unusual basal cell carcinomas are less well known. In this review, unusual basal cell carcinomas are described based on their clinical characteristics, histologic appearance, behavior, and treatment.

Technical aspects of prolonged scalp expansion

Tissue expansion offers the reconstructive surgeon a better option than the conventional methods of skin grafts or the transfer for non-hair-bearing, regional or microsurgical flaps for reconstructing large defects that cannot be repaired with adjacent hair-bearing flaps. Aspects of preoperative planning and technical factors of scalp expansion are presented to assist the clinician in managing these difficult reconstructive challenges.

Utility of the subcutaneous hinge flap in nasal reconstruction

The subcutaneous pedicle hinge flap provides excellent reconstruction of deep defects of the lateral base and caudal sidewall of the nose that extend into the cheek. The indications, flap design, and operative technique are described.

Basic suture materials and suturing techniques

There is a need for surgeons to be able to make a logical decision regarding which suture materials to use in a given clinical situation because the choice of wound-closure materials may make a difference in wound healing and the ultimate functional and cosmetic result obtained. This article will review the basic physical, handling, and tissue-reaction characteristics of commonly used suture materials. Basic suturing techniques are also reviewed. Knowledge of multiple suturing techniques provides versatility, individuality, and optimal closure of surgical wounds.

Increased expression of stromelysin-3 in basal cell carcinomas

We examined the expression of two groups of matrix metalloproteinases (MMPs), stromelysin and interstitial collagenase, in human skin cancer by northern blot analysis and in situ hybridization. Stromelysin-3 (ST-3) mRNA was overexpressed more than tenfold in 17 of 19 (89%) specimens of basal cell carcinoma (BCC) but in only three of 13 (23%) cutaneous squamous cell carcinomas (SCCs). Stromelysin-1 and -2 (ST-1/2) mRNA was overexpressed in three of 19 (16%) BCC and three of 13 (23%) SCC. Collagenase mRNA was overexpressed in nine of 19 (47%) BCC and three of 13 (23%) SCC. No mRNA for ST-3, ST-1/2, or collagenase was detected by northern analysis in 21 specimens of adjacent normal skin. Because of these findings, we examined the specific location of the ST-3 mRNA in BCC specimens by in situ hybridization. ST-3 mRNA was particularly abundant in the characteristic stroma adjacent to the invasive basaloid tumor islands of the BCC and absent in the malignant cells. Moreover, ST-3 mRNA was expressed and induced by phorbol ester treatment in adult dermal fibroblasts but not in keratinocytes. In vitro studies have shown that MMPs are involved in the degradation of extracellular matrix molecules. Our finding of ST-3 mRNA overexpression in 17 of 19 (89%) BCC specimens is consistent with a role for this molecule in local invasion of stroma by BCC. Our in situ hybridization data suggested that while ST-3 is not expressed by malignant basal cells themselves, these tumor cells may induce the expression of ST-3 in adjacent nonmalignant stromal elements such as fibroblasts.

Histology and physiology of tissue expansion

BACKGROUND

Tissue expansion is a concept based on the skin's natural ability to stretch in response to an underlying force.

OBJECTIVE

The purpose of this article is to review the histological and physiological changes that occur within the soft tissue and underlying structures during tissue expansion.

METHODS

An extensive search of the literature reviewing these changes is summarized herein.

RESULTS

Conventional tissue expansion may result in epidermal hypertrophy, decreased dermal, muscle, and adipose thickness, and bone resorption. A vascular capsule and angiogenesis provides a highly vascular flap and improves flap viability. Few soft tissue changes occur during rapid tissue expansion. The ability of the skin to increase in surface area during conventional tissue expansion is primarily because of biological tissue creep. Rapid expansion may result from mechanical tissue creep.

CONCLUSION

Many soft tissue changes occur during tissue expansion. Most of these changes return to the pre-expansion state over time following discontinuation of the expansion process.

Microcystic adnexal carcinoma

Microcystic adnexal carcinoma is a rare cutaneous neoplasm characterized by invasive, relentless, and destructive local growth. The incidence of perineural invasion and tumor recurrence is high. We report two cases of microcystic adnexal carcinoma with typical clinical features. The use of formalin-fixed, paraffin-embedded horizontal Mohs sections is described in one case. We also review the current concepts and management of microcystic adnexal carcinoma.

Merkel cell carcinoma

Merkel cell carcinoma is a malignant neuroendocrine tumor with features of epithelial differentiation. Biologically aggressive, it may be difficult to diagnose and, particularly in its late stages, even more difficult to treat effectively. This article addresses what is known and what is still controversial about the histogenesis, diagnosis, and management of Merkel cell carcinoma and the structure and function of the Merkel cell from which it is believed to be derived. The incidence, clinical presentation and diagnosis, ultrastructure, immunocytochemistry, treatment, and prognosis of this tumor will be discussed.

Carbon dioxide laser treatment of actinic cheilitis. Clinicohistopathologic correlation to determine the optimal depth of destruction

BACKGROUND

The carbon dioxide laser is an effective modality for the treatment of actinic cheilitis, but the number of passes required is unknown. After each pass different visual tissue qualities are observed.

OBJECTIVE

Our purpose was to identify and characterize histologically the tissue zones seen after laser impact and thereby to determine the optimal depth of destruction of diseased tissue.

METHODS

Twenty-three biopsy specimens from 14 patients were obtained from zones of different tissue qualities after one and three passes with the laser. Specimens were histologically examined for the presence or absence of diseased epithelium and degree of thermal necrosis.

RESULTS

Complete destruction of the epithelial layer was observed in all specimens irrespective of the number of laser passes. The amount of dermal homogenization increased with multiple passes.

CONCLUSION

Treatment to the first or second surgical zone is effective for actinic cheilitis.

The paramedian scalp reduction with posterior Z-plasty. A technique to minimize the "slot" defect

BACKGROUND

One consistent and undesired sequela resulting from scalp reductions has been the "slot" or "trough" defect, referring to the scar following the final reduction. Attempts to correct this have not been entirely satisfactory.

OBJECTIVE

To present an approach to minimize the "slot" defect that consists of staged modified paramedian scalp reductions combined with a large posterior Z-plasty during the final reduction.

METHODS

A paramedian crescent-shaped ellipse was marked onto the patient's scalp parallel and adjacent to the existing fringe hair. Subsequent reductions were performed in a similar manner approximately 2 months apart. The final reduction consisted of mobilization and transposition of the large flaps used in the posterior Z-plasty.

RESULTS

Patients who underwent the staged modified paramedian reductions combined with a posterior Z-plasty had significant minimization and adequate camouflage of the undesirable "slot."

CONCLUSION

Combining a large posterior Z-plasty with a paramedian reduction minimizes the slot defect.

Soft tissue reconstruction with skin grafting

Free skin grafts for soft tissue reconstruction can be classified into three types: full-thickness skin grafts, split-thickness skin grafts, and composite grafts. The indications, techniques, donor site considerations, and postoperative complications of each type of skin graft are reviewed.

Squamous cell carcinoma of the skin (excluding lip and oral mucosa)

The striking impression obtained from reviewing the cancer literature is how difficult it is to analyze the data for answers to many important biologic, behavioral, prognostic, and therapeutic questions about squamous cell carcinoma of the skin. This article addresses current concepts, controversies, and management of cutaneous squamous cell carcinoma (excluding the lip and oral mucosa).

Treatment of keratoacanthomas with intralesional methotrexate

Multiple modalities exist for the treatment of keratoacanthoma. Excisional surgery is currently the treatment of choice for the majority of keratoacanthomas. This can result in functional and cosmetic defects when large or strategically located lesions are treated. An effective nonsurgical treatment would be desirable in such cases. Intralesional therapy, particularly with 5-fluorouracil, has been shown to be effective in the treatment of keratoacanthomas. Systemic methotrexate has been tried, with variable success. We report an open, noncontrolled study of nine consecutive patients with unusually large or strategically located solitary keratoacanthomas treated successfully with intralesional methotrexate. All lesions responded promptly, with complete resolution after a mean of 3.0 weeks and a mean of 1.7 injections. No side effects occurred, and scarring was minimal. We concluded that intralesional methotrexate is a simple and effective modality for the treatment of select keratoacanthomas and may offer greater efficacy, a more rapid response, decreased pain, and lower cost compared with intralesional 5-fluorouracil.

Hair transplantation in advanced male pattern alopecia. The role of incisional slit grafting

The technique of incisional slit grafting is described and discussed. The results of the use of this technique for hair transplantation in patients with Norwood Type VII or advanced alopecia are reported.

Incisional slit grafting

Incisional slit grafting, a new and greatly improved technique in hair transplantation, is described. Incisional slit grafting utilizes larger numbers of smaller grafts than does traditional punch grafting. No tissue is removed from the recipient bed. The vascular supply is conserved, resulting in an increased graft yield. The clumping and stalking effect associated with traditional round grafting is eliminated largely, and a more natural frontal hairline is achieved.

Multicenter evaluation of the hemodynamic effects of bisoprolol in patients with mild to moderate hypertension

Twenty-six patients with mild-to-moderate essential hypertension participated in a 6-week outpatient, multicenter, randomized, double-blind, placebo-controlled two-way crossover study to assess the hemodynamic effects of bisoprolol (20 mg QD) at steady state. Hemodynamic assessments included sitting blood pressure, heart rate, and left-ventricular ejection fraction by radionuclide ventriculography after 7 days of bisoprolol or placebo at trough (24 h post-dose) and peak (3 h post-dose) values. The group adjusted mean ejection fraction was not significantly different in patients receiving bisoprolol compared with the placebo group at either peak or trough measurements; in fact, means in patients taking bisoprolol were slightly higher than in the placebo group. No symptomatic hypotension was documented. Blood pressure, measured 24 hours after dosing, was significantly lower in those receiving bisoprolol when compared with the placebo group, by 7.7 mm Hg and 9 mm Hg for diastolic and systolic blood pressure, respectively. Similarly, mean values of heart rate were 10 beats/min lower in the bisoprolol patients than in the placebo group. Only headache and insomnia occurred as adverse events. Bisoprolol (20 mg QD) effectively lowered blood pressure over a 24-hour period without significantly reducing ejection fraction or causing adverse clinical or biochemical events.

Facial nerve palsy as a result of squamous cell carcinoma of the skin

Perineural invasion is increasingly recognized as a significant mode of tumor spread in squamous cell carcinoma (SCC) of the skin. Clinically, it is very difficult to diagnose perineural involvement in the majority of patients due to the lack of symptoms. The occasional propensity for perineural invasion from SCCs of the skin of the head and neck region is well documented and, although SCCs arising from actinically damaged skin reportedly have a low incidence of metastasis or deep invasion, failure to recognize this potential mode of spread could result in fatal consequences.

Disseminated Mycobacterium chelonae ssp. abscessus in an immunocompetent host and with a known portal of entry

A unique case is presented in which disseminated Mycobacterium chelonae ssp. abscessus was found in a normal immunocompetent host after a traumatic injury. Although disseminated disease is known to occur in immunocompromised and postsurgical patients, this case is unusual in that it occurred in a patient with no evidence of immunodeficiency and with a known portal of entry.