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BACKGROUND: Mohs Micrographic Surgery (MMS) is commonly used to treat high-risk basal cell carcinoma (BCC). OBJECTIVES: Correlate clinicopathologic preoperative features with the number of MMS stages (primary endpoint) and margins (secondary endpoint) required for BCC complete excision. METHODS: We retrospectively analyzed BCCs treated by MMS in a 2-year period at the study's institution. Variables studied included the patient gender, age, immune status, lesion size, location, if it was a primary, recurrent, or persistent tumor, histopathologic characteristics, number of surgical stages, and amount of tissue excised. RESULTS: 116 BCCs were included. The majority (61.2%, n = 71) required a single-stage surgery for complete clearance, requiring a final margins of 3.11 ± 2.35 mm. Statistically significant differences between locations in different high-risk areas (periocular, perioral, nose, ear) and the number of MMS stages required for complete excision (p = 0.025) were found, with periocular tumours requiring the highest mean of stages (2.29 ± 0.95). An aggressive histopathology significantly influenced the number of MMS stages (p = 0.012). Any significant relation between clinicopathological features and variation in the final surgical margins was found, just certain tendencies (male patients, persistent tumor, periocular location, and high-risk histopathological tumors required larger margins). Neither patient age or tumor dimension correlated significantly with both number of MMS stages and final surgical margins. STUDY LIMITATIONS: Limitations of this study include its single-center nature with a small sample size, which limits the value of conclusions. CONCLUSION: Main factors related to a greater number of MMS stages were periocular location and high-risk histopathological subtype of the tumor.

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Abstract Background Mohs Micrographic Surgery (MMS) is commonly used to treat high-risk basal cell carcinoma (BCC). Objectives Correlate clinicopathologic preoperative features with the number of MMS stages (primary endpoint) and margins (secondary endpoint) required for BCC complete excision. Methods We retrospectively analyzed BCCs treated by MMS in a 2-year period at the study's institution. Variables studied included the patient gender, age, immune status, lesion size, location, if it was a primary, recurrent, or persistent tumor, histopathologic characteristics, number of surgical stages, and amount of tissue excised. Results 116 BCCs were included. The majority (61.2%, n = 71) required a single-stage surgery for complete clearance, requiring a final margins of 3.11 ± 2.35 mm. Statistically significant differences between locations in different high-risk areas (periocular, perioral, nose, ear) and the number of MMS stages required for complete excision (p = 0.025) were found, with periocular tumours requiring the highest mean of stages (2.29 ± 0.95). An aggressive histopathology significantly influenced the number of MMS stages (p = 0.012). Any significant relation between clinicopathological features and variation in the final surgical margins was found, just certain tendencies (male patients, persistent tumor, periocular location, and high-risk histopathological tumors required larger margins). Neither patient age or tumor dimension correlated significantly with both number of MMS stages and final surgical margins. Study limitations Limitations of this study include its single-center nature with a small sample size, which limits the value of conclusions. Conclusion Main factors related to a greater number of MMS stages were periocular location and high-risk histopathological subtype of the tumor.

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Abstract Background: There are conflicting data regarding the prognostic value of the lymphatic basin drainage pattern in melanoma patients and the evidence is scant in the setting of negative sentinel lymph node biopsy. Objective: To investigate whether the pattern of lymphatic basin drainage influences the risk of nodal disease in patients with melanoma of the trunk and negative sentinel lymph node biopsy. Methods: A case series of patients with trunk melanoma and negative sentinel lymph node biopsy was retrospectively evaluated. Clinicopathological features, the pattern of lymphatic drainage and nodal, metastatic, and overall recurrence-free survival were reviewed. Results: Of the 135 patients included, multiple lymphatic basin drainage was identified in 61 (45.2%). Ten of the 74 (13.5%) patients with single drainage developed nodal recurrence, compared with 2 of the 61 (3.6%) patients with multiple drainages (p = 0.04). Nodal recurrence-free survival was significantly longer in the group with multiple drainages than in the group with single drainage (175.6 vs. 138.7 months; p = 0.04). In multivariate analysis, single drainage was associated with a higher risk of nodal recurrence (HR = 4.54; p = 0.05). No significant differences in metastatic and overall recurrence-free survival were found between groups. Study limitations: Retrospective analysis, single-center study, small sample, detailed histopathologic information not always present. Conclusions: In patients with trunk melanoma and negative sentinel lymph node biopsy, multiple lymphatic basin drainage may be an independent risk factor for nodal disease recurrence. This factor may help to identify patients with negative sentinel lymph node biopsy with a higher risk of nodal recurrence.

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BACKGROUND: There are conflicting data regarding the prognostic value of the lymphatic basin drainage pattern in melanoma patients and the evidence is scant in the setting of negative sentinel lymph node biopsy. OBJECTIVE: To investigate whether the pattern of lymphatic basin drainage influences the risk of nodal disease in patients with melanoma of the trunk and negative sentinel lymph node biopsy. METHODS: A case series of patients with trunk melanoma and negative sentinel lymph node biopsy was retrospectively evaluated. Clinicopathological features, the pattern of lymphatic drainage and nodal, metastatic, and overall recurrence-free survival were reviewed. RESULTS: Of the 135 patients included, multiple lymphatic basin drainage was identified in 61 (45.2%). Ten of the 74 (13.5%) patients with single drainage developed nodal recurrence, compared with 2 of the 61 (3.6%) patients with multiple drainages (p = 0.04). Nodal recurrence-free survival was significantly longer in the group with multiple drainages than in the group with single drainage (175.6 vs. 138.7 months; p = 0.04). In multivariate analysis, single drainage was associated with a higher risk of nodal recurrence (HR = 4.54; p = 0.05). No significant differences in metastatic and overall recurrence-free survival were found between groups. STUDY LIMITATIONS: Retrospective analysis, single-center study, small sample, detailed histopathologic information not always present. CONCLUSIONS: In patients with trunk melanoma and negative sentinel lymph node biopsy, multiple lymphatic basin drainage may be an independent risk factor for nodal disease recurrence. This factor may help to identify patients with negative sentinel lymph node biopsy with a higher risk of nodal recurrence.

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A reconstrução de defeitos que envolvam até 2/3 da extensão dos lábios é desafiadora, levando-se em consideração a importância funcional e estética desta estrutura. Existem diversas técnicas cirúrgicas descritas para esta finalidade, salientando-se o retalho de Abbe- Estlander, o retalho de Karapandzic e o retalho de Bernard-Burrow-Webster. A escolha da melhor abordagem deve levar em conta a dimensão e localização do defeito e as comorbidades do doente. O retalho de Yu constitui uma alternativa a ser considerada em relação a outros métodos, permitindo obter geralmente excelentes resultados cosmético- -funcionais.

The reconstruction of defects involving up to 2/3 of the lip extension is challenging, considering the functional and aesthetic importance of this structure. There are several surgical techniques described for this purpose, highlighting the Abbé-Estlander flap, the Karapandzic flap, and the Bernard-Burrow- Webster flap. The choice of the best approach should consider the size and location of the defect as well as the comorbidities of the patient. The reverse Yu flap is an alternative to be considered in relation to other methods, allowing obtaining excellent cosmetic-functional results in general.

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Os defeitos cutâneos da pálpebra inferior frequentemente requerem reconstruções com enxertos ou retalhos para evitar-se o ectrópio. A retirada de um carcinoma basocelular da pálpebra inferior de uma paciente de 39 anos resultou em um defeito exclusivamente cutâneo, com diâmetros transversal e vertical de 32 e 13mm, respectivamente. Apesar da grande dimensão do defeito, a elevação da fáscia suborbicular dos olhos para o periósteo da borda orbital lateral permitiu o fechamento primário. A posição da pálpebra inferior também foi reforçada com uma cantopexia lateral, com excelentes resultados estético e funcional.

Cutaneous defects of the lower eyelid frequently require reconstructions with grafts or flaps to avoid ectropion. Removal of a basal cell carcinoma from the lower eyelid of a 39-year-old patient resulted in an exclusively cutaneous defect, with transversal and vertical diameters of 32 and 13mm, respectively. Despite the large size of the defect, the elevation of the suborbicularis oculi fascia to the periosteum of the lateral orbital border made primary closure possible. The position of the lower was also reinforced with a lateral canthopexy, with excellent aesthetic and functional results.

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The reconstruction of facial surgical defects is usually challenging for the dermatologic surgeon. Three different cases of facial defects in which tunneled island flaps were used are reported. In 2 cases, wide defects involving the nasal dorsum and ala were repaired using a nasolabial island flap tunneled through the lateral side of the nose. A tunneled island glabellar flap was used for medial canthus reconstruction in the third case. Despite complex pedicle dissection and frequent trapdoor deformation, tunneled island flaps allow reconstruction of wide defects in a single-staged procedure, camouflaging the scar of the donor area in boundaries of cosmetic units and preserving the facial central symmetry.

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Abstract The reconstruction of facial surgical defects is usually challenging for the dermatologic surgeon. Three different cases of facial defects in which tunneled island flaps were used are reported. In 2 cases, wide defects involving the nasal dorsum and ala were repaired using a nasolabial island flap tunneled through the lateral side of the nose. A tunneled island glabellar flap was used for medial canthus reconstruction in the third case. Despite complex pedicle dissection and frequent trapdoor deformation, tunneled island flaps allow reconstruction of wide defects in a single-staged procedure, camouflaging the scar of the donor area in boundaries of cosmetic units and preserving the facial central symmetry.

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Pemphigoid gestationis is a rare, autoimmune blistering dermatosis of pregnancy. No increase in fetal or maternal mortality has been demonstrated, but a greater prevalence of premature and small-for-gestational age babies has been reported. Topical and systemic corticosteroids and antihistamines are the manstay of treatment. The authors report a case of a 27-year-old woman at 28-weeks gestation with sudden onset of pruriginous vesicles and blisters in the abdomen and limbs. Systemic corticosteroids were introduced and maintained throughout gestation to prevent flares and tapered after the birth of a healthy child.

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Pemphigoid gestationis is a rare, autoimmune blistering dermatosis of pregnancy. No increase in fetal or maternal mortality has been demonstrated, but a greater prevalence of premature and small-for-gestationalage babies has been reported. Topical and systemic corticosteroids and antihistamines are the manstay of treatment. The authors report a case of a 27-year-old woman at 28-weeks gestation with sudden onset of pruriginous vesicles and blisters in the abdomen and limbs. Systemic corticosteroids were introduced and maintained throughout gestation to prevent flares and tapered after the birth of a healthy child.

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The earlobe is an anatomical structure that has a significant aesthetic role. Its surgical repair places a challenge due to the difficulty of obtaining a natural appearing and durable outcome. The authors present two options: the Gavello technique and the bilobed flap, after the excision of malign neoplasms of the earlobe. The Gavello technique makes use of a bilobed flap with an anterior base to mold the new earlobe. D'Hooghe's bilobed flap with a pre and post-auricular lobe allows the reconstruction of small earlobes. Both techniques, although old, acquire an important and current interest in earlobe reconstruction, by reason of the moderate degree of difficulty, the use of a single time surgical act and under local anesthesia, with a proper aesthetic result.

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The earlobe is an anatomical structure that has a significant aesthetic role. Its surgical repair places a challenge due to the difficulty of obtaining a natural appearing and durable outcome. The authors present two options: the Gavello technique and the bilobed flap, after the excision of malign neoplasms of the earlobe. The Gavello technique makes use of a bilobed flap with an anterior base to mold the new earlobe. D'Hooghe's bilobed flap with a pre and post-auricular lobe allows the reconstruction of small earlobes. Both techniques, although old, acquire an important and current interest in earlobe reconstruction, by reason of the moderate degree of difficulty, the use of a single time surgical act and under local anesthesia, with a proper aesthetic result.

O lóbulo auricular é uma estrutura anatómica com uma importância estética significativa. O desafio inerente à sua reconstrução relaciona-se com a dificuldade em obter um resultado duradouro e cosmeticamente aceitável. Os autores apresentam duas opções: a técnica de Gavello e o retalho bilobado, após excisão de neoplasias malignas do lóbulo auricular. A técnica de Gavello, recorre a um retalho bilobado com base anterior, para constituir o novo lóbulo auricular. O retalho bilobado de D'Hooghe, com lobos pré e pós-auriculares, permite a reconstrução de defeitos de pequenas dimensões. As duas técnicas descritas, apesar de antigas, mantém-se actuais pela execução de grau de dificuldade média, em tempo cirúrgico único, sob anestesia local com a obtenção de resultados cosmeticamente aceitáveis.

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Lipschütz Ulcer, or ulcus vulvae acutum, is a rare and probably underdiagnosed entity that usually presents as an acute painful vulvar ulcer in young women. The etiology is unknown, although recent reports have associated it with the Epstein-Barr virus. The diagnosis is made by exclusion after ruling out sexually transmitted diseases, autoimmune causes, trauma, and other etiologies of genital ulcerations. We report a case of a young woman who developed flu-like symptoms and painful vulvar ulcers. Complementary examinations ruled out sexually transmitted diseases and the other usual causes of genital ulcers; lesions healed with no sequelae or recurrences. This case represents a rare important differential diagnosis of genital ulceration.

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Lipschütz Ulcer, or ulcus vulvae acutum, is a rare and probably underdiagnosed entity that usually presents as an acute painful vulvar ulcer in young women. The etiology is unknown, although recent reports have associated it with the Epstein-Barr virus. The diagnosis is made by exclusion after ruling out sexually transmitted diseases, autoimmune causes, trauma, and other etiologies of genital ulcerations. We report a case of a young woman who developed flu-like symptoms and painful vulvar ulcers. Complementary examinations ruled out sexually transmitted diseases and the other usual causes of genital ulcers; lesions healed with no sequelae or recurrences. This case represents a rare important differential diagnosis of genital ulceration.

A Úlcera de Lipschütz, ou ulcus vulvae acutum, é uma entidade rara mas provavelmente subdiagnosticada, que se apresenta como úlcera vulvar aguda dolorosa numa mulher jovem. A etiologia é desconhecida embora relatos recentes a tenham associado à primo-infecção pelo vírus Epstein-Barr. O diagnóstico é estabelecido após exclusão de doenças sexualmente transmissíveis, causas autoimunes, traumáticas e outras etiologias de úlceras genitais. Relatamos o caso de uma jovem que desenvolveu quadro gripal e dolorosas úlceras genitais. Os exames complementares excluiram doenças sexualmente transmissíveis e as outras causas habituais de ulceração genital. As lesões cicatrizaram sem sequelas e sem recorrências. Este caso representa um diagnóstico diferencial importante e raro de ulceração genital.

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Closure of perioral surgical defects involving the oral commissures is highly challenging. We describe a 69-year-old male patient with a large basal cell carcinoma of the right perioral region, extending to the right oral commissure. This lesion was radically excised, and the resulting surgical defect was closed using a homolateral double opposing rhomboidal flap. The final result was esthetically very satisfactory, with total preservation of lip function. Double opposing rhomboidal flaps are viable surgical options for the reconstruction of surgical defects involving the perioral area and oral commissures. In this relatively simple procedure, donor skin is obtained from the nearby cheek and mandibular areas, under low risk of surgical complications, preserving lip function without distortion of the labial anatomy.

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Closure of perioral surgical defects involving the oral commissures is highly challenging. We describe a 69-year-old male patient with a large basal cell carcinoma of the right perioral region, extending to the right oral commissure. This lesion was radically excised, and the resulting surgical defect was closed using a homolateral double opposing rhomboidal flap. The final result was esthetically very satisfactory, with total preservation of lip function. Double opposing rhomboidal flaps are viable surgical options for the reconstruction of surgical defects involving the perioral area and oral commissures. In this relatively simple procedure, donor skin is obtained from the nearby cheek and mandibular areas, under low risk of surgical complications, preserving lip function without distortion of the labial anatomy.

A abordagem de defeitos cirúrgicos da região perioral, em particular das comissuras labiais, é um desafio importante na prática cirúrgica dermatológica. Apresentamos o caso de um doente do sexo masculino, de 69 anos, com extenso carcinoma basocelular ulcerado da região perioral direita, com envolvimento da comissura labial. Foi realizada excisão radical da lesão e reconstrução do defeito cirúrgico com retalho romboidal duplo das regiões geniana e mandibular homolaterais. O resultado cosmético final foi satisfatório, com preservação da funcionalidade das estruturas labiais. O retalho romboidal duplo é uma alternativa viável para a reconstrução de defeitos cirúrgicos da comissura labial, de execução relativamente simples, com baixo risco de complicações, que oferece óptimos resultados funcionais e cosméticos, sem distorção da anatomia labial.

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Squamous cell carcinoma is the most common malignant neoplasm of the lips, and in about 90% of cases it is located on the lower lip due to higher cumulative exposure to ultraviolet radiation. The authors present two surgical techniques for reconstruction of large lower lip defects, resulting from surgical excision of tumors, exemplifying and comparing them with two clinical cases.

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O carcinoma de células escamosas é a neoplasia maligna mais frequente dos lábios, e em cerca de 90 por cento dos casos, localiza-se no lábio inferior, por causa da maior exposição cumulativa à radiação ultravioleta. Os autores apresentam duas técnicas cirúrgicas para a reconstrução de grandes defeitos do lábio inferior, resultantes da excisão cirúrgica tumoral, exemplificando-as e comparando-as através de dois casos clínicos.

Squamous cell carcinoma is the most common malignant neoplasm of the lips, and in about 90 percent of cases it is located on the lower lip due to higher cumulative exposure to ultraviolet radiation. The authors present two surgical techniques for reconstruction of large lower lip defects, resulting from surgical excision of tumors, exemplifying and comparing them with two clinical cases.

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