british society for dermatological surgery: summaries of papers

British Society for Dermatological Surgery: Summaries ofPapers

DS-1Dermatoscope use and disinfection in thedermatology department of a university teachinghospitalK. Chittari, J.M. Orendi and B.B. TanDermatology and Microbiology Departments, University Hospital of Stafford-

shire, Stoke-on-Trent, U.K.

Dermatoscopes are instruments used by dermatologists to

improve direct visualization of structures underneath the stra-

tum corneum. They have been shown to increase diagnostic

accuracy for pigmented lesions. As dermatoscopes are often

applied directly to cutaneous and mucocutaneous surfaces on

multiple patients in sequential fashion, like stethoscopes

(Breathnach AS, Jenkins DR, Pedler SJ. Stethoscopes as possible

vectors of infection by staphylococci. BMJ 1992; 305: 1573–4),

they are not cleaned between patients. One might consider der-

matoscopes to be a possible source of transmission of infection.

As there is no existing disinfection policy specific for dermato-

scopes, we carried out a study to identify the risk of transmis-

sion of potentially pathogenic bacteria through dermatoscope

use and to identify the best method to reduce the above said

risk. Over a period of 4 weeks, we looked at the existing practice

of dermatoscope use using three different immersion fluids

(Aqua gel�, liquid paraffin and rinse-free hand alcohol gel).

Bacterial cultures were taken from the contact plate lens of der-

matoscopes at the end of each clinic. On the fifth week, a proto-

col of disinfection was introduced using 70% sterile isopropyl

alcohol pads to clean dermatoscopes after each patient use. We

examined the impact of bacterial contamination and load after

the introduction of this protocol. A total of 66 swabs was taken

at the end of 66 consecutive dermatology clinical sessions. Fifty-

one of them were taken before the introduction of the disinfect-

ant protocol and 15 were taken after. All three dermatoscopes

grew coagulase-negative Staphylococcus species. The highest den-

sity of heavy growth of bacteria was found on dermatoscopes

using Aqua gel� and liquid paraffin as immersion fluid. Rinse-

free hand alcohol gel had scanty to moderate growth of skin

bacteria. There was no growth of bacteria after the introduction

of the disinfectant protocol from any of the dermatoscopes. A

variable growth of coagulase-negative Staphylococcus species was

found in this study when the dermatoscopes were not cleaned

between patients. The introduction of disinfecting dermato-

scopes using 70% isopropyl alcohol pads after use on each

patient significantly reduced the risk of bacterial contamination

regardless of which immersion fluid was used. We recommend

cleaning of dermatoscopes after each use with 70% isopropyl

alcohol as a simple and effective method to prevent transmission

of pathogenic bacteria.

DS-2Impact of introducing dermatoscopy into a teachinghospital skin tumour clinic on melanoma diagnosisover a 4-year period: retrospective analysisA. Palmer, J. Bowling and K. HollowoodOxford Radcliffe Hospitals NHS Trust, Oxford, U.K.

Melanoma incidence rates are increasing. Dermatoscopy has

been reported to increase the diagnostic accuracy of melanoma

and melanoma in situ. Dermatoscopy was introduced as a diag-

nostic technique to our skin tumour clinic in October 2004

with the expectation of improving the diagnostic accuracy of

melanoma detection. The aim of this study was to determine

what effect the introduction of dermatoscopy has had on the

incidence of melanoma and melanoma in situ diagnosis and

the average Breslow thickness in the 2 years following intro-

duction of dermatoscopy compared with the 2 years preceding

introduction of dermatoscopy. A retrospective study was car-

ried out of patients who attended the Department of Derma-

tology’s nonselective skin tumour clinic between October

2002 and October 2006. All patients diagnosed with mela-

noma during this 4-year period were included in the study.

Data were obtained from the histopathology department and

included: histopathological subtype of melanoma, Breslow

thickness, Clark level, site of lesion, age and sex of patient.

Between October 2002 and 2006, a total of 653 melanomas

were diagnosed (n = 136, 144, 185 and 188 in years 1, 2, 3

and 4, respectively). While the number of in situ melanomas

remained relatively constant (n = 53, 50, 62 and 45 in years

1, 2, 3 and 4, respectively), there was an increasing number

of invasive melanomas (n = 83, 94, 123 and 143 in years 1,

2, 3 and 4, respectively). This increase in melanoma diagnosis

was predominantly seen in the female subgroup with superfi-

cial spreading malignant melanoma. There was no statistically

significant reduction in Breslow thickness over this 4-year per-

iod (P = 0Æ2). Although our results suggest dermatoscopy

may have some effect on increasing the detection of mela-

noma during the study period, there was no associated reduc-

tion in the average Breslow thickness, and no increase in the

detection of melanoma in situ during this time. These findings

suggest that the increase in detection of melanoma cannot be

attributable to the use of dermatoscopy alone.

� 2007 The Authors

106 Journal Compilation � 2007 British Association of Dermatologists • British Journal of Dermatology (2007) 157 (Suppl. 1); 106–118

DS-3A randomized study comparing tissue conservationin conventional vs. Mohs’ surgery of basal cellcarcinomaF.M. Muller, R.S. Dawe, H. Moseley and C.J. FlemingNinewells Hospital and Medical School, Dundee, U.K.

Basal cell carcinomas (BCCs) are slow growing, locally inva-

sive malignant skin tumours. Morbidity associated with BCCs

is related to local tissue invasion and destruction. Standard

treatment of small, primary BCCs in the U.K. involves surgical

excision with excision margins varying from 3 to 15 mm.

Mohs’ micrographic surgery (MMS) is recognized globally as

the gold standard for high-risk BCCs that are recurrent, are

morphoeic or are at sites of recognized high risk for recur-

rence. The main advantage of MMS over conventional surgery

is the chance of complete tumour removal in 99% (Rowe DE,

Carroll RJ, Day CL Jr. Long-term recurrence rates in previously

untreated (primary) basal cell carcinoma: implications for

patient follow-up. J Dermatol Surg Oncol 1989; 15: 315–28) for

primary and 95% for recurrent tumours. It is also thought,

based on empirical evidence, to be tissue sparing when com-

pared with conventional surgery, but no randomized con-

trolled trials exist to support this. One recent randomized

controlled study, although it was not a primary outcome

measure, commented on defect size and showed that the aver-

age defect size for standard surgically treated lesions that

required a re-excision was about twice that of the average

defect size resulting from multistage MMS when more than

one stage was needed, but no firm conclusion regarding tissue

conservation was reached (Smeets NW, Krekels GA, Ostertag

JU et al. Surgical excision vs Mohs’ micrographic surgery for

basal-cell carcinoma of the face: randomised controlled trial.

Lancet 2004; 36: 1766–72). It has been argued that the most

important outcome after BCC surgery is the cosmetic and

functional deficit following repair. This is dependent on oper-

ator skills, and irrespective of operator, a smaller defect is eas-

ier to repair. We have therefore completed a randomized

study investigating tissue conservation in conventional surgery

vs. MMS, using final wound defect size as the primary out-

come measure, to test the hypothesis that MMS spares tissue

more than standard surgery. Patients with a nodular BCC of

less than 1 cm in diameter, at least 1 cm away from the eye

or nose were randomly allocated to either MMS or standard

surgery. Higher risk tumours were excluded, and were all

treated with MMS. Wolf and Zitelli suggest 4-mm excision

margins (Wolf DJ, Zitelli JA. Surgical margins for basal cell

carcinoma. Arch Dermatol 1987; 123: 340–4) to achieve 95%

tumour eradication. Prior to surgery the diameters of the

tumours were measured using a Vernier calliper and tumour

areas calculated using appropriate formulae for approximately

round and elliptical tumours. After surgical removal of the

tumour, digital photographs of the defect including a scale

were taken. An interim analysis was performed after 30

patients as outlined in the sample size estimate. Based on pre-

determined rules (the mean defect size of the standard surgery

group was more than 1Æ5 times larger than the MMS group)

the study was terminated early. The median area of tumour in

the MMS group was 58Æ1 mm2 vs. 45Æ6 mm2 in the standard

surgery group. The median area of the surgical defects in the

MMS group was 116Æ6 mm2 vs. 187Æ7 mm2 in the standard

surgery group [confidence interval (CI) 61–126, P < 0Æ0001].

The median area of healthy tissue (surgical defect minus

tumour area) removed in the MMS group was 41 mm2 vs.

148Æ67 mm2 in the standard surgery group (CI 84–118,

P < 0Æ0001). To our knowledge this is the first randomized

trial showing that MMS is superior to standard surgery with

regards to tissue conservation. It is likely that this superiority

is greater with infiltrative tumours in high-risk anatomical

sites.

DS-4The accuracy of histopathological evaluation ofsurgical margin control in the resection ofnonmelanoma skin cancer: frozen-sectionMohs’ technique vs. formal pathologist reviewR. Barry, R. Ashton,* H. Smith� and S. KeohanePortsmouth Dermatology Centre, Portsmouth, Hampshire, U.K.; *Royal

Hospital Haslar, Gosport, Hampshire, U.K. and �Royal Hampshire County

Hospital, Winchester, Hampshire, U.K.

The dual benefit of Mohs’ micrographic surgery (MMS) relates

to the higher cure rates achieved in the management of pri-

marily nonmelanoma skin cancer, allied to the greater preser-

vation of normal adjacent tissue in cosmetically sensitive facial

areas. The efficacy of the Mohs’ technique is dependent upon

the ability of the surgeon to accurately interpret the frozen

histopathological specimens. The evaluation of margin control

is usually the sole responsibility of the Mohs’ surgeon as,

worldwide, most units do not routinely send their samples for

formal review by the pathologist. Recently, both the cost-

effectiveness and necessity of regular usage of MMS has been

called into question both by health economists and surgical

colleagues (Essers BA, Dirksen CD, Nieman FH et al. Cost-

effectiveness of Mohs micrographic surgery vs surgical exci-

sion for basal cell carcinoma of the face. Arch Dermatol 2006;

142: 187–94; Griffiths RW, Suvarna SK, Stone J. Basal cell car-

cinoma histological clearance margins: an analysis of 1539

conventionally excised tumours. Wider still and deeper? J Plast

Reconstr Aesthet Surg 2007; 60: 41–7). At our unit, the frozen

sections are sent for independent review by a pathologist. We

present the data on 500 patients who had Mohs’ surgery per-

formed by one of three surgeons between June 2005 and

December 2006. The mean age of the group was 66 (range

18–95). Four hundred and ninety patients (98%) had a diag-

nosis of basal cell carcinoma (BCC) of which 41 (8%) were

morphoeic and 61 (12%) were recurrent. There were seven

cases of SCC. Eighty-seven patients (17%) were recipients of

solid organ transplants and were receiving immunosuppres-

sion at the time of surgery. In 20 cases (0Æ04%), there was

discrepancy between the report of the pathologist and the


Journal Compilation � 2007 British Association of Dermatologists • British Journal of Dermatology (2007) 157 (Suppl. 1); 106–118

British Society for Dermatological Surgery 107

surgeon. The average size of the initial tumour was 30 mm.

This subgroup was representative of the group as a whole in

that 19 patients had BCC and there was one SCC. The majority

were primary BCC with three cases being recurrent lesions

and one morphoeic. This discrepancy was significant in two

patients who required further intervention for residual disease.

In the other 18 cases, the discordance was due to annotation

differences, notation error and due to the fact that the Mohs’

surgeon did not routinely review all slides if the sections clo-

sest to the patient were clear. We believe that these data fur-

ther validate the practice of experienced Mohs’ surgeons

interpreting their own frozen section specimens.

DS-5Time taken for dermatological surgery: a prospectiveauditM. Tewary, A. Affleck and S. VarmaQueen’s Medical Centre, Nottingham, U.K.

There is increasing pressure on dermatologists to provide an

efficient service with government initiatives like payment by

results and skin cancer treatment targets. We observed that the

time requested for surgical procedures appeared to be variable

in our department. The aim of this audit was to compare the

time allocated for procedures against actual times taken to per-

form the procedures. We looked for patterns in times taken

for standard procedures by specific grades of operator. We

aimed to standardize times given for procedures to improve

efficiency of service and to look specifically for patient groups

needing more time. The audit was done prospectively over 3

months. A stop clock was used to measure the total time in

theatre and the time for procedure for each patient (first inci-

sion to final suture). Types of procedures included punch

biopsies, shave biopsies, curettage and cautery and scalpel

excisions. Types of repair included linear closure, flaps, grafts

and second intention healing. A total of 268 patients, 142

male and 126 female patients, had skin surgery. One hundred

and eighty-four out of 268 (69%) patients were aged over 60

years. Excision of basal cell carcinoma was the most common

procedure (248 out of 268). Linear closure was the most fre-

quent repair performed. Ninety per cent of procedures were

not within the time allocated. Time was overestimated in

118/155 patients (77%) by approximately 12 min and under-

estimated in 35/155 patients (23%) by approximately 15

min. Time spent in theatre was double the time taken to per-

form the actual procedure. Almost double the time was

required for older patients. One hundred and thirty-nine out

of 268 (51%) lesions for surgery were on the face. Facial

procedures took about 10 min longer than on other sites.

Allocated times for smaller procedures had been overestima-

ted. Juniors took longer to do procedures. Contributory factors

for prolonged time in theatre included difficult haemostasis,

bandaging (5–14 min), patient disabilities like poor mobility,

use of wheelchair, deafness or blindness. Interestingly,

nonoperating team members often grossly under- or overesti-

mated times required for the procedures. This reflects the need

for clearer guidance regarding standardization for timings of

surgical procedures. In this audit, most procedures required

less time than requested on the referral form, indicating a

potential to improve efficiency and service. We have now

designed a new proforma including mean times for proced-

ures as a guide. In conclusion, to maximize efficiency several

patient-specific and operator-specific factors, often predictable,

should be taken into account when allocating time for skin

surgery.

DS-6Time and motion: testing efficiency in the derma-tology procedure settingJ. Fisher, H. Lotery* and C. Henderson*University of Southampton School of Medicine, Southampton, U.K. and

*Southampton University Hospitals Trust, Southampton, U.K.

Time and motion studies are a validated means of determining

efficiency and identifying sources of delay in a complex work-

ing environment. This analytical technique was applied to the

dermatological surgical services provided by a university hos-

pital department of dermatology. The objectives were to iden-

tify any sources of low efficiency in dermatological surgical

service provision and to make recommendations for increasing

efficiency. Three types of surgical session for dermatology

were observed: consultant-led procedure list, nurse-led pro-

cedure list and dermatology day theatre list. The activities of

staff were noted every 2 min throughout the sessions and the

data compiled for processing in Microsoft Excel. The results

show that treatment of dermatology patients in the day theatre

was less efficient and cost-effective than the other settings.

Consultant-led procedure lists were the most efficient. Nurse-

led sessions were cost-effective, but less efficient than the con-

sultant-led lists. Paperwork and generic communication were

identified as major constituents of nonoperating time. We

conclude that the most efficient setting for dermatological pro-

cedures appears to be the consultant-led procedure list. Time

might be saved by issuing generic communications in written

format, and through the use of a well-designed proforma to

reduce time spent on paperwork. Our results demonstrate the

advantages of broad, objective appraisal of practice as opposed

to a simple numerical target-driven approach that fails to

address specific aspects of efficiency.


Journal Compilation 2007 British Association of Dermatologists • British Journal of Dermatology (2007) 157 (Suppl. 1); 106–118

108 British Society for Dermatological Surgery

DS-7Surgical assessment scale to match surgicalprocedures to surgical skills for use in skin cancermanagementL. Paul and J. BrittonPrincess Royal Hospital, Hull, U.K.

Surgical procedures must be performed by an appropriately

trained surgeon. Often, patients requiring dermatological sur-

gery are assessed by one healthcare professional, but the proced-

ure is undertaken on another surgeon’s list. Dermatology

departments now have numerous surgeons with varying levels

of ability. A classification system was devised that grades a

patient’s lesion to ensure appropriate matching to the surgeon’s

skills. The aim of the study was to validate the accuracy of the

grading levels. The classification system uses primarily the site

and the size of the lesion, and the type of procedure. Using this

classification system, lesions were categorized by a consultant

dermatological surgeon, a dermatology registrar, a dermatology

specialist nurse, a GP registrar and a general medicine senior

house. A 100% concordance rate was achieved between all the

healthcare professionals. This classification system enables the

most appropriate surgeon to be chosen to treat a patient that

s/he may not previously have seen. It can be used by all health-

care professionals, regardless of surgical experience, who now

assess patients in the dermatology outpatient department. It

ensures that the operating individual is capable of performing

the procedure. It maximizes the skills and resources of more

experienced surgeons by minimizing their simpler procedures,

which others are capable of doing. In the current financial

climate, this classification will help to determine costing of

these procedures. It is simple to use and provides a method to

maintain training and governance standards for dermatologists

when coordinating the management of cutaneous malignancy

in skin cancer networks.

DS-8Postoperative questionnaire survey of patientsundergoing nail surgeryD. Shipley and D. de BerkerBristol Dermatology Centre, Bristol, U.K.

As part of an ongoing project to improve the accuracy of

advice given to patients prior to nail surgery, patients who

had undergone surgery were invited to complete a question-

naire. Questionnaires were posted to 96 patients who had

undergone any surgical procedure involving the distal digit or

nail; 63 (66%) were returned. Thirty-one patients were 2– 4

months and 32 were 9–12 months postoperation. Forty-six

of 63 had surgery on a finger, 17 of 63 patients had toe sur-

gery (14 great toes). Seventy-eight per cent of patients

thought they had completely understood the nature of the sur-

gery at the time of the operation; 63% of patients felt they

completely understood limitations to their normal activities in

the 2 weeks after the operation. Limitations not completely

anticipated included: length of time to full recovery, difficul-

ties with activities of daily living and the need for dressing

changes. Sixteen per cent of patients had ‘very bad pain’ dis-

turbing sleep; 35% moderate; 30% mild; and 19% no pain.

Twenty-two (35%) patients took no analgesia at all (six of

these were experiencing moderate pain). Seventy-nine per cent

were not taking any analgesia by the 7th day after the

operation. One patient required analgesics up to 6 weeks after

surgery. Six patients were given antibiotics by their GP. Sev-

enty-six per cent of patients experienced bleeding through the

dressing at the first dressing change only. There were no sig-

nificant problems with dressing changes. Forty-six per cent of

patients described altered sensation, usually in the pulp, lateral

borders of the distal digit or around the proximal nail fold.

The most frequent complaints were of numbness, tingling, or

pins and needles. In patients surveyed at 9–12 months, altered

sensation was still present in 9 of 32 (28%), although most

(5 of 9) were still experiencing improvement. Data were ana-

lysed using the v2 test to determine whether postoperative

paraesthesia was influenced by the type of operation or the

presence of moderate or severe postoperative pain. The associ-

ation of altered sensation with certain types of operation was

statistically significant (P < 0Æ05). Where the nail was replaced

to provide protection to the nail bed, the old nail remained in

place for an average of 5 weeks (range 10 days to 16 weeks).

When asked how they would advise a friend undergoing a

similar operation 46% patients were generally encouraging.

Others made specific practical comments about planning for

the recovery period. Analysis of this postoperative question-

naire has provided more specific information about the conse-

quences of nail surgery for patients and allows for a better

informed discussion at the time of preoperative consent. It

also highlights the frequency of altered sensation as a conse-

quence of nail surgery, a point which is not well elucidated in

standard surgical texts.

DS-9The use of topical imiquimod (Aldara�) in thetreatment of lentigo maligna of the head and neckE. Craythorne and C. Lawrence*Kings’s College Hospital, London, U.K. and *Royal Victoria Infirmary,

Newcastle upon Tyne, U.K.

Lentigo maligna (LM) typically presents at sun-exposed sites

in the elderly patients as an asymmetric, slow-growing, irre-

gularly pigmented macule with an irregular indented border.

With changes in sun-exposure behaviour LM is becoming

more prevalent in middle-aged and younger adults. LM pre-

sents a difficult clinical problem and generally there is little

consensus on the optimum form of management. The recom-

mended guidelines for treatment of LM are surgical excision

with excision margins into clinically normal skin of 2–5 mm

and others have suggested that up to 20% of cases of LM

would require margins greater than this. However, lesions are




commonly large and located on cosmetically important head

and neck sites. Excision may result in a poor cosmetic out-

come and it is difficult to justify this approach when the risk

of malignant transformation is relatively low. We describe our

experience with the use of imiquimod in a group of patients

with LM on the head and neck where surgery was not an

option. Eight patients with histologically confirmed recurrent

or difficult to treat LM of the head and neck were treated.

Patients were instructed to apply the cream to the pigmented

area and to a minimum 1-cm margin around the pigmented

area once a day, 5 days per week for 6 weeks. Each patient

was then reviewed with clinical photographs and biopsy if

indicated. Six of the seven patients who developed the brisk

inflammatory response had clinical resolution of their LM.

Patients with a clinical response were followed up for an aver-

age of 32 months (range 10–57) without clinical recurrence.

Two of the patients failed to develop a brisk inflammatory

reaction; it was these two who did not achieve a clinical reso-

lution of their LM. Interestingly, it was one of these patients

who on stopping application of a concurrent barrier cream

and given a second course of imiquimod, did have a brisk

reaction and clinical resolution of LM. Our study shows that

imiquimod is potentially an excellent nonsurgical treatment

for LM particularly in those patients who present with large or

recurrent lesions on the head and neck. Our observations sup-

port the concept that an inflammatory response is a prerequis-

ite for treatment success with imiquimod.

DS-10What proportion of skin cancers are managedprimarily by dermatologists? The Oxford experienceT. McPherson, V. Brown, J. Bowling and R. TurnerDepartment of Dermatology, Churchill Hospital, Oxford, U.K.

The NICE guidance on skin cancer services ‘Improving Out-

comes for People with Skin Tumours’, published in 2006,

confirms the central role of dermatologists in the management

of all types of skin cancer. One of the aims detailed in the

guidelines is to reduce the number of skin cancers currently

managed in primary care. They also emphasize the require-

ment for local data collection to acquire epidemiological infor-

mation and to guide service provision. To address these issues

we have analysed the skin cancer database acquired by our

histopathology department for 6 months (July to December)

of three consecutive years, 2004 to 2006. The numbers of

malignant melanoma (MM) (including lentigo maligna mela-

noma), invasive squamous cell carcinoma (SCC) and basal cell

carcinoma (BCC), and the department or GP surgery in which

the sample originated were noted. In this 18-month period,

1894 of 3276 (58%) skin cancers originated from dermatolo-

gists. The rest were obtained from plastic surgery (29%), GPs

(12%) and 1% from other hospital departments (for example

oral surgery, ENT). By histological type 59% of MM samples,

42% of SCCs and 62% of BCCs were from dermatology. The

NICE guidance highlights the scarcity of data regarding pri-

mary care skin cancer surgery activity levels. From their audit

of nine NHS trusts, the proportion of MM biopsied by GPs

ranged from 1Æ4–13%, compared to 0Æ7–10% for SCC and

1Æ3–8Æ8% for BCC. Our findings show that the GP biopsy rates

in our region are within this range for MM (8%), but are

higher for SCC (15%) and BCC (12%). Over the 3 years inclu-

ded in our study, the proportion of MM biopsied in primary

care reduced by 6% compared with BCC and SCC which both

increased (by 2% and 6%, respectively). The reasons for this

change may include the implementation of the ‘2-week wait-

ing time standard’ to fast track potential melanomas and the

drive to manage more ‘nonurgent’ skin lesions in primary

care. Interestingly, in the 3 years surveyed, the total number

of MM and BCC increased by 39% and 27%, respectively,

compared to a reduction of 18% in the number of SCC.

Although dermatologists are removing the majority of skin

cancers in our region, implementation of the NICE guidelines

should increase this further over the coming years as the pro-

portion of skin cancers biopsied from primary care reduces. In

addition, the number of new cases of skin cancer is projected

to continue to increase for many years to come. The challenge

will be to ensure that service provision expands in parallel and

that standards of care are maintained to improve outcomes for

all patients affected.

DS-11Completeness of excision of malignant melanomas:changing rates in primary care and hospital practiceA. Ranasinghe, J. Gass, N. Tompson, E. Rytina* andP. ToddDepartments of Dermatology and *Histopathology, Addenbrooke’s Hospital,

Cambridge, U.K.

The incidence of malignant melanoma continues to rise in the

U.K. and is the major cause of death from skin cancer (NICE

Guidelines. CSG Improving Outcomes for People with Skin

Tumours including Melanoma. The Manual 2006). Survival is

strongly correlated with the Breslow thickness at diagnosis and

the definitive treatment of primary melanoma is currently

complete surgical excision (Roberts DLL, Anstey AV, Barlow

RJ, Cox NH et al. U.K. Guidelines for the management of cuta-

neous melanoma. Br J Dermatol 2002; 146: 7–17). We assessed

the rate of incomplete primary excision of malignant mela-

nomas between the years 2001 to 2005 and 2005 to 2006.

We compared these results between primary care and hospital

practitioners. Pathology reports from a British hospital were

analysed retrospectively. Patients undergoing primary excision

of melanoma by primary care practitioners and hospital practi-

tioners were identified. The completeness of excision was

assessed at deep and peripheral margins. Metastatic or recur-

rent lesions and diagnostic biopsies were excluded. Six hun-

dred and eight patients had a primary excision of melanoma

between January 2001 and December 2005, of which 7%




were excised by primary care practitioners and 93% by hospi-

tal practitioners. The mean age was 60 years, and 53% were

female. A total of 16% were incomplete excisions. Compared

with hospital practitioners, primary care practitioners had a

significantly higher rate of incomplete excision (14% vs. 36%,

P = 0Æ001). Prior to excision, there was a clinical diagnosis of

melanoma in 64% of incompletely excised lesions from hospi-

tal practitioners, compared with only 20% of incomplete exci-

sions from primary care practitioners. Following these results,

we then examined the multidisciplinary team records of 110

patients treated for melanoma over 7 months between August

2005 and February 2006. Fifteen per cent of these were per-

formed by primary care practitioners. Compared to hospital

practitioners, primary care practitioners had a significantly

higher rate of incomplete excision (16% vs. 56%). In conclu-

sion we have shown that, in our area, treatment of malignant

melanomas by primary care practitioners is associated with

higher incidence of incomplete primary excision and uncertain

clinical diagnosis. Furthermore, primary care practitioners are

now excising more melanomas, with a high percentage of

incomplete surgical clearance. As per NICE guidelines, we

recommend that all lesions clinically suspected of melanoma

should be referred for specialist treatment to an operator with

appropriate expertise for the tumour site.

DS-12‘Chewing gum’ hypertrophy complication of afull-thickness skin graft on the nose: spontaneousresolution over 4 weeksA. Affleck and S. Varma*Department of Dermatology, Ninewells Hospital and Medical School, Dundee,

U.K. and *Department of Dermatology, Nottingham University Hospitals

NHS Trust, Nottingham, U.K.

We bring to attention an uncommon and little reported com-

plication of a full-thickness skin graft (FTSG) on the nose. We

believe this to be a gross example of graft hypertrophy such

that the FTSG resembled a piece of chewing gum stuck on the

tip of the nose. Fortunately, this settled quickly and spontane-

ously. An 80-year-old man underwent Mohs’ micrographic

surgery to a squamous cell carcinoma on the right nasal tip

and was clear after two layers. A FTSG was fashioned from the

preauricular cheek with a tie over bolster. At 7 days, the FTSG

was pink with excellent contour, texture and colour match.

The patient returned unexpectedly after 4 weeks with a

10-day history of elevation of the graft. No clot or fluid could

be evacuated. The graft continued to thicken and became ele-

vated, resembling a lump of dried out chewing gum 2 weeks

later. Removal and replacement of the graft was considered

but as the patient was due to go on holiday he preferred no

intervention. Gradually the FTSG flattened spontaneously over

4 weeks with an excellent long-term aesthetic result. FTSGs

are often a good choice for defects on the nose. Occasional

complications include graft failure, infection, acute bleeding

or haematoma, colour or texture mismatch, contracture or

hypertrophy. A recent study found graft hypertrophy to be the

commonest complication of FTSG (Leibovitch I, Huilgol SC,

Richards S et al. The Australian Mohs database: short-term

recipient-site complications in full-thickness skin grafts. Derma-

tol Surg 2006; 32: 1364–8). This can look unattractive to the

patient and dermatologist and so corrective treatment is often

used. Treatment options include silicone gel sheets, topical

steroids, intralesional steroid injection, dermabrasion and CO2

laser. Gentle manual massage can help in smoothing and soft-

ening a FTSG rendering it more pliable and mobile. The cause

of this complication is unknown although the site of the

abnormal swelling is considered to be dermal rather than epi-

dermal. It may be a similar process to that of hypertrophic

scars. Our case is probably an extreme form of graft hypertro-

phy as it settled spontaneously and highlights that active inter-

vention may not be needed. Surgical dermatologists should be

aware of the ‘chewing gum’ complication of a FTSG and that

conservative management may be all that is necessary. Future

studies comparing different treatment options in the manage-

ment of FTSG hypertrophy would be useful.

DS-13A case of DIY Mohs’ surgery using bloodrootobtained from the internetA. Affleck and S. Varma*Department of Dermatology, Ninewells Hospital and Medical School, Dundee,

U.K. and *Department of Dermatology, Nottingham University Hospitals

NHS Trust, Nottingham, U.K.

We wish to highlight a potentially serious problem of self-

treatment of a basal cell carcinoma (BCC) by a patient who

obtained bloodroot (Sanguinaria canadensis) from an internet site

(www.cancerx.org/). A number of patients are seeking alter-

natives to surgery and may be seduced by reports of success

with home treatment using various botanical preparations

including bloodroot which act as escharotic agents. Late recur-

rences and metastasis following self-treatment have been

reported (McDaniel S, Goldman GD. Consequences of using

escharotic agents as primary treatment for nonmelanoma skin

cancer. Arch Dermatol 2002; 138: 1593–6). A 51-year-old man

presented with a 2-month history of a 5-mm lesion on the

dorsal nose skin. A shave biopsy revealed BCC. He was offered

Mohs’ micrographic surgery (MMS) but was very upset by the

thought of aesthetic disturbance to his nose. Following long

discussions and despite being fully informed he decided to

self-treat with bloodroot. His rationale was that this was the

same preparation that was used by Fred Mohs when he

described MMS. He used this on his nose each day for 8 con-

secutive days. He described 3 days of agonising pain. After 2

weeks, a large eschar of fixed tissue separated to leave a

wound which then took 2 weeks to heal. He initially experi-

enced a good response and was anticipating a cure, but then

applied the bloodroot on two further occasions as he felt the




cancer was returning. He has been left with a fair cosmetic

outcome and remains under long-term review. He has had

two subsequent biopsies to papules that have developed at the

scar site which have not shown BCC (12 months review). This

patient misinterpreted bloodroot treatment as self-MMS. He

failed to appreciate the importance of microscopic control

after the central eschar had separated, the technique originally

pioneered by Frederic Mohs in the late 1930s using chemical

fixation in situ by means of a paste containing bloodroot and

zinc chloride prior to excision. This version of MMS was

known as chemosurgery and has now been almost completely

replaced by the Mohs’ fresh-tissue technique which is quicker

and less painful for the patient. Fortunately, our patient is free

of tumour thus far and he is now prepared to undergo con-

ventional MMS should he develop a recurrent BCC in the

future. This case illustrates another dermatological example of

the power of the internet influencing patient care. Dermatolo-

gists should be aware of what patients may be reading and

regulatory agencies should consider reasonable standards for

sites that promote such products.

DS-14Evaluation of a novel ‘needlecatcher’ surgicalinstrument designed to reduce the incidence ofneedle stick injuries from suture needles duringskin suturingJ.D. Mckenna, S. McGlennon, M. McCallum andO. DolanRoyal Hospital, Belfast, U.K.

Needle stick injuries are a feared occupational hazard among

surgeons and their assistants, with risk of transmission of

infectious diseases. Common causes of these injuries are suture

needles penetrating the surgeon’s nondominant hand during

skin suturing. This risk could be reduced by the use of an

instrument enclosing the needle point during suture knot

tying, avoiding the use of forceps or the surgeon’s fingers.

We have been evaluating a novel prototype device not yet

commercially available. It is designed to capture the suture

needle point within an enclosed barrel during knot tying and

reloading of the needle into the needle driver. The device is

an adaptation of the Adson style of forceps widely used in

skin surgery. A hollow barrel containing a central pin is

attached to the end of the handle of the forceps. The central

pin moves with the opening and closing action of the forceps.

This allows the shaft of a suture needle to be gripped between

the pin and the inside of the hollow barrel when the needle

point is placed into the barrel. The needle is held securely

with the needle point enclosed within the barrel and therefore

is not capable of causing needle stick injury. Our aim was to

assess how easily the technique used in the operation of this

instrument could be learned by operators with different levels

of experience and to determine if the operator’s perception of

safety was improved with use. Four operators with varied

suturing experience used the instrument to assist suturing of

35 postexcision skin wounds. The design and use of the

instrument is demonstrated (video clip). Questionnaire results

of the opinions of operators following its use and a review of

the literature of suture needle safety are presented. The tech-

nique required is relatively easy to learn with minimal train-

ing. Confidence is gained with repeated use of the instrument.

All operators reported the instrument as very successful in

reducing the risk of needle stick injury and enhancing safety.

Global assessment was reported as excellent overall by three of

the four operators. No clinically significant needle blunting

was noted during its use. The process of learning any new

technique, differing from previously learned practice, will

always require a degree of training and feel slightly awkward

initially. We have shown that the skills required to use this

device can be learnt easily by operators at different levels of

experience. Enclosure of the needle point during knot tying

has the advantage of preventing needle stick injury and secur-

ing the needle in the sterile field. The development of such

safety devices should be encouraged. Use could be aimed

towards trainees or nurses with minimal prior suturing experi-

ence so that good skills are learnt early in their career. The

authors have no financial interest in this device.

DS-15Tumescent liposuction: an effective treatment forjuxta-articular Dercum’s diseaseA.S. Belgi, P.W. Preston, E.J.C. Stewart* andR.J. MotleyWelsh Institute of Dermatology, University Hospital of Wales, Cardiff, U.K.

and *The Prossor White Dermatology Centre, Leigh, U.K.

A 65-year-old lady with a history of pain around her left knee

first presented 24 years ago. Pain was severe enough to dis-

turb her night sleep and had a crippling effect on her profes-

sional life as an occupational health assistant. After numerous

visits to a GP, orthopaedic surgeon, physiotherapist, vascular

surgeon and undergoing various radiological investigations

including MRI scan she was finally referred to a dermatologist

– 20 years after first developing the symptoms. She was diag-

nosed with juxta-articular Dercum’s disease and referred to us

for possible treatment with liposuction. On examination, she

had tender soft swelling on the inferomedial aspect of her left

knee. The joint itself was not involved. We treated her with

tumescent liposuction using 0Æ2% lignocaine with 1 : 2 000

000 as local anaesthetic. She had almost instant pain relief and

was very satisfied with the treatment. Recovery was swift and

uncomplicated and she could walk without pain for the first

time after many years. The liposuction procedure lasted only

40 min. Three years later she presented to us with juxta-arti-

cular Dercum’s disease involving her right knee joint. We trea-

ted this with tumescent liposuction, again with good effect.

Dercum’s disease or adiposis dolorosa is a rare progressive dis-

ease characterized by localized overgrowth of fat associated




with pain. The pain can be out of proportion to physical find-

ings and is unresponsive to conventional analgesics. Diagnosis

of juxta-articular Dercum’s disease is essentially clinical but

can be easily missed unless sought for. Various treatment

options have been suggested including injection of intraven-

ous lignocaine, oral mexiletine for pain relief, and surgical

excision. Liposuction using tumescent local anaesthesia is a

quick, safe and effective treatment for Dercum’s disease. It is

well tolerated as an outpatient procedure and as the only scars

are 1 or 2 small puncture marks it is cosmetically superior to

open surgery for this condition.

DS-16A prospective study of poly-L-lactic acid (Sculptra�)injections in femalesG. Fairris and A. PagePrivate Practice, Winchester, U.K.

The injection of eight to ten vials of 0Æ15 g poly-L-lactic acid

(PLA) into the atrophied areas of the cheeks of HIV-infected

males with lipoatrophy produced a 7Æ2 mm increase in total

cutaneous thickness (TCT) and an evident aesthetic improve-

ment (Valantin M, Aubron-Olivier C, Ghosn J et al. Polylactic

acid implants (New-Fill) to correct lipoatrophy in HIV-infec-

ted patients: results of the open-label study VEGA. AIDS 2003;

17: 2471–7). Despite its widespread use, to date there have

only been anecdotal reports of PLA’s effectiveness in the treat-

ment of age-related facial volume loss in females. We sought

to address this lack of knowledge. Fifteen female subjects,

aged 42–59 years, were injected five times over 8 months

with two vials of 0Æ15 g PLA per treatment. The first three

injection sessions were 4 weeks apart. Then, after assessment

at 6 months, each subject was given two further treatments.

Forty-eight hours before treatment, each vial of PLA was dilu-

ted with 4 ml of water. Immediately before treatment, 1 ml

of 2% lignocaine was added. In the lower and mid-face, 0Æ1 ml

‘sausages’ of PLA were injected under the dermis about 5 mm

apart using the fanning and cross-hatching techniques

and a half-inch 26 gauge needle. In the upper face, 0Æ1 ml

deposits of PLA were injected on periosteum under the orbi-

cularis oculi or in the temporalis. The PLA was spread evenly

with deep massage. Before treatment, 6 and 12 months later,

a 5–12 MHz linear array ultrasound probe with offset

(HDI5000, Philips, Philips Medical Systems, Global Informa-

tion Center, Eindhoven, Netherlands) was used to measure

TCT and a Canon EOS 20D camera was used to photograph

the subjects face-on and at a 45� angle. The order of the

before and after photographs was randomized and assessed by

five members of the lay public while displayed side by side

on a 19-inch computer monitor. TCT increased by 1Æ3 mm

(P = 0Æ002) after 6 months and 2Æ7 mm after 12 months

(P < 0Æ0001). Only after 12 months, could the observers reli-

ably identify the before photograph. All subjects believed that

fourth and fifth injections produced a bigger change in the

shape of their face than the first three. The combined findings

of this and the VEGA study suggest that the increase in TCT

produced by PLA is dose-dependent. In order to produce an

obvious improvement, many females with facial volume loss

will require injection with 100Æ15 g vials of PLA. The costs

of the study were met by the manufacturer but the authors

were not paid and have no financial links with the manufac-

turer.

DS-17Neofibroplasia misinterpreted as squamous cellcarcinoma. A potential histological pitfall offixed-tissue Mohs’ micrographic surgery forsquamous cell carcinomaL. Naysmith, A. Husain, C. Lawrence and J. LangtryRoyal Victoria Infirmary, Newcastle Upon Tyne, U.K.

Mohs’ micrographic surgery (MMS) allows margin control for

tumour-negative margins with the potential for tissue conser-

vation. It is recognized that the histological interpretation of

the more commonly used frozen Mohs’ micrographic sections

of squamous cell carcinoma (SCC) can be difficult. Conse-

quently, fixed-tissue (slow Mohs) has been advocated as an

alternative to frozen-tissue MMS in order to better distinguish

tumour morphology and staining characteristics from in-

flammatory cells and adnexal tissues. We report a 75-year-old

white man who presented with a 7-week history of an enlar-

ging crusted nodule on the left nasal side wall. Examination

revealed a 10 x 9 mm discrete centrally crusted nodule which

was clinically consistent with a SCC. A debulking excision was

followed by three stages and eight blocks of slow MMS over 6

days. There was a 4-day interval between stages 1 and 2 and a

2-day interval between stages 2 and 3. The histology of the

debulking excision specimen was of a well-differentiated SCC

extending to the margins of the specimen. Stage 1 of the

MMS revealed poorly differentiated SCC with perineural inva-

sion. The second MMS stage showed marked fibroblastic pro-

liferation and degenerative changes in the muscle with a few

mitotic figures suggestive of SCC. Somewhat surprisingly, hist-

ology of the third MMS stage showed similar changes and

prompted immunohistochemistry studies revealing both stages

2 and 3 negative for Cocktail cytokeratin stain, a specific anti-

body for squamous epithelium. Neofibroplasia is the exuber-

ant granulation tissue reaction seen after any surgery. In this

case the response was overwhelming, possibly in view of the

4-day interval between the first two stages. Slow Mohs’ tech-

nique requires more time for tissue fixation with a resultant

delay, usually of 1–2 days, between stages of excision. The

more prolonged delay in this case may be accountable for the

neofibroplastic changes, which we have not seen and would

not have expected to see with frozen-tissue MMS. This case

highlights firstly the potential pitfall of neofibroplasia mimick-

ing SCC occurring with slow MMS, resulting in unnecessary




tissue removal, and secondly emphasizes the value of cytokera-

tin stains to confirm the presence or absence of SCC.

DS-18Congenital dermatofibrosarcoma protuberans of thescalp in a 4-year-old boy excised by Mohs’micrographic surgeryL. Naysmith, R. Milner, F. Charlton and J. LangtryRoyal Victoria Infirmary, Newcastle Upon Tyne, U.K.

Congenital dermatofibrosarcoma protuberans (DFSP) poses a

diagnostic and therapeutic challenge. Not only is this low-

grade fibrohistiocytic tumour extremely rare in childhood, but

it may mimic benign-looking lesions such as vascular birth-

marks leading to a delay in diagnosis. We report a four and a

half year old boy who presented to the paediatricians at 6

months of age with a small frontal scalp swelling. This was

thought clinically to be a bruise and his parents were reas-

sured. His family moved to another part of the country and

he re-presented at the age of 3 years to plastic surgery with

the same persistent but enlarged lesion. At this point the clin-

ical impression was of a sebaceous cyst and it was surgically

excised. Histology, however, showed a pleomorphic spindle

cell proliferation with a storiform architecture occupying the

entire dermis and infiltrating into subcutaneous fat. Immuno-

histochemistry was positive for CD34, and a diagnosis of

incompletely excised DFSP was made. He was referred to our

unit when the poorly defined tumour of the scalp measured

63 x 60 mm. Excision of the tumour by Mohs’ micrographic

surgery (MMS) using the fixed-tissue technique (slow MMS)

was carried out with tumour-negative margins after two stages

and 20 blocks. He remains free from recurrence at 10 months

after surgery. DFSP is rare, with a high recurrence rate but

low potential for metastasis, and usually presents in mid adult

life on the trunk or limbs. Congenital DFSP is particularly rare

with a predilection for the trunk and extremities. The initial

clinical appearance of congenital DFSP is often a red-blue vas-

cular looking macule or plaque, leading to the misdiagnosis of

a vascular malformation, before progressing to a more nodular

lesion. Treatment of DFSP is surgical. MMS is favoured over

2–3-cm wide surgical margins as the former offers histological

margin control with likely lower recurrence rates and tissue

conservation. The drawback of repeated general anaesthetic

exposures for congenital DFSP may limit its use. Congenital

DFSP of the scalp is a rare entity but given the locally

aggressive nature of these tumours with a high potential for

recurrence, early diagnosis and adequate surgical excision is

advised.

DS-19Dermatofibrosarcoma protuberans: an unusualpresentation and a challenging caseE. Craythorne, A. Robson,* S. Diaz-Cano, J. Salisburyand S. MacfarlaneKing’s College Hospital, London, U.K. and *St Thomas’ Hospital, London,

U.K.

Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-

growing, infiltrative skin tumour of intermediate malignancy,

with a limited potential for metastasis but a high incidence of

local recurrence. It arises in the dermis, subsequently invading

deeper tissues. Due to its highly infiltrative growth pattern,

DFSP often extends far beyond the clinical margins; this

accounts for the high incidence of recurrence following stand-

ard surgical excision. Even after wide excision with a 3-cm

surgical margin and deep excision to fascia, as is recommen-

ded, the reported incidence of recurrence varies from 11 to

20%. Mohs’ micrographic surgery is increasingly being heral-

ded for its improved recurrence rate of 0–6%. We report the

rare and interesting case of a 47-year-old Jamaican lady who

presented with a 4-year history of a large 3 cm, firm nodule

on the right shoulder. Surrounding this, there were three

smaller hyperpigmented plaques with features suggestive of

dermatofibromas. All were separated by at least 5 cm of clinic-

ally normal skin. The histology of the initial biopsies was vari-

able, with DFSP and dermatofibroma patterns observed in

different areas. Following multidisciplinary discussion, she

underwent wide excision of the central nodule that was felt to

be DFSP, and standard excision of the three satellite lesions.

Similar histological variation was observed in these specimens;

thus, a diagnosis of DFSP, with admixed features of dermato-

fibroma, was made. On review of the pathology each of the

satellite lesions were said to be clear at the margins. Explana-

tions include the possibility of sampling error, skip lesions

within the tumour, or that the tumours had arisen separately.

The patient had a further wide excision, resulting in a large

defect requiring grafting. Pathological review of the final sam-

ple did not contain any residual DFSP. This case raises interest-

ing questions regarding diagnosis and management of this

rare presentation of DFSP. We discuss what value Mohs’

micrographic surgery might have played in our patient, its

usefulness in showing if these lesions were contiguous and

the feasibility of its use in such a large lesion.

DS-20The ‘lip switch’ flap for correction of excessiveshortening, following excision of squamous cellcarcinoma of the lower lipD. Shah, R. Parkin, A. Morris and R. MotleyUniversity Hospital of Wales, Welsh Institute of Dermatology, Cardiff, U.K.

A 68-year-old lady on long-term immunosuppression for

cryoglobulinaemia presented with a rapidly growing squa-

mous cell carcinoma on the right side of her chin and lower




lip. This was removed under micrographic control with loss

of 40% of the length of the lower lip. The wound healed well

following direct closure, but despite several months of postop-

erative massage, the subsequent reduction in length of the

lower lip created difficulty with mastication, oral continence

and oral hygiene. We elected to correct the discrepancy in lip

length using a ‘lip-switch’ (or Abbe) flap. The surgical scar on

the lower lip was re-incised through the full thickness of the

lip and a full-thickness triangular piece of upper lip, raised on

a medial pedicle, which included the labial artery, was rotated

into the defect. The upper lip was closed primarily and the tri-

angular flap sutured into the lower lip, thus increasing its

length. After 3 weeks the pedicle was divided and the remain-

ing wounds closed directly. All surgery was performed under

local anaesthesia on an outpatient basis. This two-stage pro-

cedure corrected the shortening of the lower lip, reduced the

discrepancy in lengths of the upper and lower lip and provi-

ded a good functional and cosmetic solution to her problem.

DS-21Bilateral island pedicle flap repair in a case of lowervermilion lip basal cell carcinomaL. Naysmith, C. Lawrence and J. LangtryRoyal Victoria Infirmary, Newcastle Upon Tyne, U.K.

The vermilion border of the lower lip is a site more com-

monly associated with squamous cell carcinoma. Basal cell car-

cinoma (BCC) at this site is unusual but when present behaves

in an aggressive fashion. Complete surgical excision and suc-

cessful repair of lower vermilion lip defects can be challen-

ging. We report the case of a 24-year-old female sun-bed user

with a 1-year history of an enlarging crusted lesion on the

central lower lip which had been unsuccessfully treated as her-

pes simplex infection. On examination she had a 1-cm ill-

defined crusted plaque involving the outer mucosal, vermilion

and central cutaneous lower lip. A diagnostic biopsy showed a

micronodular BCC which was subsequently completely excised

using formalin fixed horizontal tissue sections (slow Mohs) in

two stages and five blocks. Perineural invasion was noted in

the first layer, confirming the aggressive nature of the tumour.

The final full-thickness defect measured 2 x 1 cm representing

33% of the vermilion width. Staying within the principles of

aesthetic reconstruction, the defect was closed with bilateral

island pedicle flaps using tissue of identical colour, thickness

and texture and avoided the unnecessary sacrifice of normal

tissue and reduction in oral aperture that occurs with a wedge

resection repair. The bilateral island pedicle flap provides an

excellent functional and cosmetic result for vermilion lip

defects. It comes with the reassuring benefit of providing tis-

sue for a full-thickness graft in the event of unpredictable flap

dynamics.

DS-22Bilateral transposition flap: a simple and effectivemethod for closure of large defects, especially of thelimbsS. Dhoat, R. Verdolini, L. Bugatti* and G. Filosa*Newham General Hospital, London, U.K. and *Ospedale di Jesi, Ancona,

Italy

Excision of large tumours of the limbs, particularly of the

lower legs, can be challenging because of difficulties related to

wound closure. In addition, skin necrosis and the develop-

ment of leg ulcers are significant risks, especially in elderly

patients with impaired blood circulation. Large defects may

require grafting, with its inherent problems. Flaps can also be

used (Tritsch H, Pullmann H. Double-lobed rotation pedicle

flap. Hautarzt 1977; 28: 653–7; Keser A, Sensoz O, Mengi AS.

Double opposing semicircular flap: a modification of opposing

Z-plasty for closing circular defects. Plast Reconstr Surg 1998;

102: 1001–7), but the methods usually employed to repair

large wounds are not particularly applicable to the limbs. We

have developed a simple but effective technique for the clo-

sure of large wounds, resulting from the excision of tumours.

Our method consists of two longitudinal, lobe-shaped flaps

obtained from two opposite sides of the wound. We then

rotate the two flaps around two fulcra placed at the antipodes

of the wound by approximately 90�. After suture of the two

longitudinal donor areas, the two flaps usually fall into place

spontaneously, with no need for pulling or stretching. The

two flaps are then sutured to the upper and lower borders of

the defect and finally together, with a transversal suture. If

appropriately measured and shaped, this final suture develops

a minimal longitudinal tension, which is ideal for allowing

the two flaps to adhere to the subcutis. Over the past 12

months we have treated 13 patients using this technique, 12

for either SCC or BCC of the extremities. All had an excellent

cosmetic outcome. Healing times were short and neither

necrosis nor infection was encountered. This technique

ensures closure with skin similar in texture, colour and

thickness to the original defect. As such, lobe transposition by

rotating opposite twin flaps is now our method of choice for

removing large tumours on the extremities. Its advantages

over established flap procedures lie in its simplicity, optimal

blood supply and low suture tension.




Posters

DS-23Repair of full-thickness defects in the ala using arotated island pedicle flap from the cheekO. Kerr and R. MotleyUniversity Hospital of Wales, Cardiff, U.K.

Various methods have been described for repairing full-thick-

ness alar defects – and the choice depends on size, location of

the defect on the ala and whether or not there is loss of the

alar margin. We describe two patients with large alar defects

(> 50% of the ala) with a full-thickness loss in part and loss

of the alar rim in one patient. Both defects were adjacent to

the base of the ala (nasolabial fold) and were repaired using a

skin flap raised from the adjacent cheek on a medially based

muscular pedicle. The flap was rotated through 180� and

sewn into place. In one case the internal mucosal defect was

repaired with a full-thickness graft (harvested from the adja-

cent cheek). In the second case, an additional piece of skin

distal to the flap was retained, and after de-epithelialization of

the ‘hinge’ turned under – to create an internal lining to the

nose. Both patients had a good functional and cosmetic out-

come. We advocate this single-stage flap as a useful option for

some patients with full-thickness alar defects.

DS-24Scalp ulceration secondary to giant cell arteritis: adiagnosis not to be missedJ. Williams and S. MacfarlaneKing’s College Hospital, London, U.K.

A 73-year-old man was referred by his GP as a 2-week wait

with a possible SCC. For the past month a painful and crusted

lesion had been growing slowly on his right scalp. He gave a

history of headaches for the previous 4–6 weeks and felt

unwell. Past medical history included hypertension and inter-

mittent claudication and he was a smoker. On examination he

had two ulcerated, crusted lesions with surrounding dusky

purple discoloration on the right temporoparietal scalp and a

further similar lesion on the left upper forehead. There was

diffuse tenderness on palpation and both temporal arteries

were swollen with no pulse. A clinical diagnosis of temporal

arteritis was made. An urgent ESR was only 23 mm in the first

hour, and CRP 12Æ6 mg L–1 but because of the clinical find-

ings he was treated immediately with high-dose oral predniso-

lone and omeprazole cover. Skin biopsies were taken the next

day from the scalp lesions, which showed surface ulceration

and superficial inflammation with no evidence of malignancy.

A temporal artery biopsy showed florid giant cell arteritis with

prominent fibrinoid necrosis and a chronic inflammatory cell

infiltrate in the media, predominantly comprising plasma cells

plus scattered giant cells. There was marked destruction of the

intima and the artery was partially occluded by fibroblastic

proliferation. Within 10 days of steroid treatment his ESR had

fallen to 6 mm in the first hour and CRP to < 5 mg L–1, and

the ulceration started to heal. He remains on prednisolone.

Cutaneous ulceration in the context of giant cell arteritis is

extremely rare and suggests extensive vascular involvement

since scalp necrosis only occurs when all four supplying arter-

ies are compromised. It is associated with a mortality rate of

41% and a 67% incidence of irreversible loss of vision – a

worse prognosis than in giant cell arteritis without cutaneous

signs. Treatment with high-dose steroids should therefore not

be delayed. Although a raised ESR and CRP may be helpful in

making the diagnosis they are not always high, and the preva-

lence of temporal arteritis with a normal ESR has been estima-

ted as ranging from 2 to 8Æ7%. Temporal artery biopsy should

be undertaken as soon as possible once treatment has com-

menced and there is no evidence that this causes further com-

promise of scalp circulation. With adequate corticosteroid

therapy the prognosis for these scalp lesions is very good and

complete healing is usual. This case highlights the importance

of dermatologists being aware of giant cell arteritis as a differ-

ential diagnosis of scalp ulceration in elderly patients since

early appropriate treatment is essential to prevent devastating

complications.

DS-25Improving information given to patients with skincancer: when and how this should be givenB. Balogun-Ojuri and N.J. LevellNorfolk and Norwich University Hospital, Norwich, U.K.

We aimed to identify the type of information about their con-

dition given to target patients (patients referred by GPs with

suspicion of possible squamous cell carcinoma or malignant

melanoma). We also wished to identify the most appropriate

time for patients to receive such information. The audit took

place at a dermatology outpatient department. One hundred

and nineteen target patients referred between May and mid-

July 2006 were audited using a purpose-designed question-

naire sent out 4–12 weeks after the diagnosis. Patients were

asked about the type of information received, understanding

and adequacy of the information and when they felt the infor-

mation would have been most beneficial. Of the 119 patients

who were sent questionnaires, 68 (57%) responded. Regar-

ding information given to these patients about skin cancer

prior to attending outpatients, 88% received only verbal infor-

mation by their GP. At the outpatient appointment, 13% said

they did not get enough information and 24% were only sat-




isfied to some extent. A majority of all patients, 67%, said the

best time to receive information about their condition was

when the diagnosis was confirmed, while 13% wanted infor-

mation before diagnosis was confirmed. At diagnosis, 71%

said they had understood completely the information given to

them so far about their condition, while 27% understood only

to some extent. Fifty-three per cent did not indicate a need

for additional information, whereas 32% said they would have

preferred written information from the doctor, 9% wanted

contact details for other sources and 3% wanted audio infor-

mation, as well as information in larger print. This study

shows that information needs for skin cancer patients are very

variable. A significant number of patients either did not

receive enough information or did not understand that given.

Twelve to thirteen per cent were particularly unhappy and did

not recollect verbal information from GPs, were not happy

with information in outpatients and would have liked infor-

mation before diagnosis. Nearly half the patients would have

liked more information than they received and the majority of

patients would have liked information to be given at the time

diagnosis was confirmed. Written, audio and larger print in-

formation would have been useful to some, as would direc-

tions to other sources of information. This audit has identified

varying information needs in hospital skin cancer patients and

shown a need for greater flexibility and clarity in explanation.

(NICE 2006/09. Guidance to Improve Healthcare Services for Skin Can-

cers. Issued 21 February 2006.) No commercial funding was

used in this audit.

DS-26Fire in the biopsy roomG. Wylie and C. ClarkGlasgow Royal Infirmary, Glasgow, U.K.

Fire is a well-recognized hazard in surgical operating theatres

with the triad of ignition source, fuel and oxidiser. During

dermatological surgery oxygen is seldom used and conse-

quently the risk is reduced. However, ignition can occur with

hyfrecation and hot-wire cautery, most commonly in conjunc-

tion with alcohol-based cleansing solutions. This risk is now

recognized and fires are infrequent but hazards remain from

other fuel sources. We report two recent incidents. Case 1: a

woman had curettage for a seborrhoeic wart at her temple

using an aqueous aseptic solution (Hibitane�, GlaxoSmith

Kline, Uxbridge, U.K.). The wound bed was fulgurated using

a Conmed hyfrecator (blunt tip, 10 W, high). Scalp hair within

the surgical field was ignited and fire spread locally before

being rapidly extinguished. Residual mild skin erythema had

resolved by the next day. It transpires that she had applied

two different flammable hair styling products just prior to

attending for the procedure. Case 2: a patient had a

fibroepithelial polyp shaved again using Hibitane. Topical 30%

aluminium chloride solution (Driclor�; Stiefel, High

Wycombe, U.K.) was applied for haemostasis. A persistent

bleeding point was hyfrecated (Conmed, blunt tip, 10 W,

high) igniting the residual Driclor which burned briefly with

a blue flame and self-extinguished. Driclor was introduced as

a convenient haemostatic without the potential for tattooing

the skin. Both of our cases resolved without significant seque-

lae beyond distress for patient and doctor alike. However, they

highlight the need to exclude flammable products within the

biopsy room and to constantly re-evaluate the fire risk of

materials introduced to dermatological surgery.

DS-27Mohs’ micrographic surgery for recurrent BCC: theSunderland experienceC. Blasdale and J.A.A. Langtry*Sunderland Royal Hospital, Sunderland, U.K. and *Royal Victoria Infirmary,

Newcastle upon Tyne, U.K.

In the 5-year period, January 2001 to December 2005, 347

Mohs’ micrographic surgical excisions were carried out by a

single dermatological surgeon (J.A.A.L.). Fifty-six procedures

(16%) were performed for clinically recurrent basal cell carci-

noma (BCC). All lesions were on the head and neck, with the

commonest sites being the nose and periocular area. The med-

ian time between most recent treatment and presentation with

recurrence was 34 months (range 3 months to 20 years).

Thirty-seven lesions had been treated previously only once,

and 19 lesions treated by two or more previous procedures,

up to a maximum of 11. Ten per cent had previously been

treated by cryotherapy, 10% by curettage and cautery, 57% by

excision and 14% by radiotherapy. A further two cases had

had a combination of radiotherapy and surgery and one had

been treated by Mohs’ micrographic surgery. The time to pre-

sentation of recurrence varied with treatment modality and

was shown to be shortest for cryotherapy and longest for

radiotherapy. In 24 cases, histology reports from the time of

primary treatment were available. Two of these were pretreat-

ment biopsies, and 22 excision specimens. Twelve of the exci-

sions were reported to be complete, and 10 incomplete.

Infiltrative or morphoeic areas were reported in 25%, with

one superficial BCC and all others solid or cystic. No correl-

ation was seen when histology at first treatment and at recur-

rence were compared, with all previously infiltrative or

morphoeic tumours reported at recurrence as solid BCC, and a

similar number of lesions with nonaggressive histology at first

presentation showing infiltrating/morphoeic features at recur-

rence. Tumour clearance was achieved in 32% after one Mohs’

stage, and 34%, 23% and 5% after 2, 3 and 4 stages, respect-

ively. Only two patients required more than four stages, and

one patient declined further treatment before clearance was

achieved. The median postoperative wound defect was

283 mm2 (range 31–3707); the size of wound was predicted

by preoperative lesion size but not by primary treatment type

or time to recurrence.




DS-28Quality assurance in the surgical management ofbasal cell carcinomas: an audit of complete excisionrates in primary and secondary careM. Griffiths, J. Vella, L. Maxwell, B. Gee and R. CarrWarwick Hospital, Warwick, U.K.

The recent guidance (National Institute of Clinical Excel-

lence. Improving Outcomes for People with Skin Cancers. NICE Febru-

ary 2006) states that all patients with skin cancer should be

offered the same quality of care regardless of where the

treatment is carried out and regardless of the grade and

type of doctor they see. The gold standard for basal cell

carcinoma (BCC) management remains surgical excision

with clear resection margins. We identified completeness of

excision as a surrogate marker for best practice and under-

took an audit of BCC excision rates in primary and second-

ary care. A retrospective audit was undertaken of BCCs

excised by dermatologists and plastic surgeons (hospital spe-

cialists) and general practitioners (GPs) from January 2005

to December 2005, inclusive. The site of lesion, clinical

diagnosis, histological subtype, peripheral and deep margins

were extracted from the pathology reports. A total of 414

BCC excision biopsies were identified. Of these 217 were

excised by dermatologists, 156 by the plastic surgeons and

41 by general practitioners. The incomplete excision rate

for the hospital specialists was 6Æ2%, 5Æ6% involving the

peripheral margin and 2Æ0% the deep margin. The incom-

plete excision rate for GPs was 24Æ0%, 24Æ0 % involving

the peripheral margin and 13Æ0% the deep margin. Hospital

specialists excised 86Æ6% of BCCs with more than 1 mm

margins compared with only 46Æ5% for GPs. Malignancy

was suspected in 95Æ4% of hospital specimens but in only

54% of GP cases. In summary, half of BCCs excised by GPs

were not identified as BCCs prior to the removal. Approxi-

mately one-quarter of BCCs excised by GPs were incom-

pletely excised. The recent NICE guidance suggests that

low-risk BCCs can be managed in primary care but this

audit shows GPs have difficulty in diagnosing BCCs. Inac-

curate diagnosis results in inadequate management and this

has been shown with melanomas (Khorshid SM, Pinney E,

Bishop JA. Melanoma excision by general practitioners in

north-east Thames region, England. Br J Dermatol 1998; 138:

412–17). GPs must be trained in diagnosis as well as sur-

gery, regularly attend skin cancer multidisciplinary team

meetings and be subject to satisfactory audit if they are to

continue to have a role in the management of skin cancer.

DS-29Infection rate after dermatosurgical procedures inthe dermatology department of a university teachinghospitalK. Chittari and B.B. TanUniversity Hospital of North Staffordshire, Stoke-on-Trent, U.K.

This was a prospective observational study to look at the rate of

surgical wound infection and other factors that influence the

outcome of wound infection such as choice of procedure, ana-

tomical sites, use of topical antibiotics, and aseptic techniques

used by both operator and assistant during simple dermatosurgi-

cal procedures. Procedures involving flaps and graft repair were

excluded. Patients were enrolled if they were

immunocompetent, not receiving chemotherapy or steroids and

had not taken antibiotics within the 7 days preceding surgery.

The skin was cleaned with chlorhexidine and local anaesthetics

were used for all patients. Where indicated, subcutaneous and

interrupted skin sutures were used. One hundred and seventeen

procedures were carried out in 1 month. Seventy-three patients

fulfilled enrolment criteria and consented for this study. On fol-

low-up, 11 patients were not contactable. Hence, data from 62

patients were analysed. There were 72 procedures carried out in

this cohort of 62 patients. There were 25 excisions, 20 curet-

tages, 19 incisions, seven punch biopsies and one shave biopsy.

Head and neck constituted 52% of the biopsy sites followed by

18% from the trunk, 13% from the upper limbs, 13% from the

lower limbs and 4% from the genitalia. All primary operators

wore sterile gloves but only 25% of assistants wore sterile gloves.

Seventy wounds (97%) had topical antibiotic polymyxin B sul-

phate application immediately postoperatively before placement

of dressings. One patient (1%) developed microbiologically pro-

ven Staphylococcus aureus infection on his buttock area where an in-

cisional biopsy took place. He was later treated with oral

flucloxacillin. Infection rate after uncomplicated dermatosurgical

procedures in our department is low. Factors such as certain ana-

tomical sites, for example, the genitalia area, and the lack of use

of sterile gloves by the assistant do not seem to have contributed

to the wound infection. Although often overlooked, topical anti-

biotic agents played an important role in skin surgery. Topical

polymyxin B sulphate is widely use in our department. Its bacte-

ricidal property provides a safe and effective option in wound

healing (Thornton Spann C, Taylor SC, Weinberg JM. Topical

antimicrobial agents in dermatology. Clin Dermatol 2003; 21: 70–

7). Although this is a small study to reach any significant conclu-

sion, it demonstrated that the use of a topical antibiotic may have

a role in reducing postoperative wound infection.




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