Shave Excision Research Articles

Management of advanced rhinophyma with shave excision and noncultured autologous skin cell transplantation

Rhinophyma is a benign skin disorder characterized by hypertrophy of the nasal skin, inflammation and telangiectatic changes. This process disfigures the nose and represents the final stage of acne rosacea. The mainstay of treatment is surgery and various techniques have been proposed. We hereby, present a case of a patient with advanced rhinophyma who was treated by tangential skin excision and non-cultured autologous skin cells application. This method hastened wound healing, reduced dressing changes and patient discomfort.

Bizarre Parosteal Osteochondromatous Proliferation of Long Bones: Two New Cases and Literature Study

In research on tumors of mesenchymal origin, although the type localized in the short, tubular bones has been evaluated in detail, there have been no reports to date regarding the clinical, radiological and treatment characteristics of the type localized in the long bones. In this study, Nora’s lesions localized in the long bones were investigated in terms of their characteristics and behavior. An extensive literature review was performed using PubMed, MEDLINE (1983 - 2012) and Google Scholar. Search terms included ‘‘bizarre parosteal osteochondromatous proliferation’’ (BPOP) and ‘‘Nora’s lesion’’. The literature search yielded 88 articles and a total of 43 patients. The median age of the cases was 26 years. BPOP occurred with equal frequency in men and women. The most frequent sites of involvement were the femur (25%) and the ulna (23%). Plain radiographs of 20 cases were available, but only a small number of cases had CTs (n = 11) and MRIs (n = 12) performed. It was determined that 66% of the lesions led to cortical changes, while 23.5% led to medullary invasion or soft tissue infiltration. As to treatments, “simple excision” (intralesional) was performed on seven lesions, marginal resection was performed in nine patients, wide resection was performed in two patients, “shark-bite” surgery was performed in one patient and “shave excision” was performed in one patient. The mean follow-up period was 30.9 months. Local recurrence rate was 18.75%. Clinically and in terms of radiological images, we believe that this lesion observed in the long bones consists of four phases: stages I, II, III and IV. We believe this type of lesion demonstrates no spontaneous recovery, and that it is a progressive lesion involving cortical destruction and medullary infiltration. As such, we consider marginal resection to be the appropriate technique for treating this lesion. J Med Cases. 2014;5(6):315-325 doi: http://dx.doi.org/ 10.14740 / jmc1624w

Electrocautery versus ablative CO2 laser in the treatment of seborrheic keratoses

BackgroundSeborrheic keratosis is one of the most common benign epidermal skin tumors. Its pathogenesis remains largely unclear. The treatment of choice is ablation of the lesion by curettage, shave excision, electrocautery, cryotherapy, or ablative lasers.ObjectiveThe aim of this study was to compa

Optimal management of common acquired melanocytic nevi (moles): current perspectives.

Although common acquired melanocytic nevi are largely benign, they are probably one of the most common indications for cosmetic surgery encountered by dermatologists. With recent advances, noninvasive tools can largely determine the potential for malignancy, although they cannot supplant histology. Although surgical shave excision with its myriad modifications has been in vogue for decades, the lack of an adequate histological sample, the largely blind nature of the procedure, and the possibility of recurrence are persisting issues. Pigment-specific lasers were initially used in the Q-switched mode, which was based on the thermal relaxation time of the melanocyte (size 7 μm; 1 μsec), which is not the primary target in melanocytic nevus. The cluster of nevus cells (100 μm) probably lends itself to treatment with a millisecond laser rather than a nanosecond laser. Thus, normal mode pigment-specific lasers and pulsed ablative lasers (CO2/erbium [Er]:yttrium aluminum garnet [YAG]) are more suited to treat acquired melanocytic nevi. The complexities of treating this disorder can be overcome by following a structured approach by using lasers that achieve the appropriate depth to treat the three subtypes of nevi: junctional, compound, and dermal. Thus, junctional nevi respond to Q-switched/normal mode pigment lasers, where for the compound and dermal nevi, pulsed ablative laser (CO2/Er:YAG) may be needed. If surgical excision is employed, a wide margin and proper depth must be ensured, which is skill dependent. A lifelong follow-up for recurrence and melanoma is warranted in predisposed individuals, although melanoma is decidedly uncommon in most acquired melanocytic nevi, even though histological markers may be seen on evaluation.

Bizarre Parosteal Osteochondromatous Proliferation of Long Bones: Two New Cases and Literature Study

In research on tumors of mesenchymal origin, although the type localized in the short, tubular bones has been evaluated in detail, there have been no reports to date regarding the clinical, radiological and treatment characteristics of the type localized in the long bones. In this study, Nora’s lesions localized in the long bones were investigated in terms of their characteristics and behavior. An extensive literature review was performed using PubMed, MEDLINE (1983 - 2012) and Google Scholar. Search terms included ‘‘bizarre parosteal osteochondromatous proliferation’’ (BPOP) and ‘‘Nora’s lesion’’. The literature search yielded 88 articles and a total of 43 patients. The median age of the cases was 26 years. BPOP occurred with equal frequency in men and women. The most frequent sites of involvement were the femur (25%) and the ulna (23%). Plain radiographs of 20 cases were available, but only a small number of cases had CTs (n = 11) and MRIs (n = 12) performed. It was determined that 66% of the lesions led to cortical changes, while 23.5% led to medullary invasion or soft tissue infiltration. As to treatments, “simple excision” (intralesional) was performed on seven lesions, marginal resection was performed in nine patients, wide resection was performed in two patients, “shark-bite” surgery was performed in one patient and “shave excision” was performed in one patient. The mean follow-up period was 30.9 months. Local recurrence rate was 18.75%. Clinically and in terms of radiological images, we believe that this lesion observed in the long bones consists of four phases: stages I, II, III and IV. We believe this type of lesion demonstrates no spontaneous recovery, and that it is a progressive lesion involving cortical destruction and medullary infiltration. As such, we consider marginal resection to be the appropriate technique for treating this lesion. J Med Cases. 2014;5(6):315-325 doi: https://doi.org/10.14740/jmc1624w

Superficial Acral Fibromyxoma on the Palm

relatively new entity, most likely representing a fibrohistiocytic neoplasm. This tumor presents as a slowly growing solitary nodule, usually confined to the dermis and subcutaneous tissue. It has a distinct predilection for finger nails and toe nails of young to middle-aged adults. Here, we report a case of SAFM occurring on the palm, which is very rare site. A 58-year-old Korean woman presented with a history of a nodular mass on the palm of her right hand (Fig. 1). The tumor had been present for several years and had gradually increased in size. There were no subjective symptoms, such as pain. The patient underwent shave excision of this tumor. The lesion measured 0.7×0.7 cm. It was domeshaped, moderately circumscribed, firm, and had a uniform consistency. Histological examination showed a moderately cellular proliferation of spindled fibroblast-like and stellate cells embedded in myxoid matrix (Fig. 2A, B). The tumor cells were arranged in a loose storiform and focally fascicular pattern. Nuclear pleomorphism or mitotic activity was not present. Immunohistochemically, tumor cells were positive for CD99, negative for CD34 and epithelial membrane antigen (EMA) (Fig. 2C∼E). At 6 months follow-up, there was no recurrence of the tumor. SAFM typically is detected in adulthood as a solitary slow-growing mesenchymal mass involving the periungual and subungual regions of the fingers and toes. Hollmann et al. 2 reported 124 cases of digital fibromyxoma; most tumors occurred on the digits, with the majority growing in close proximity to the nail (97% on fingers, 96% on toes). Occurrence on the palm is very rare. The histopathological characteristics of these tumors are distinctive, showing a moderately cellular dermal proliferation of spindle-shaped fibroblast-like cells in a myxoid or collagenous matrix. The differential diagnosis for SAFM includes a fibrous histiocytoma variant, dermatofibrosarcoma, cutaneous myxoma, acquired fibrokeratoma, sclerosing perineurioma, and the acral myxoinflammatory fibroblastic sarcoma. Immunohistochemical results of SAFM are controversial. Tumor cells have been reported positive for CD34 (21/23, 91.3%), EMA (18/25, 72%), and CD99 (11/13, 84.6%) in one study 1 , but positive for only CD34 (42/61, 68.8%) and

The Characteristics and Second Intention Healing After Shave Excision of Nevi on the Lid Margin in East Asians

The aim of this study was to report the characteristics and secondary-intention healing after shave excision of nevi on the lid margin in East Asians. Forty patients who underwent shave biopsy of an eyelid mass and were diagnosed with a nevus were retrospectively evaluated regarding their sex and age and the location, size, complication, and recurrence of the nevus. In all patients, shave biopsy was performed carefully to induce secondary-intention wound healing, and they received follow-up for at least 1 year. Among 40 patients, 21 were men, and 19 were women. The average age of the patients was 35.3 ± 14.9 years. Twenty-one nevi were found on the upper lid, and 19 were found on the lower lid. In 1 patient, nevi were found on both the upper and lower lids. There were no significant differences in incidence according to sex and location of the nevi (upper or lower lid); however, the half that were located in the nasal area and the dermal type of nevus were the most common. Junctional nevi were not found in any of our cases. There were no complications and recurrences found in our cases, even after shave excision. Eyelid nevi in Korean patients commonly develop at a young age. There was no difference in the incidence of nevi between the upper and lower lids, but the nasal area of the lid was a more common location for the development of a nevus. The dermal type was the most common in our cases. Healing by secondary intention is a safe and effective alternative to surgical reconstruction after a shave excision of nevi on lid margin.

New Rhinophyma Severity Index and Mid-Term Results following Shave Excision of Rhinophyma

Background: Rhinophyma is a progressive nasal deformity resulting from hyperplasia of the sebaceous glands and connective tissue, with a negative effect on quality of life. Partial-thickness shave excision has been used for the treatment of rhinophyma, but the mid- and long-term efficacy of the treatment is unknown. Objectives: We analysed the clinical outcomes of shave excision in patients with rhinophyma in our centre between 2005 and 2009. Methods: The entire nose was shaved using a scalpel while under tumescent anaesthesia. The clinical assessment was scored using a novel Rhinophyma Severity Index. Results: Thirty-three patients with rhinophyma and shave excision were recruited for the study. A mid-term follow-up examination was possible in 23/33 (69.7%) patients. After a mean follow-up of 37.4 ± 13.2 months, 21 (91.3%) patients showed an improved Rhinophyma Severity Index (3.3 ± 1.1 to 1.7 ± 0.9, p < 0.0001). All patients reported a high level of satisfaction after surgery (excellent or good result). Eleven (47.8%) patients developed rhinophyma recurrence. Conclusion: Shave excision under tumescent anaesthesia is an effective treatment for rhinophyma. The treatment is associated with high patient satisfaction and minimal side effects. A possible recurrence of rhinophyma must be addressed, however, while obtaining informed consent.

Deeply infiltrating endometriosis of the rectum: shave, disc or segmental excision?

Dear Editor, The article by Ruffo et al. [1] describes a single-center series of 750 segmental resections of the mid or low rectum for deeply infiltrating endometriosis. Although the authors’ relatively low complication rate is impressive, we are concerned about the large number of low or very low anastomoses being performed in otherwise well and young (median age, 33 years) women without accompanying report of bowel function. Anterior resection syndrome is well documented, particularly after low rectal anastomoses, the management of which can be difficult [2–4]. Considering that endometriosis surgery is in many ways a quality-of-life operation to alleviate symptoms, we are interested in the authors’ comments. In our experience as well as that of others, most rectal endometriosis can be managed with shave or disc excisions without recourse to segmental resection [5, 6]. Although Ruffo et al. describe pathological confirmation of endometriosis, it will be important to determine the extent of disease on pathology. In our opinion, segmental resection should be reserved for patients with multicentric involvement or where a less invasive procedure is deemed inadequate. The authors did not make any comments on discs or shave excisions; if all patients were managed with segmental resection, then we consider this approach overly aggressive. We recently published our experience with rectal endometriosis and reported that the majority of patients (71 %) can be spared the morbidity of segmental resection by undergoing a disc excision of the anterior rectal wall because most will have focal rectal wall involvement [5]. This avoids the morbidity of full rectal mobilization, which risks rectal denervation and preserves the native rectal reservoir, which in turn reduces the likelihood of bowel dysfunction. Routine mobilization of the splenic flexure, as highlighted by Ruffo et al., necessarily implies a generous segmental resection. We are concerned about the appropriateness of this aggressive approach. We do not contest the safety and feasibility of laparoscopic management of rectal endometriosis, and recent publications testify that rectal resection can indeed be performed with low complication rates. Other than cyclical bleeding in 20 % and a preoperative median dyschezia score of 6.7, it was difficult to grasp the severity of patients’ symptoms in the series of Ruffo et al. to justify such aggressive surgical management. One could argue that even a 3 % anastomotic leak rate, 2 % rectovaginal fistula rate, 0.7 % risk of ureteric injury, and 14.5 % temporary ileostomy rate is excessive if the rectal resection was unwarranted in the first place. As we discuss in our recent article, the literature seems divergent in that there seems to be a lack of consensus as to whether bowel resection is warranted [6]. In the absence of definitive evidence to support one approach or the other, and in an era of patient-centered care, we urge all authors to move away from only reporting on short-term surgical outcomes and instead focus on functional outcomes with regard to symptom control, fertility, and bowel function outcomes. C. E. Koh (&) M. J. Solomon Surgical Outcomes Research Center, Royal Prince Alfred Hospital, Camperdown, NSW, Australia e-mail: cherry_koh@hotmail.com

Simultaneous papillary fibroelastomas of the pulmonary and aortic valves

Cardiac papillary fibroelastomas (PFEs) are uncommon valve tumors. Multiple PFEs at the same or different locations in the heart account for less than 10% of patients with PFE. We herein describe a case of an asymptomatic PFE of both pulmonary and aortic valves which was incidentally diagnosed by echocardiography in a 60-year-old woman. Both PFEs were removed surgically without valve replacement. To our knowledge, this combination of lesions has not been previously reported. Even though PFEs are classified as benign cardiac tumors, they can present serious complications, such as embolic episodes, mechanical obstruction or valvular dysfunction. Valve-sparing shave excision of the lesions can be readily accomplished in most instances with good long-term results. All surgically removed valvular lesions should be histopathologically examined to confirm the echocardiographic diagnosis.

Successful Treatment of Multiple Cutaneous Neurofibromas Using a Combination of Shave Excision and Laser Photothermocoagulation with a 1,444-nm Neodymium-Doped Yttrium Aluminum Garnet Laser

Successful Treatment of Multiple Cutaneous Neurofibromas Using a Combination of Shave Excision and Laser Photothermocoagulation with a 1,444-nm Neodymium-Doped Yttrium Aluminum Garnet Laser

Role of tracheal resection in thyroid cancer

To provide a critical review of recent literature on the role of tracheal resection in thyroid cancer. The current body of literature is centered on the controversy regarding how radical the extent of tracheal resection needs to be to achieve long-term control of thyroid carcinoma with tracheal invasion. Proponents of shave excision are guided by the reported survival outcomes comparable to segmental resections in a selected group of patients. Others believe that all patients should have a segmental sleeve resection to ensure clearance of transmural disease. Recent advances in microsurgical reconstruction may allow selected patients to undergo tracheal resection when a large tracheal defect is anticipated. Tracheal invasion by well differentiated carcinoma is a marker of a more aggressive tumor behavior, defining a subpopulation of patients at a greater risk of recurrence and death. The goal of surgical intervention in this scenario is complete resection with no gross residual disease. A well designed prospective multi-institutional trial, taking into account depth of invasion, risk group stratification, histology, presence of distant metastasis, radioactive iodine trapping ability, adjuvant treatment, and long-term survival data, is needed to compare the outcomes following more conservative shave excision and segmental tracheal resection.

Topical 0.1% rapamycin for angiofibromas in paediatric patients with tuberous sclerosis: A pilot study of four patients

Tuberous sclerosis complex (TSC) is an autosomal dominant genodermatosis characterised by the development of hamartomatous tumours in multiple organs including the brain, skin, kidneys, heart and lungs. Facial angiofibromas are the most visible and unsightly of the cutaneous manifestations of TSC, often resulting in stigmatisation for both the affected individuals and their families. Current treatments include vascular laser, ablative lasers and other destructive techniques such as shave excision and electrodessication. For the best outcome these treatments have to be repeated throughout childhood and teenage years, necessitating multiple general anaesthetics. We report a pilot study of topical rapamycin in four children with TSC and facial angiofibromas. Two patients were trialled on 0.1% rapamycin in petrolatum and the other two patients with 0.1% rapamycin solution (Rapamune) applied topically. Both preparations were rapidly and equally effective, however the 0.1% in petrolatum was much better tolerated. Younger patients with smaller angiofibromas had the best response with near complete clearance. Both preparations were more cost effective than pulsed dye laser under general anaesthesia. Although larger studies are needed, this treatment shows a potential to be a first-line management for facial angiofibromas in TSC and appears safe to start in early childhood.

Optimizing the shave excision technique to aid accurate histological diagnosis

Optimizing the shave excision technique to aid accurate histological diagnosis

Dermoscopy improves diagnosis of tinea nigra: A study of 50 cases

Tinea nigra is a relatively uncommon dematiaceous fungal infection of the palms and soles, which clinically may mimic a melanocytic lesion. We sought to ascertain how frequently misdiagnosis of this infection occurred and whether the use of dermoscopy helped in its diagnosis. Fifty consecutive cases of tinea nigra diagnosed at a dermatopathology laboratory were examined with regard to the clinical diagnosis, use of dermoscopy and the mode of management. Of the 50 cases, 21 (42.0%) were treated by shave or surgical excision. The clinical diagnosis of tinea nigra was made in five cases (10.0%) and suggested along with other diagnoses in a further two cases (4.0%). The dermatologists (n = 9) gave the correct diagnosis in four patients (44.4%), the general practitioners (n = 38) gave the correct diagnosis in one patient (2.6%) and the three surgeons involved did not give the correct diagnosis. When dermoscopy was used, in seven of 13 (53.8%) cases tinea nigra was suggested as a probable diagnosis but when dermoscopy was not used (n = 37) tinea nigra was not clinically diagnosed (P < 0.001). The diagnosis of tinea nigra is significantly improved by dermoscopy, the disease should be considered as a cause of palmar or plantar pigmentation.

Sebaceous hyperplasia

Sebaceous hyperplasia is a benign proliferation of sebaceous glands. These benign lesions can be found throughout the integument, but have a greater tendency to occur on the face, upper neck and chest. The use of dermatoscopy helps in the differentiation of these lesions from other disorders, such as molluscum contagiosum, sebaceous adenoma, sebaceous carcinoma and, most importantly, basal cell carcinoma. Multiple pathophysical pathways may play a role in the evolution of sebaceous hyperplasia. Better understanding of the multiple signaling molecules and hormonal changes may lead to less painful and more permanent treatment of these benign lesions that may be troubling to those affected. Current treatment includes shave excision, isotretinoin therapy, bichloroacetic acid, cryotherapy, carbon dioxide laser ablation, electrodessication, erbium or yttrium aluminum garnet laser ablation and pulsed-dye laser photothermolysis.

Ear Keloids as a Primary Candidate for the Application of Mitomycin C after Shave Excision: In Vivo and In Vitro Study

Although many methods have been developed to treat ear keloids, new therapeutic options are still needed. To determine the effects of topical mitomycin C (MC) on shave-removed wounds and fibroblasts of ear keloids. Fourteen ear keloids in 12 patients were shaved, and MC (1 mg/mL) was applied to the resected bed for 5 minutes. The application was repeated 3 weeks later. All patients were assessed 2, 4, and 6 months after the procedure to evaluate the cosmetic results, recurrence, and postsurgical complications. An in vitro study to determine the effects of MC on fibroblasts of the excised keloids was conducted using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, the measurement of total cell counts, and immunoassay of DNA synthesis. Only one recurrence occurred (on the ear helix), and the patients were satisfied with the cosmetic outcomes. The results of the MTT assay, total cell counts, and DNA synthesis immunoassay confirmed the suppressive effects of MC on the keloid fibroblasts. The application of topical MC to the resected bed of shave-removed ear keloids was successful in preventing recurrences and providing an acceptable cosmetic outcome.

Atypical, incapacitating nodules in a woman with paraplegia: Treatment with shave excision

Atypical, incapacitating nodules in a woman with paraplegia: Treatment with shave excision

Cryosurgery後およびshave excision後に生じた再発腫瘍の病理組織像の比較－母斑細胞母斑および日光角化症－

Cryosurgery後およびshave excision後に生じた再発腫瘍の病理組織像の比較－母斑細胞母斑および日光角化症－

Extensive verrucous seborrheic keratosis mimicking deep mycoses

Sir, A 55-year-old male farmer presented with asymptomatic, slowly progressive cauliflower-like growths initially appearing on back with subsequent involvement of other parts of body of 20 years duration. There was no preceding history of trauma, bleeding/discharge from lesions or any systemic complaints. Physical examination revealed multiple skin colored and hyperpigmented soft non tender verrucous plaques and nodules of varying sizes, asymmetrically distributed over limbs and trunk predominantly, with little involvement of palms, soles and scalp [Figures 1–3]. Hair, nails and mucous membranes were normal.Figure 1: Verrucous plaques over trunk and limbsFigure 2: Verrucous plaques asymmetrically distributed over limbsFigure 3: Close up of a lesion over handRoutine hematological investigations, liver, renal functions and chest X-ray were normal. Serology for HIV was negative. Repeated biopsies from lesions over back showed hyperkeratosis, acanthosis and papillomatosis with good number of horn cysts in epidermis. Dermis showed capillary proliferation and mild lymphocytic infiltrates [Figure 4]. There was no evidence of malignancy, and staining for Acid fast bacilli and Periodic acid schiff was negative. Features were suggestive of acanthotic seborrheic keratosis.Figure 4: Histopathology showing hyperkeratosis, acanthosis and papillomatosis with horn cysts in epidermis (H and E, ×40)Seborrheic keratosis is a common benign epithelial tumor of unknown etiology, which can arise anywhere on the skin but with the exception of palms and soles. The mucus membranes are also generally spared. Lesions may be solitary, but more often they are disseminated in large numbers, especially in older patients.[1] Extensive truncal seborrheic keratosis in association of lepromatous leprosy has been documented.[2] Atypical presentations mimicking other dermatological disorders have also been observed. Giant perianal seborrheic keratosis mimicking Condylomata acuminata and pigmented seborrheic keratoses of the vulva clinically mimicking a malignant melanoma have been reported.[34] A case of seborrheic keratosis following Blaschko's lines has been published.[5] A giant lesion of seborrheic keratosis on perineal and scrotal areas in a mentally disabled young man complicated by myiasis has been reported recently.[6] Seborrheic keratoses may be removed to exclude the presence of malignancy (if clinical findings are equivocal), to treat inflammation caused by irritation, or most commonly cosmetic reasons. The treatment of choice is removal of the lesion using one of various operative procedures currently available viz shave excision, crurettage, electrodessication, cryotherapy and ablative lasers. Despite some reports on topical (vitamin D analogs, tazarotene) and systemic (vitamin D analogs) drug therapy in seborrheic keratoses, such approaches have generally proven to be unsuccessful. Patients with a large number of seborrheic keratoses, sometimes well over 100, present a particular challenge, if the patient wishes to have them removed given the limitations on performing multiple surgeries.[1] Treatment option of surgical excision in multiple sittings was declined by the patient. Involvement of palms and soles and extensive verrucous seborrheic keratosis mimicking deep mycoses hitherto unreported were interesting observations in this therapeutically challenging case.