Skin Graft Reconstruction Research Articles

P-03-047 Skin graft reconstruction for a buried penis after a necrotizing infection

P-03-047 Skin graft reconstruction for a buried penis after a necrotizing infection

Scalp surface skin grafts in reconstruction of external auditory meatus in congenital aural atresia

To investigate the clinical application of scalp skin grafts in reconstruction of external auditory meatus in congenital aural atresia. We conducted a retrospective study on 85 patients of congenital aural atresia, all of whom were unilateral, operated from March of 2008 to December of 2010 in ENT department of the Sun Yat-Sen Memorial Hospital. The patients enrolled in the study were between 6 to 37 years old (median age 12 years), 55 male and 30 female. Scalp surface graft in ipsilateral temporal region was harvested to cover the bony external auditory meatus. All of these scalp split-thickness skin grafts survived without necrosis, no restenosis was found in these external auditory meatus. Neither scar nor alopecia was found in the skin-harvesting region, and hairs grew well. Granulations occurred in 27 cases in the first to sixth month posteroperatively, 20 cases recovered after local treatment. In the first year, 30 cases obtained hearing improvement more than 15 dB, 36 cases gained more than 25 dB and 19 cases gained more than 35 dB. Totally 8 patients were lost in the 4 to 5 years of follow-up, 70 cases (70/77, 90.9%) developed new external auditory meatus, 7 cases (7/77, 9.1%) suffered from stenosis in different degrees, but no atresia was found in these patients. Scalp split-thickness skin grafts has significant clinical advantage in meatoplasty of congenital aural atresia.

Gender does not affect the prognosis of Fournier's gangrene: a case-matched study.

Female gender is accepted as a poor prognostic factor for Fournier's gangrene (FG). However, there is a paucity of data in the literature regarding this matter. This case-matched study was designed to investigate the impact of gender on outcomes of FG. Study patient data were retrieved from 120-patient, prospectively maintained database. Thirty-two female patients with FG were case-matched to 32 male patients based on symptom duration (days), FG severity index score, patient age, etiology, and presence of diabetes mellitus (DM) terms. Outcomes of FG were compared between the 2 groups. Median age was 57 years (range: 22-80 years), and 35 (54.7%) patients had DM. Patients underwent average of 3 debridement procedures (range: 1-9 debridements), and 15 (23.4%) received diverting stoma. Overall mortality rate was 28.1% (18 of 64 patients). Female gender was associated with widespread disease (p=0.009), increased need for consecutive debridements (p=0.005), prolonged length of intensive care unit stay (p=0.035), and increased requirement for split-thickness skin graft reconstruction (p=0.040). However, mortality rates were comparable between genders (p=0.264). FG is often more extensive in females and seems to be associated with anatomical features of female pelvis. However, female gender is not a factor affecting prognosis of patients with FG.

Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft

ABSTRACTPurpose: To review and present the results of a one-step method employing a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft for reconstruction of large upper eyelid defects after tumour surgery.Methods: This was a retrospective case-series of 8 patients who underwent reconstruction of the upper eyelid after tumour removal. The horizontal defect involved 50–75% of the lid (3 pts.), more than 75% (3 pts.), and more than 75% plus the lateral canthus (2 pts.). The posterior lamella was reconstructed with contralateral upper eyelid tarsal plate. The anterior lamella was reconstructed with a laterally based myocutaneous pedicle flap in 7 patients, leaving a raw surface under the brow which was covered with a free skin graft. In 1 patient with little skin left under the brow, the anterior lamella was reconstructed with a bi-pedicle orbicularis muscle flap together with a free skin graft.Results: All patients healed without necrosis, did not suffer from lagophthalmos, achieved reasonable cosmesis, and did not need lubricants. In one patient, a contact lens was necessary for three weeks because of corneal erosion. One patient still needs a contact lens 3 months after excision to avoid eye discomfort.Conclusion: Large upper eyelid defects can be reconstructed with a free tarsal plate graft and a laterally based myocutaneous pedicle flap in combination with a free skin graft. Two-step procedures can probably be avoided in most cases.

Paediatric distal fibula reconstruction using a pedicled composite second metatarsal flap: A technical note

The case of a 4-year-old boy in whom a pedicled second metatarsal flap was used for lateral malleolar reconstruction after lawnmower injury is presented. Leg initial assessment demonstrated a 5cm bone loss at the distal fibula combined with severe soft tissue damage. Immediate healing was achieved with split-thickness skin graft but secondary reconstruction was necessary to obtain bone replacement with soft tissue coverage to allow bone growth and shoe donning. To avoid microsurgical fibular epiphyseal transplant morbidity and complications, we used a pedicled second metatarsal flap based on the dorsalis pedis vessels including the second metatarsal bone, the skin of the second toe and the brevis pedis muscle. Repair of the donor side was performed with direct suture and no post-operative course complication was noted. At seven-year follow-up, transferred bone had excellent growth and the patient had adequate ankle function and stable ride. The case provides technique descriptions, considerations in the paediatric population, an overview of other techniques and a seven-year follow-up. It suggests that vascularized chimeric second metatarsal flap may be a useful option in paediatric distal fibula reconstruction.

My Beautiful Hair

Abstract Introduction This is a problem-base-learning (PBL) teaching case intended for first-year medical school human gross anatomy during the course of anatomical dissection and discussion sessio...

Abdominal or forearm V-Y? Comparison of radial forearm free flap donor site following skin graft reconstruction - what do patients think?

Introduction: The radial forearm free flap remains the workhorse flap for oral and oropharyngeal reconstruction and has stood the test of time. Donor site morbidity can be a problem and multiple methods of wound closure have been described. The easiest and most reliable method is skin grafting. Two networks within our training regions use two different full thickness skin graft donor sites to close the free flap donor area. We set out to measure clinicians and patient's view of these methods.

Extramammary Paget's disease of the perianal region: a 20-year experience.

To evaluate the results obtained from cases of perianal Paget's disease (PPD) and to provide a current perspective in the diagnostic evaluation and surgical management of this condition. A retrospective review of a single quaternary referral centre's experience with PPD from January 1994 to December 2013 was performed. Medical records were reviewed to collect data on demographics, preoperative investigations, complications, pathology and recurrence. A review of existing literature was also performed. Five patients (four females, one male) with histologically confirmed PPD were identified. The median age of presentation was 72 (range 61 to 78). Three patients were recurrences following previous excisions and first presentations in two patients. Only one patient had an underlying diagnosis of cancer. The median time to diagnosis was 24 months. Four patients underwent wide local excision with skin graft and/or local flap reconstruction and one patient required an abdominoperineal excision for recurrence. Four patients had involved lateral margins despite wide local excision but follow-up to date has only revealed one local recurrence. A review of available literature suggests that synchronous cancers can occur in up to 33% of patients and that a further 10% may be associated with metachronous cancers. Surveillance recommendations seem anecdotal and do not appear to be supported by available literature. PPD is a management challenge. Association with synchronous and metachronous carcinomas may not be as strong as initially thought. Surgery is the mainstay treatment with the need to balance between minimizing disease recurrence and functional sequelae from excessive tissue loss.

Fat and epidermal cell suspension grafting: a new advanced one-step skin regeneration surgical technique

BackgroundDystrophic skin scarring commonly occurs following skin cancer resections. In particular, the cosmetic outcome of skin graft reconstructions, following epidermoidal carcinoma removal, is generally poor due to wide marginal tumour excision, loss of subcutaneous tissues, and subsequent pigmented atrophic scarring of the graft coverage. Skin grafting sequelae need a three dimensional correction to restore either the epidermal layer or the dermal/subdermal volume and vascularization.MethodsThe surgeons combined CO2 laser ablation, subdermal lipofilling according to the Coleman’s technique and epidermal cell suspension autografting to correct wide depressed and dyschromic facial scar. The Authors applied this new technique on three nasal skin cancer resected patients: two of them actually need a longer follow-up, the third patient, a 48 yr old caucasian male, presented a skin grafting scar due to sclerodermiform basal cell carcinoma removal. This case is reported discussing pre-intra and post-operative records up to a complete twelve months follow-up.ResultsRecords at six and twelve months follow-up after surgery demonstrate a fully integrated skin graft and a good restoration of the treated area, presenting the same texture and pigmentation of the adjacent untreated skin. Optimal, stable three-dimensional skin cosmetic restoration was obtained in a single stage surgical procedure.ConclusionAutologous non-cultured epidermal cell suspension transplantation on an epidermal laser ablated skin area, in combination with lipofilling subdermal reconstruction, appears to be an effective, simple and time-saving method to correct skin graft sequelae, in skin cancer patients. This new technique allows to restore a three-dimensional morphological structure of the treated area and to recover a natural appearance of the skin at the same time. The Authors believe that this technique can be safely used to treat any kind of dystrophic scarring.

The “collerette” technique for skin excision and biopsy: an efficient method for managing lentigo maligna of the head and neck

Melanoma is responsible for 75% of all skin cancer-related deaths. Lentigo maligna (LM), the most prevalent melanoma in situ (MIS), accounts for 79-83% of all MIS. Its location in the head and neck area requires that tissue be spared in the course of clearing the tumor. We conducted a therapeutic study based on our practice experience with the so-called "collarette" skin biopsy technique used in the management of LM. Thirty-one patients were diagnosed with LM in the head and neck area. These included 16 women and 15 men with a mean±standard deviation (SD) age of 64.4±13.6years (range: 33-88years). The majority (36%) of lesions were located on the cheek. To clear the tumor, surgery was performed using margins of >10mm in 71% of cases. The average surface area of the surgical defect was 5.8cm(2) (range: 1.1-15.5cm(2) ). Reconstructive skin grafts were performed in the majority (68%) of cases. After the removal of the central tumor, 16 cases of MIS and 15 cases of invasive melanoma were identified. Only one patient experienced recurrence over a mean±SD follow-up of 31±16months. The so-called "collarette" or "spaghetti" skin excision and biopsy technique is an advantageous and efficient way to achieve tumor clearance and represents an equally effective alternative to Mohs micrographic surgery in the treatment of LM in the head and neck area.

Artificial dermis (Matriderm®) followed by skin graft as an option in dermatofibrosarcoma protuberans with complete circumferential and peripheral deep margin assessment

Dermatofibrosarcoma protuberans (DFSP) is a locally invasive neoplasia with a pattern of infiltrative growth that leads to extended resections. To avoid unnecessary resections and spare tissues, its treatment requires an adequate assessment of the margins. We present a case where artificial dermis (Matriderm®) was used followed by skin graft for reconstruction. We present a 50-year-old woman with a DFSP in the occipital region. She was referred to us after a first surgery with positive margins. A wide local excision with a 2-cm margin was performed and periosteal tissue was also removed, which led to exposure of the skull. Matriderm was placed on the bone surface and dressings were changed every other day. Meanwhile, margins were evaluated by the complete circumferential and peripheral deep margin assessment (CCPDMA) and were positive for DFSP in the superior margin. After 4 weeks the area was completely covered by granulation tissue and a new resection followed by reconstruction with a skin graft was performed. With regard to the difficulties in the margin assessment in DFSP, we present artificial dermis (Matriderm) as an option for reconstructive surgery in these patients, especially when a skin graft cannot be performed as a first option.

The Use of Integra® Dermal Regeneration Template in the Reconstruction of Traumatic Degloving Injuries

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

Closure of Scalp and Forehead Defects Using External Tissue Expander

To describe the novel use of an external tissue expander in the reconstruction of scalp and forehead defects. A prospective review was performed on 7 patients who underwent extirpation of head and neck malignant neoplasms resulting in scalp and forehead defects. Reconstruction was performed using an external tissue expander device. Patient clinical factors, defect size, and photographs were collected. Seven patients had large scalp and forehead defects ranging in greatest dimension from 5.0 ×4.0 to 8.0 ×7.0 cm. The external tissue expander was in place for 6 to 14 days, reducing the defect sizes by 50% to 99%. At the time of device removal, primary closure was achieved in 5 patients. One patient required bilateral advancement rotation flaps, and 1 patient healed by second intention. One patient with a history of scalp irradiation and diabetes had partial skin loss after device removal and required reconstruction with a latissimus dorsi myocutaneous free flap. There were no other postoperative complications, wound breakdown, or device failures. External tissue expansion is a safe and effective technique for closing large scalp and forehead defects that would otherwise require skin grafting or free flap reconstruction.

The VAC-Basket for Easy Fixation of Scrotal Skin Grafts

The vacuum assisted closure (VAC, Kinetic Concepts, Inc., San Antonio, TX, USA) device has revolutionized wound management in recent years due to its ability of exudate clearance, tissue granulation induction and edema reduction [1]. It also has been shown very beneficial in aiding skin graft take in difficult anatomical regions [2]. Fournier's gangrene is characterized by perineal tissue necrosis caused by bacterial infection. Therapy usually consists of wide debridement together with appropriate antibiotic drug administration to reduce bacterial burden and control infection. After the initial debridement, the reconstructive surgeon faces large raw surface areas in the perineogenital region that have to be covered. This typically can be achieved by skin grafts or local flaps. Due to the three-dimensional character of this region, fixation of the skin graft may be difficult and hinders therefore optimal graft take. In such difficult cases, the VAC device has been utilized as the optimal initial wound dressing [3,4]. Here we want to present our modification for easy fixation and application of a skin graft in scrotal reconstruction after Fournier's gangrene. A 54-year-old patient was admitted to our Urology department for treatment of a massive soft tissue infection in the perineogenital region. After initial debridement and antibiotic therapy, the patient presented to our department with a global skin defect over the scrotum that was well granulated. The decision was made in favor of skin graft reconstruction. To enhance graft fixation, we constructed our VAC-basket out of a regular commercially available VAC-Granu Foam medium dressing kit (Figs. 1, ​,2).2). The unmeshed skin graft was harvested from the right lateral thigh region and was initially fixed with multiple interrupted 4-0 Polysorb (Covidien, Mansfield, MA, USA) sutures. Then, the wound edges were secured with double-sided adhesive hydrogel strips (VAC gel). Now, the VAC-basket was snugly fit over the skin-grafted scrotum und fixed with some skin staples. Finally, the dressing was completed with drapes and the SensaTRAC-pad. The dressing was left in place for 5 days and then completely removed. Skin graft take was excellent (Figs. 3-​-5).5). We were able to discharge the patient, who was instructed in further local wound care, after another 3 days from our unit. Fig. 1 Creation of the VAC-basket out of a regular VAC GranuFoam dressing. The Foam is first cut in the upper third in a horizontal plane and the lower two-thirds are brought together in the median just as small flaps and secured with simple skin staples. ... Fig. 2 The next step involves trimming of the upper flaps so that a triangular flap remains which allows for closure of the basket and forms the bottom of the VAC-basket. Fig. 3 The patient presented with a global skin defect over the scrotum after debridement from Fournier's gangrene. Defect coverage was achieved with an unmeshed split-thickness skin graft. Fig. 5 At two-weeks follow-up there was excellent graft take. We here describe a useful application and modification of the VAC-system for easy fixation of skin grafts in the scrotal region. The usefulness of the VAC system in the perineogenital region has been described in the past [3,4]. However, applying the VAC sponge to this often-difficult area is tedious. Our modification is novel in so far, that a basket is created out of a regular VAC sponge in order to hold the scrotum and its attached skin graft. The VAC-basket further expands the clinical utilization of the very useful VAC-therapy.

Surgical Treatment of Nonmalignant Tracheoesophageal Fistula: A Thirty-Five Year Experience

Acquired nonmalignant tracheoesophageal fistula in the adult patient develops in a variety of conditions. We have applied surgical closure with success for 35 years. From 1975 to 1991, 38 patients underwent surgical repair of a tracheoesophageal fistula. A retrospective study of 36 additional patients undergoing surgical repair from 1992 to 2010 was conducted. The most common causes were postintubation injury (n=17, 47%), trauma (n=6, 17%), prior laryngectomy (n=6, 17%), and prior esophagectomy (n=4, 11%). Four patients presented after failing fistula control with an endoluminal stent. The tracheal defect was closed with resection and reconstruction (n=17, 41%), laryngotracheal resection (n=5, 12%), membranous tracheal repair (n=17, 41%), or repair over a tracheal T tube (n=2, 5%), while esophageal repair consisted of 2-layer closure (n=31, 78%), 1-layer closure (n=6, 15%), esophagostomy (n=1, 3%), end-to-end esophageal anastomosis (n=1, 3%), or full thickness skin graft reconstruction (n=1, 3%). The esophageal and tracheal repairs were buttressed by interposing pedicled muscle or omental flaps in all patients. There was 1 postoperative death (3%). Recurrence after repair developed only in fistulas arising after esophagectomy or laryngectomy (n=4, 11%). Fistula closure was ultimately successful in 34 patients (94%). Twenty-nine patients (83%) resumed oral intake and 25 patients (71%) were breathing without a tracheal appliance. Successful closure of benign tracheoesophageal fistula is achieved with several surgical techniques based on buttressed repair and restoration of normal breathing and swallowing. Closure of complex postsurgical fistula may fail. Endoluminal stenting was not found useful.

Pleomorphic Hyalinising Angiectatic Tumour: A Tumour Diagnosis of Suspicion

A 62 year old male was referred to our service complaining of a 5 year history of a painful, erythematous swelling on the proximal third of his right tibia. A previous MRI scan displayed appearances suggested to be consistent with fat necrosis, erythema nodosum or pretibial myxoedema. On examination there was an ill-defined, soft, subcutaneous mass on the right anterior leg measuring approximately 30mm x 40mm in diameter. The overlying skin was warm to palpation and mildly tender but with no epidermal changes. There were no associated neurovascular signs or lymphadenopathy. An incisional biopsy revealed histological features highly suggestive of Pleomorphic Hyalinizing Angiectatic Tumour (P.H.A.T). Wide local excision of 3cm margin (90 x 85mm) was subsequently performed with split skin graft reconstruction. The patient remains recurrence-free at 1 year post surgery. Pleomorphic Hyalinizing Angiectatic Tumour is an unusual, highly vascular soft tissue tumour, usually occurring in the subcutis of the lower extremity. Differential diagnoses include neurilemoma and malignant fibrous histiocytoma and, as illustrated by this case report, erythema nodosum or even pretibial myxoedoema. Clinical suspicion of PHAT should initiate MRI scan and incision biopsy. Current literature suggests that, due to a 20-33% rate of local recurrence, P.H.A.T should be treated by wide local excision by a 3cm margin and is to include deep fascia, down to periosteum. It should be reviewed regularly as reports of multiple recurrences 25 years after excision suggest that life-long review may be prudent. J Med Cases. 2012;3(6):334-336 doi: https://doi.org/10.4021/jmc573w

Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy

Salvage total pharyngolaryngectomy after failed organ-preserving therapy often results in composite defects involving the alimentary tract, trachea, and neck skin. This retrospective study examined combined use of the free jejunum flap and the pectoralis major muscle flap with skin graft for such a complex reconstruction. We reviewed 11 patients who underwent free jejunum transfer for alimentary reconstruction and pedicled pectoralis major muscle flap transfer with a skin graft on the muscle for simultaneous neck skin resurfacing after salvage total pharyngolaryngectomy from 2005 through 2010. The operative morbidity rate was 27.3%. No pharyngocutaneous fistula developed in this series. Oral intake could be resumed within 3 weeks after surgery in all patients. Seven of 11 patients had a functional tracheostoma with adequate stomal patency. Combined use of free jejunum and pectoralis major muscle flap with skin graft provided secure wound closure even for complicated cases.

Giant Proliferating Pilar Tumor of the Scalp: A Minimal Risk Approach

A 61-year-old man presented with a large scalp mass of more than 30 years duration. He reported recent rapid growth, leading him to seek medical attention. On examination the lesion was approximately 20 cm in diameter with a wide base and a bulky protuberant appearance; the patient described himself as having a horned or “Viking helmet” appearance. CT imaging showed no abnormality of the underlying calvarium but was suggestive of extension of tumor through the galea in some areas. Biopsy was suspicious for proliferating pilar cell tumor. Given this rare but benign neoplasm diagnosis, the size of the disfiguring tumor, and the patient's comorbid status (anticoagulation for cardiac disease), we decided to resect the mass with limited margins to rule out malignancy definitively and treat the bulky lesion. Raney clips proved instrumental to maintaining hemostasis during the resection in this anticoagulation-requiring patient. The periosteum was preserved except for a few small areas where the tumor appeared to be very close to it. Because we needed to finalize the tumor type and assess margin status, we opted to avoid committing to a definitive flap or skin graft reconstruction and reconstructed the large scalp wound with an INTEGRA dermal regeneration template (Plainsboro, NJ) as a temporizing measure. Ultimately, all margins were negative, the diagnosis confirmed to be benign, and the patient was counseled regarding definitive reconstruction. In the short interim between the resection and his postoperative visit, remarkable wound healing had occurred and the decision was made to observe the wound without further reconstruction. Indeed, the patient opted to forgo additional reconstructive procedures as he was pleased with his result and did not want to miss further time at work.

The Use of Bovine Collagen and Skin Graft for Reconstruction of the Glans Penis Following Cancer Resection

Penile reconstruction following cancer resection has long been a challenge due to demand for both aesthetic and functional preservation. Although various methods have attempted to achieve both goals, none have succeeded entirely. In this report, we introduce a novel reconstructive technique on a 64-year-old patient with squamous cell carcinoma of the glans penis. The technique consisted of two staged procedures. First, a dermal substitute, consisting of bovine collagen, was sutured onto the defect after partial glansectomy and three weeks later, the integrated dermis was covered with autologous non-meshed partial thickness skin graft. Use of this dermal substitute in a staged fashion allowed for ability to await final pathologic margins prior to definitive reconstruction and increased dermal thickness. After 9-month follow-up, sexual function returned within 3 months and the patient remained healed. We found this technique to be useful in concurrently preserving penile function and cosmesis. Future studies should include more patients and longer follow-up.

Pleomorphic Hyalinising Angiectatic Tumour: A Tumour Diagnosis of Suspicion

A 62 year old male was referred to our service complaining of a 5 year history of a painful, erythematous swelling on the proximal third of his right tibia. A previous MRI scan displayed appearances suggested to be consistent with fat necrosis, erythema nodosum or pretibial myxoedema. On examination there was an ill-defined, soft, subcutaneous mass on the right anterior leg measuring approximately 30mm x 40mm in diameter. The overlying skin was warm to palpation and mildly tender but with no epidermal changes. There were no associated neurovascular signs or lymphadenopathy. An incisional biopsy revealed histological features highly suggestive of Pleomorphic Hyalinizing Angiectatic Tumour (P.H.A.T). Wide local excision of 3cm margin (90 x 85mm) was subsequently performed with split skin graft reconstruction. The patient remains recurrence-free at 1 year post surgery. Pleomorphic Hyalinizing Angiectatic Tumour is an unusual, highly vascular soft tissue tumour, usually occurring in the subcutis of the lower extremity. Differential diagnoses include neurilemoma and malignant fibrous histiocytoma and, as illustrated by this case report, erythema nodosum or even pretibial myxoedoema. Clinical suspicion of PHAT should initiate MRI scan and incision biopsy. Current literature suggests that, due to a 20-33% rate of local recurrence, P.H.A.T should be treated by wide local excision by a 3cm margin and is to include deep fascia, down to periosteum. It should be reviewed regularly as reports of multiple recurrences 25 years after excision suggest that life-long review may be prudent. J Med Cases. 2012;3(6):334-336 doi: https://doi.org/10.4021/jmc573w