Gold Standard for Skin Cancer Treatment: Surgery (Mohs) or Microscopic Molecular-Cellular Therapy (Curaderm)?

Non-melanoma skin cancers or keratinocyte cancers such as basal cell carcinoma and squamous cell carcinoma make up approximately 80% and 20% respectively, of skin cancers with the 6 million people that are treated annually in the United States. 1 in 5 Americans and 2 in 3 Australians develop skin cancer by the age of 70 years and in Australia it is the most expensive, amassing $1.5 billion, to treat cancers. Non-melanoma skin cancers are often self-detected and are usually removed by various means in doctors’ surgeries. Mohs micrographic surgery is acclaimed to be the gold standard for the treatment of skin cancer. However, a novel microscopic molecular-cellular non-invasive topical therapy described in this article, challenges the status of Mohs procedure for being the acclaimed gold standard.

Topical Curaderm^BEC5Therapy for Periocular Nonmela-noma Skin Cancers: A Review of Clinical Outcomes

Approximately 5 to 10 percent of all skin cancers occur in the periocular region. Basal cell carcinoma is the most frequent malignant periocular tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma, and malignant melanoma. Nonmelanoma skin tumors at the periocular area often cause disfigurement with destruction of soft conjunctival tissue. Many therapeutic methods have been recommended to combat the morbidity and mortality associated with these lesions. Excisions with frozen-section control or Mohs micrographic surgery are regarded as the gold-standard treatments for periocular basal cell and squamous cell carcinomas. However, these treatment modalities have various limitations and reconstruction surgery is often associated with these treatment options. The chemotherapeutic agents solasodine rhamnosides in a cream formulation CuradermBEC5 are specific, effective and safe treatments for nonmelanoma skin cancers with excellent cosmesis. The antineoplastic mode of action is by apoptosis. In this review it is shown that CuradermBEC5 also treats periocular basal cell carcinoma and squamous cell carcinoma with impressive cosmetic outcomes and no reconstructive surgery is required.

Evaluation of an <i>in Situ</i>Polymerizing Hydrogel Applied in Tumor Excision Cavities during Breast Conservation Surgery

Study Objective: To evaluate the imaging characteristics and healing following application of an absorbable biocompatible hydrogel into the excision cavity following breast conservation surgery. Design: Non-randomized study evaluating hydrogel application feasibility, post-operative hydrogel imaging characteristics, cavity healing following hydrogel absorption and the resulting breast cosmesis. Setting: Teaching hospital University of Essen, Germany. Patients: Seven (7) patients underwent unilateral or bilateral breast conservation surgery to remove cancerous or benign tumors. Interventions: All patients received hydrogel application following primary tumor excision. Imaging performed in the first postoperative week included ultrasound, MRI and CT. Breast cosmesis scores were obtained at one and three months following surgery. Measurements and Main Results: While preliminary, a relationship between percent cavity filling and drainage was observed, with 30% or more cavity filling resulting in decreased drainage. Additionally, the hydrogel was readily visible under ultrasound, MRI and CT imaging modalities. Finally, patients were satisfied and surgeons felt that patient cosmesis was improved relative to their prior experience. Conclusion: Initial data suggest that hydrogel filling may reduce excision cavity drainage, which may reduce seroma or hematoma formation. Additionally, these gels may improve cavity visibility and stability, furthering the use of partial breast irradiation. Finally, while more studies are required, these materials may have a role in improving long term patient cosmesis.

Randomized clinical trial comparing skin closure with tissue adhesives vs subcuticular suture after robotic urogynecologic procedures

BACKGROUND Skin closure techniques during minimally-invasive gynecologic surgery is largely based on surgeon preference.The optimum technique would theoretically be safe,rapid,inexpensive,and result in good cosmetic appearance.Cyanoacrylate tissue adhesive(Dermabond)may be a comparable and safe option for port site closure as compared with subcuticular suture.In this randomized clinical trial,we hypothesized that operative time for skin closure would be less than subcuticular suture during robotic urogynecologic procedures.AIM To compare skin closure during robotic urogynecologic surgeries for tissue adhesives and subcuticular suture.METHODS Fifty female subjects>18 years of age undergoing robotic urogynecologic procedures were randomized to have port site closure with either cyanoacrylate tissue adhesive(n=25)or subcuticular suture(n=25).All procedures and postoperative evaluations were performed by the same board certified Female Pelvic Medicine and Reconstructive Surgeon.Incisional closure time was recorded.Each subject was followed for 12-wk postoperatively.Incision cosmesis was evaluated using the Stony Brook Scar Evaluation Scale.RESULTS A total of 47 subjects(cyanoacrylate group,n=23;suture group,n=24)completed the 12-wk postoperative evaluation.Closure time was significantly less(P<0.0005)using cyanoacrylate tissue adhesive(5.4±2.0 min)than subcuticular suture(24.9±5.6 min).Cosmesis scores were significantly higher in the cyanoacrylate tissue adhesive group than subcuticular suture(P=0.025).No differences were found between bleeding,infection,or dehiscence(P=1.00,P=0.609,P=0.234,respectively).No statistical demographical differences existed between the two study arms.CONCLUSION Our study supported our original hypothesis that cyanoacrylate tissue adhesive for port site closure during robotic urogynecolgic procedures uses less time than with subcuticular suture.Our study also supports that tissue adhesive is comparable to cosmetic outcome while not jeopardizing rates of bleeding,infection,or dehiscence.

Reduced port surgery for appendectomy:Early experience and surgical technique

AIM: To evaluate our experience and surgical technique of laparoscopic appendectomy via reduced port surgery(LARPS). METHODS: Sixteen patients(8 men and 8 women; median age: 31.0 years) who underwent LARPS between November 2009 and May 2012 were included in the present study. We performed LARPS, in which access devices were inserted through an umbilical skin incision with 1 additional skin incision in the left lower abdomen. After setting access devices, pneumoperitoneum was maintained at 10 mmH g using CO2 and a 3 mm trocar was positioned(or direct puncture was performed by the Endo Relief system) under laparoscopic guidance. The mesoappendix was dissected using an ultrasonically activated device. After mesoappendix dissection, ligation was performed near the appendix base and the appendix was dissected using an ultrasonically activated device. The appendix was then removed. At the end of surgery, we administered local anesthesia with ropivacaine 1%(10 mL) for the skin incisions. The outcomes were evaluated in terms of operation time, intraoperative blood loss, length of postoperative hospital stay and surgical complications. RESULTS: Our surgical procedure allowed operators to use instruments as in conventional laparoscopic appendectomy. The basic principle of triangulation of instrumentation was maintained to some degree. LARPS was performed in 9 patients with catarrhal appendicitis, 5 with phlegmonous appendicitis, and 2 with gangrenous appendicitis. The median surgery time was 60 min and the median intraoperative blood loss was 1.2 mL. The median length of postoperative hospitalization was 4 d. There were no conversions to open surgery, no operation-related complications or mortality. CONCLUSION: Our experience and surgical technique suggest that LARPS is a safe and feasible procedure for patients with appendicitis.

Histological Findings of a Local Adipofascial Flap That Was Implanted during Breast Conserving Surgery

We report a patient with breast cancer whose breast was immediately reconstructed using a local adipofascial flap and was then subsequently resected 3 years after the original surgical procedure due to local recurrence. In order to achieve local control of the solitary recurrent lesion, we resected the remnant breast, which gave us a useful opportunity to examine the previously implanted flap histologically. A 33-year-old Japanese female was diagnosed with T2N0M0 breast cancer in the outer area of her left breast and underwent partial mastectomy with immediate reconstruction using a local adipofascial flap. The breast lesion was considered to be invasive ductal carcinoma, scirrhous carcinoma, lymphatic invasion+, venous invasion-, estrogen receptor+, progesterone receptor+, and HER2/neu-. Involvement was noted in three of the twenty-five resected axillary lymph nodes. She received adjuvant hormone therapy, but developed a solitary local recurrence of the skin forty-five months after the initial procedure, for which she received total mastectomy, systemic chemotherapy, and hormone therapy. During the histological examination of the local adipofascial flap that had been implanted into the partial breast defect, normal fatty tissue and the implanted fascia were seen at the implantation site. This is a rare report in which a local flap that was implanted during oncoplastic breast surgery was histologically examined.

Cosmetic outcome and surgical site infection rates of antibacterial absorbable （Polyglactin 910） suture compared to Chinese silk suture in breast cancer surgery： a randomized pilot research

Background The primary objective of this multicenter post-market study was to compare the cosmetic outcome of triclosan-coated VICRYL＊ Plus sutures with Chinese silk sutures for skin closure of modified radical mastectomy. A secondary objective was to assess the incidence of surgical site infection （SSI）.Methods Patients undergoing modified radical mastectomy were randomly assigned to coated VICRYL＊ Plus antibacterial （Polyglactin 910） suture or Chinese silk suture. Cosmetic outcomes were evaluated postoperatively at days 12 （±2） and 30 （±5）, and the evidence of SSI was assessed at days 3, 5, 7, 12 （±2）, 30 （±5）, and 90 （±7）. Cosmetic outcomes were independently assessed via visual analogue scale （VAS） score evaluations of blinded incision photographs （primary endpoint） and surgeon-assessed modified Hollander Scale （mHCS） scores （secondary endpoint）. SSI assessments used both CDC criteria and ASEPSIS scores.Results Six Chinese hospitals randomized 101 women undergoing modified radical mastectomy to closure with coated VICRYL＊ Plus suture （n=51） or Chinese silk suture （n=50）. Mean VAS cosmetic outcome scores for antibacterial suture （67.2） were better than for Chinese silk （45.4） at day 30 （P 〈0.0001））. Mean mHCS cosmetic outcome total scores, were also higher for antibacterial suture （5.7） than for Chinese silk （5.0） at day 30 （P=0.002）.Conclusions Patients using coated VICRYL＊ Plus suture had significantly better cosmetic outcomes than those with Chinese silk sutures. Patients using coated VICRYL＊ Plus suture had a lower SSI incidence compared to the Chinese silk sutures, although the difference did not reach statistical significance. （ClinicalTrials.gov NCT 00768222）

Cosmetic outcome of femtosecond laserassisted pterygium surgery

Background:To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery(FLAPS)with conjunctival autograft(CAG)and its potential predictive factors.Methods:This was a prospective interventional case series(NCT02866968).We included 29 patients(29 eyes)with primary pterygium who underwent FLAPS.Cosmetic outcome was graded by two graders(an ophthalmology resident and an experienced ophthalmologist)using Hirst classification system(1-4=excellent-poor).Weighted Cohen’s kappa analysis was performed to examine the intra-and inter-rater reliability.The relationship between cosmetic outcome and various factors were determined by Spearman’s correlation coefficients(r).Results:The preoperative severity of pterygium(Tan grading system)was mild/atrophic(7%),moderate/intermediate(62%),and severe/fleshy(31%).An ultrathin CAG(mean thickness of 74.5±9.8μm)was fashioned intraoperatively.An excellent cosmetic outcome of FLAPS(median±IQR)was observed at 3 months(1.0±1.0)and remained similar at 6months(1.0±0.0)and 12months(1.0±0.0)postoperatively.At final follow-up,27(93%)patients achieved good-to-excellent cosmetic outcome,with 1(3%)patient having a poor outcome due to incomplete pterygium removal.Weighted kappa analysis of Hirst grading system showed excellent intra-rater(κ=0.86-0.95)and inter-rater reliability(κ=0.84-0.88).There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness(r=0.38,P=0.06)but not with age,gender,preoperative pterygium severity,or intraoperative CAG thickness.Conclusions:FLAPS can result in an excellent cosmetic outcome,which may be attributed to the beneficial effect of an ultrathin CAG.

Subjective scar assessment scales in orthopaedic surgery and determinants of patient satisfaction: A systematic review of the literature

Purpose:Scar assessment tools can be utilized during the post-operative period to monitor scar progress.The primary aim of this systematic review was to evaluate current subjective scar assessment scales utilized in orthopaedic surgery.The secondary aim was to identify determinants of patients'satisfaction with their scars and evaluate current measurement scales.Methods:The preferred reporting items for systematic reviews and meta-analyses checklist was followed.Electronic databases,curently registered studies,conference proceedings and the reference lists of included studies were searched.There were no constraints based on language or publication status.A narrative synthesis provided a description and evaluation of scales utilized in orthopaedic surgery.Determinants of patient satisfaction were identified along with the scales used to measure satisfaction.Results:A total of 6059 records were screened in the initial search.Twenty-six articles satisfied the inclusion criteria,assessing 7130 patients.In the literature,six validated subjective scar scales were identified,including the Vancouver scar scale,patient and observer scar assessment scale,Manchester scar scale,Stony Brook scar evaluation scale,visual analogue scale,and Hollander wound evaluation scale.Studies utilizing these scales to evaluate scars following orthopaedic procedures did so successfully.These were total hip arthroplasty,total knee arthroplasty,and limb reconstruction.The scales demonstrated satisfactory validity.Functional outcomes such as restoration of movement ranked among patients'highest concerns.Scar cosmesis was found to be amongst patients'lowest priorities.Conclusions:Subjective scar assessment scales identified in the literature were not designed specifically for orthopaedic surgery.However,these were able to appropriately assess scars in the studies identified in this review.Current evidence suggests the effect of scar cosmesis on patient satisfaction with orthopaedic procedures is limited.

Comparison of cosmetic outcomes between remote-access and conventional thyroidectomy:A review of the current literature

Objective:The pursuit of an esthetically pleasing scar following open thyroid surgery has led to the development of endoscopic thyroidectomy through remote incisions placed in several locations outside the neck.The objective of this study is to review the recent literature and compare the incision site appearance and patient satisfaction with the cosmetic outcome after extracervical and conventional thyroidectomy.Methods:The English literature published since 2010 was searched through the PubMed/Medline database for studies comparing the cosmetic outcomes between remote-access endoscopic and conventional thyroidectomy using a form of scar assessment scale.Results:A total of 9 relevant papers fulfilled the eligibility criteria including 1486 patients.Among them,595 patients underwent endoscopic thyroidectomy through several remote-access approaches and 891 patients were assigned to the conventional group.Only one randomized-controlled trial was identified,whereas among the rest,four were prospective and four were retrospective nonrandomized cohorts.Regarding the extracervical modifications performed in the endoscopic groups,the axillary approach was performed in three studies and the breast approach in four studies,while the retroauricular facelift technique and the transoral vestibular method were applied in one study,respectively.Conclusions:Evaluation of the wound appearance and patient satisfaction with the cosmetic outcome at various time points during the follow-up highlighted the superiority of the extracervical approaches over the conventional cervicotomy.Considering these findings,remote-access techniques could possibly be the ideal surgical method for patients with high esthetic requirements,providing an excellent appearance of the thoroughly exposed neck.

Cosmetic outcome of femtosecond laserassisted pterygium surgery

Background:To examine the cosmetic outcome of femtosecond laser-assisted pterygium surgery(FLAPS)with conjunctival autograft(CAG)and its potential predictive factors.Methods:This Was a prospective interventional case series(NCT02866968).We included 29 patients(29 eyes)with primary pterygium who underwent FLAPS.Cosmetic outcome was graded by two graders(an ophthalmology resident and an experienced ophthalmologist)using Hirst classification system(1-4:excellent-poor).Weighted Cohen's kappa analysis was performed to examine the intra-and inter-rater reliability.The relationship between cosmetic outcome and various factors were determined by Spearman's correlation coefficients(r).Results:The preoperative severity of pterygium(Tan grading system)was mild/atrophic(7%),moderate/intermediate(62%),and severe/fleshy(31%).An ultrathin CAG(mean thickness of 74.5±9.8μm)was fashioned intraoperatively.An excellent cosmetic outcome of FLAPS(median±IQR)was observed at 3 months(1.0±1.0)and remained similar at 6 months(1.0±0.0)and 12 months(1.0±0.0)postoperatively.At final fllow-up,27(93%)patients achieved good-to-excellent cosmetic outcome,with 1(3%)patient having a poor outcome due to incomplete pterygium removal.Weighted kappa analysis of Hirst grading system showed excellent intra-rater(k:0.86-0.95)and inter-rater reliability(k:0.84-0.88).There was a weak and borderline significant correlation between good cosmetic outcome and reduced postoperative CAG thickness(r=0.38,P=0.06)but not with age,gender,preoperative pterygium severity,or intraoperative CAG thickness.Conclusions:FLAPS can result in an excellent cosmetic outcome,which may be attributed to the beneficial effect of an ultrathinCAG.Trial registration:ClinicalTrials.gov,NCT02866968.Registered in July 2016.