Facial flaps

690 Correspondence was slight induration palpable within the livedo pattern. A skin biopsy specimen demonstrated metastatic breast carcinoma with prominent lymphatic involvement. Previous studies have shown that not all patients with clinical signs of inflammation of the breast will have lymphatic involvement.' The reverse is also true in that not all patients with tumor cells in dermal lymphatics will have cellulitis-like changes.? The presence of tumor emboli in dermal lymphatics is important to recognize because it portends a poor prognosis. Because of this, some authors have suggested that the term inflammatory carcinoma be reserved to designate this type of histologic feature rather than the clinical characteristics of warmth, erythema, and tenderness. 1.2 The term dermal lymphatic carcinomatosis of the breast has also been proposed. Intravascular obstruction is a wen-known cause of livedo reticularis. Thrombotic conditions such as the anticardiolipin antibody syndrome and embolic conditions such as cholesterol emboli may present with this pattern. Metastatic spread of carcinoma with infiltration of dermal lymphatics should also be considered in the differential diagnosis of livedo reticularis.

Elizabeth M. SpiersiMl) Steven S. Fakharzadeh, MD, PhD Department of Dermatology University ofPennsylvania School of Medicine Philadelphia, Pennsylvania REFERENCES 1. Ellis DL, TeitelbaumSL. Inflammatory carcinoma of the breast: a pathologic definition. Cancer 1974;33:1045-7. 2. SaltzsteinSL. Clinically occult inflammatorycarcinoma of the breast. Cancer 1974;34:382-8.

Journal of the American Academy of Dermatology October 1994

reconstructing them separately is an excellent concept well known for nasal and other facial defects" and "this philosophy should extend to the lip." Therefore those interested in the original concepts and applications of serial subunit lip repairs are referred t0 2 and not to another of my papers (on vermilionectomy design)," which was incorrectly listed in their article as the proper source. Also important, however, is the fact that the description of the sequence of subunit repair is reversed in the article by Summers and Siegle. The "cutaneous portion of the lip defect" should be closed initially and the mucosal defect then closed separately and subsequently. The difference in sequence is critical because the cutaneous lower lip acts as a much more stable structure toward which, or onto which, the lip mucosa can then be moved or attached.

Lawrence M. Field, M D 700 Promontory Point Lane, Suite 1103 Foster City, CA 94404 REFERENCES 1. Field L. A new approach to reconstructingvermillion and sub-vermilion defects. Abstracts, Xth International Congress of Dermatologic Surgery, Brussels, Belgium, October 1989. 2. Field L. Sequential infravermilion and supravermilion lip reconstruction. J Dermatol Surg OncoI1992;18:209-14. 3. DzubowL. Liprepair. J DermatolSurgOnc011992;18:171. 4. Field L. An improved design for vermilionectomy with a mucous-membrane advancement flap. DermatolSurg Oncol 1991;17:833-4.

Abdominal sonogram may prevent complications from liver biopsy Facial flaps To the Editor: I am honored to be referenced in Summers and Siegle's extensive continuing medical education treatise on facial flaps (J AM ACAD DERMATOL 1993;29:91741) and bring special focus to their section on the lower lip. A reference given on my work is incorrect, and I believe that the specific work not properly referenced to be of sufficient import to your readership to correct the error. Having spent almost a quarter century evolving a new concept of serial cosmetic subunit lip repairs, 1,2 I am delighted to read that the authors have also adopted that approach. By doing so, they may avoid the "significant associated morbidity, including some degree of microstomia" associated with the "often extensive removal of uninvolved tissue" seen in traditional V-wedge type excisions. Editorial comment on the appropriateness of this new subunit method of lip repair was expressed by DZUOoW,3 stating "dividing a wound into subunits and

To the Editor.' Weare conducting a study correlating the results of abdominal ultrasound examination with the findings from needle biopsy of the liver in patients treated with methotrexate for psoriasis or cutaneous T-cell lymphoma. To date 47 patients have received both procedures. In two such patients previous sonograms helped prevent potential major complications from liver biopsy. A 76-year-old man with extensive treatment-resistant mycosis fungoides was scheduled for liver biopsy. However, a previous abdominal sonogram revealed bowel interposed between the liver and the abdominal wall. Because of the risk of bowel perforation liver biopsy was not performed. A 47-year-old man receiving methotrexate therapy for extensive mycosis fungoides was scheduled for liver biopsy. Abdominal sonogram revealed a diffusely echogenic liver consistent with fatty infiltration, and two hypoechoic regions in the right lobe of the liver measur-