- Email: [email protected]
Comment Re: ‘Treatment of basal cell carcinoma with surgical excision and perilesional interferon-α’
Correspondence and communications 0 /flexion 45 , while no motion of the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joint was identified. Recently, on-top plasty in which the ulnar digit ray was transferred to the radial ray was applied for thumb polydactyly. The resulting radial digit was narrow and hypoplastic, but the ulnar digit presented a well-aligned and aesthetic nail and a dominant appearance, although the ulnar metacarpal bone was markedly hypoplastic.2,3 The present case involved central hand deficiencies. Normally, the strategy in such a case is to create a commissure across the cleft4 with excision of the floating finger. However, a floating finger has a neurovascular band in its pedicle,5 and here we identified and divided the band with tender care for preservation. The proximal phalanx of the long finger was moved from its original position bridging the heads of the third and fourth metacarpals and united with the floating finger to create a long finger. Care was taken to save the vein and the artery for perfusion throughout the procedure. Attention needs to be paid to the position of a reconstructed finger to avoid vessel compression or twisting. It is also important to ease the tension on vessels, especially when the skin or tissue is stitched. In the present case, the created proximal phalanx had epiphyses at both the proximal and distal ends. Hence, the long finger grew faster than the other phalanges, and we were able to achieve cosmesis with the preservation of five digits. On-top plasty for a floating finger should be considered under parental consent with awareness of the risk of tip necrosis or poor motion.
Conflict of interest The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Funding None.
877 Development for their enthusiastic discussions, encouragement, and invaluable comments on this study.
References 1. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. “On-top plasty” for amputated fingers. Plast Reconstr Surg 1968;42:242e8. 2. Iba K, Wada T, Yamashita T. Atypical thumb polydactyly with duplicated metacarpal bone: a report of 2 cases. Ann Plast Surg 2013;70:38e41. 3. Iba K, Wada T, Yamashita T. On-top plasty using a free metacarpal head graft for lengthening of proximal phalanx in symbrachydactyly e a case report. Hand Surg 2013;18:273e5. 4. Barsky AJ. Cleft hand: classification, incidence, and treatment. Review of the literature and report of nineteen cases. J Bone Jt Surg Am 1964;46:1707e20. 5. Hasegawa K, Namba Y, Kimata Y. Thumb polydactyly with a floating ulnar thumb. Acta Med Okayama 2013;67:391e5.
Takehiko Takagi Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan E-mail address: [email protected] Atsuhito Seki Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan Joji Mochida Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan Shinichiro Takayama Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.02.016
Ethical approval Ethical Approval in National Center for Child Health and Development was given. The relevant Judgement’s reference number is 890.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Acknowledgements We thank all the other members of Department of Orthopaedic Surgery, National Center for Child Health and
Comment Re: ‘Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a’ Dear Sir, The article titled “Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a”1 was published in the July 2013 issue. The authors demonstrated the superiority of combined treatment of surgical excision with interferon over surgical excision only for solid/nodular basal cell carcinoma (BCC). However, the surgical excision of BCC was performed with security margin of only 2 mm
878
Correspondence and communications
which is undertreatment of BCC as per the guidelines established by Telfer et al., in 2008.2 The surgical management of primary basal cell carcinoma, the commonest skin cancer in humans, is highly effective with recurrence rate as low as <2% in a completely excised lesion.2 In a large series of treatment of two thousand-sixteen BCC, Breuninger & Dietz3 clearly demonstrated the subclinical infiltration of BCC (lesion up to 10 mm in diameter) as high as 30% in ones resected with 2 mm, 16% with 3 mm and 5% with 5 mm margin. It further increases to 48, 34 and 18% with 2, 3 & 5 mm margin respectively for BCC with diameter of 10e20 mm. Wettstein et al. demonstrated recurrence in one out of 13 patients in control group treated with surgery compared to none in the study group of 10 patients treated with surgery with intralesional injection of interferone-a 2b. In the view of inadequate peripheral excision margin, the recurrence in control group cannot be validated. Although the team mentioned about all the specimens having undergone frozen section (FS) analysis, frozen section itself lacks 100% accuracy. As established in a large study across 34 hospitals by Howanitz & colleagues,4 there was 3.5% discordance between frozen section and final histologic diagnosis, furthermore, they also mentioned about previous reporting of FS accuracy rate as low as 89%. On the basis of all these, the authors conclusion about the use of interferon-alpha with surgery in future to decrease the rate of recurrence without additional morbidity is dubious in the absence of appropriate controls.
Ethical approval Not required.
Funding N/A.
Conflict of interest None.
References 1. Wettstein R, Erba P, Itin P, et al. Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a. J Plastic Reconstr Aesthetic Surg 2013;66:912e6. 2. Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008;159:35e48. 3. Breuninger H, Dietz K. Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol 1991;17(7): 574e8. 4. Howantiz PJ, Hoffman GG, Zarbo RJ. The accuracy of frozensection diagnoses in 34 hospitals. Arch Pathol Lab Med 1990; 114(4):355e9.
Indira Yonjan Lama Plastic Surgery Department, North Bristol Trust, Southmead Way, Bristol BS10 5NB, UK E-mail address: [email protected]
Simon Wharton Plastic & Reconstructive Surgery, Russells Hall Hospital, Dudley Group of Hospitals NHS Trust, Dudley DY1 2HQ, UK DOI of original j.bjps.2013.03.008
article:
http://dx.doi.org/10.1016/
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.01.007
RE: Pleomorphic adenomas: Post-operative radiotherapy is unnecessary following primary incomplete excision: A retrospective review Dear Sir, We read with interest the article by Robertson et al.,1 which suggests radiotherapy should not be used to manage incompletely excised pleomorphic adenoma. The authors identify their follow up of 85 months as relatively short yet make firm recommendations. The first recurrence has been reported twenty years after initial treatment and facial palsy complicates up to a third of patients undergoing surgery, although it is frequently temporary.2e4 However, surgery in recurrence carries a higher risk of facial nerve injury,5 which is more likely to impact on the group who did not receive post-operative radiotherapy. Moreover, pleomorphic adenoma (PA) recurrence can involve the skull base or old scars making adequate salvage surgery difficult and often requiring locoregional reconstruction adding a layer of complexity and surgical morbidity. This leaves a situation whereby a patient can conceivably have a combination of facial nerve sacrifice, residual disease and therefore the need for subsequent radiotherapy. Despite the inadequate follow-up in this study it is demonstrated radiotherapy does indeed lower crude recurrence rate. The functional implication of facial nerve sacrifice at any age is profound. It condemns patients to lifelong surgery to obtain eye protection and oral continence at the very least. Whilst techniques have evolved since the 1980s, rehabilitating patients with facial nerve loss is resource intensive, multi-stage and often socially disabling. Radiation techniques have also evolved significantly in recent decades. With the advent of computer tomography (CT) planning and conformal delivery techniques, the volume treated has reduced compared to older series using field-based treatment. Many patients now are treated with intensity modulated radiotherapy (IMRT). With its highly conformal dose distributions and relative skin sparing there
Conflict of interest The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Funding None.
877 Development for their enthusiastic discussions, encouragement, and invaluable comments on this study.
References 1. Kelleher JC, Sullivan JG, Baibak GJ, Dean RK. “On-top plasty” for amputated fingers. Plast Reconstr Surg 1968;42:242e8. 2. Iba K, Wada T, Yamashita T. Atypical thumb polydactyly with duplicated metacarpal bone: a report of 2 cases. Ann Plast Surg 2013;70:38e41. 3. Iba K, Wada T, Yamashita T. On-top plasty using a free metacarpal head graft for lengthening of proximal phalanx in symbrachydactyly e a case report. Hand Surg 2013;18:273e5. 4. Barsky AJ. Cleft hand: classification, incidence, and treatment. Review of the literature and report of nineteen cases. J Bone Jt Surg Am 1964;46:1707e20. 5. Hasegawa K, Namba Y, Kimata Y. Thumb polydactyly with a floating ulnar thumb. Acta Med Okayama 2013;67:391e5.
Takehiko Takagi Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan E-mail address: [email protected] Atsuhito Seki Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan Joji Mochida Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, Japan Shinichiro Takayama Department of Orthopaedic Surgery, National Center for Child Health and Development, Japan ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.02.016
Ethical approval Ethical Approval in National Center for Child Health and Development was given. The relevant Judgement’s reference number is 890.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Acknowledgements We thank all the other members of Department of Orthopaedic Surgery, National Center for Child Health and
Comment Re: ‘Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a’ Dear Sir, The article titled “Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a”1 was published in the July 2013 issue. The authors demonstrated the superiority of combined treatment of surgical excision with interferon over surgical excision only for solid/nodular basal cell carcinoma (BCC). However, the surgical excision of BCC was performed with security margin of only 2 mm
878
Correspondence and communications
which is undertreatment of BCC as per the guidelines established by Telfer et al., in 2008.2 The surgical management of primary basal cell carcinoma, the commonest skin cancer in humans, is highly effective with recurrence rate as low as <2% in a completely excised lesion.2 In a large series of treatment of two thousand-sixteen BCC, Breuninger & Dietz3 clearly demonstrated the subclinical infiltration of BCC (lesion up to 10 mm in diameter) as high as 30% in ones resected with 2 mm, 16% with 3 mm and 5% with 5 mm margin. It further increases to 48, 34 and 18% with 2, 3 & 5 mm margin respectively for BCC with diameter of 10e20 mm. Wettstein et al. demonstrated recurrence in one out of 13 patients in control group treated with surgery compared to none in the study group of 10 patients treated with surgery with intralesional injection of interferone-a 2b. In the view of inadequate peripheral excision margin, the recurrence in control group cannot be validated. Although the team mentioned about all the specimens having undergone frozen section (FS) analysis, frozen section itself lacks 100% accuracy. As established in a large study across 34 hospitals by Howanitz & colleagues,4 there was 3.5% discordance between frozen section and final histologic diagnosis, furthermore, they also mentioned about previous reporting of FS accuracy rate as low as 89%. On the basis of all these, the authors conclusion about the use of interferon-alpha with surgery in future to decrease the rate of recurrence without additional morbidity is dubious in the absence of appropriate controls.
Ethical approval Not required.
Funding N/A.
Conflict of interest None.
References 1. Wettstein R, Erba P, Itin P, et al. Treatment of basal cell carcinoma with surgical excision and perilesional interferon-a. J Plastic Reconstr Aesthetic Surg 2013;66:912e6. 2. Telfer NR, Colver GB, Morton CA. Guidelines for the management of basal cell carcinoma. Br J Dermatol 2008;159:35e48. 3. Breuninger H, Dietz K. Prediction of subclinical tumor infiltration in basal cell carcinoma. J Dermatol Surg Oncol 1991;17(7): 574e8. 4. Howantiz PJ, Hoffman GG, Zarbo RJ. The accuracy of frozensection diagnoses in 34 hospitals. Arch Pathol Lab Med 1990; 114(4):355e9.
Indira Yonjan Lama Plastic Surgery Department, North Bristol Trust, Southmead Way, Bristol BS10 5NB, UK E-mail address: [email protected]
Simon Wharton Plastic & Reconstructive Surgery, Russells Hall Hospital, Dudley Group of Hospitals NHS Trust, Dudley DY1 2HQ, UK DOI of original j.bjps.2013.03.008
article:
http://dx.doi.org/10.1016/
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.01.007
RE: Pleomorphic adenomas: Post-operative radiotherapy is unnecessary following primary incomplete excision: A retrospective review Dear Sir, We read with interest the article by Robertson et al.,1 which suggests radiotherapy should not be used to manage incompletely excised pleomorphic adenoma. The authors identify their follow up of 85 months as relatively short yet make firm recommendations. The first recurrence has been reported twenty years after initial treatment and facial palsy complicates up to a third of patients undergoing surgery, although it is frequently temporary.2e4 However, surgery in recurrence carries a higher risk of facial nerve injury,5 which is more likely to impact on the group who did not receive post-operative radiotherapy. Moreover, pleomorphic adenoma (PA) recurrence can involve the skull base or old scars making adequate salvage surgery difficult and often requiring locoregional reconstruction adding a layer of complexity and surgical morbidity. This leaves a situation whereby a patient can conceivably have a combination of facial nerve sacrifice, residual disease and therefore the need for subsequent radiotherapy. Despite the inadequate follow-up in this study it is demonstrated radiotherapy does indeed lower crude recurrence rate. The functional implication of facial nerve sacrifice at any age is profound. It condemns patients to lifelong surgery to obtain eye protection and oral continence at the very least. Whilst techniques have evolved since the 1980s, rehabilitating patients with facial nerve loss is resource intensive, multi-stage and often socially disabling. Radiation techniques have also evolved significantly in recent decades. With the advent of computer tomography (CT) planning and conformal delivery techniques, the volume treated has reduced compared to older series using field-based treatment. Many patients now are treated with intensity modulated radiotherapy (IMRT). With its highly conformal dose distributions and relative skin sparing there