Summary Background Dermatofibrosarcoma protuberans (DFSP) is a rare skin cancer. Standard treatment in the UK is either wide local excision (WLE) or Mohs micrographic surgery (MMS). It is unclear which approach has the lower recurrence rate. Objectives We undertook a retrospective comparative review of surgical management of DFSP in the UK National Health Service in order to define (i) current surgical practice for primary and recurrent DFSP, (ii) local recurrence rates for primary DFSP and (iii) survival outcomes for DFSP. Methods A retrospective clinical case‐note review of patients with histologically confirmed DFSP (January 2004 to December 2013) who have undergone surgical treatment. Results The surgical management of 483 primary and 64 recurrent DFSP in 11 plastic surgery and 15 dermatology departments was analysed. Almost 75% of primary DFSP (n = 362) were treated with WLE and 20% (n = 97) with MMS. For recurrent DFSP, 69% (n = 44) and 23% (n = 15) of patients underwent WLE and MMS, respectively. Recurrent primary DFSP occurred in six patients after WLE and none after MMS. The median follow‐up time was 25·5 months (interquartile range 6·8–45·1) for new and 19·8 (IQR 4·5–44·5) for recurrent DFSP [Correction added on 1 Feb 2021, after first online publication: 4.8 years (interquartile range 3.5‐5.8) was incorrect], with eight reported deaths during the follow‐up analysis period (one confirmed to be DFSP related). Conclusions WLE was the most common surgical modality used to treat DFSP across the UK. The local recurrence rate was very low, occurring only after WLE. Although a prospective randomized controlled trial may provide more definitive outcomes, in the absence of a clearly superior surgical modality, treatment decisions should be based on patient preference, clinical expertise and cost.
Background Chest wall resection following wide local excision for bone tumor results in a large defect. Reconstructing this defect is complex and requires skeletal and soft tissue reconstruction. We describe the reconstruction of a large skeletal defect with a three-dimensional (3-D) printed custom-made, anatomically designed, titanium alloy ribs and hemi-sternum implant. Method To design the implant manual bone threshold segmentation was performed to create a 3-D virtual model of the patient’s chest and the tumor from sub-millimeter slice computed tomography (CT) scan data. We estimated the extent of resection needed to ensure tumor-free margins by growing the tumor by two cm all around.. We designed the implant using an anatomical image of the ribs and right hemi-sternum and then fabricated a 3D model of them in titanium metal using TiMG 1 powder bed fusion technology. At surgery the implant was slotted into the defect and sutured to the ribs laterally and hemi-sternum medially. Results Histology confirmed clear all around microscopic margins. Following surgery and at 18 month follow up the patient was asymptomatic with preserved quality of life and described no pain, localized tenderness or breathlessness. There was no displacement or paradoxical movement of the implant. Conclusion Our techniques of CT segmentation, editing, computer aided design of the implant and fabrication using laser printing of a custom-made anatomical titanium alloy chest wall ribs and hemi-sternum for reconstruction is feasible, safe and provides a satisfactory result. Hence, a patient specific 3-D printed titanium chest wall implant is another useful adjunct to the surgical approach for reconstructing large chest wall defects whilst preserving the anatomical shape, structure and function of the thorax.
Background Increasingly radical surgery combined with neo-adjuvant radiotherapy present a challenge for the reconstructive surgeon. The study objective was to review outcomes of Vertical Rectus Abdominis Myocutaneous (VRAM) flap-based perineal reconstruction following resectional surgery for pelvic malignancies. Methods Single-centre retrospective analysis of patients undergoing immediate VRAM flap reconstruction of a perineal/pelvic defect for pelvic malignancy between July 2009 and November 2017. Primary outcome was perineal morbidity (surgical site infection (SSI), flap loss or dehiscence and perineal hernia). Secondary outcomes were length of stay and donor site morbidity (SSI, full-thickness dehiscence and incisional hernia). Results A total of 178 patients (96 females) were included. Median age was 67 years (range 28-88). The majority were performed for locally advanced rectal adenocarcinoma (n = 122; 68.5%) and 136 (76.4%) patients had received neoadjuvant radiotherapy. Four patients had complete flap loss (2.3%), and 40 had perineal dehiscence (22.5%); however, only, 18 patients required a return to theatre during the admission for perineal-related complications (10.1%). Abdominal dehiscence occurred in six patients (3.4%). Median length of post-operative stay was 15 days (6-131). Sixty-day mortality rate was 1.1%. SSI at the midline and perineum occurred in 34 (19.1%) and 38 patients (21.3%), respectively. At 90-day post-operatively, 75.6% of perineal wounds were healed. During a median followup of 44.5 months, twelve, eleven and 39 patients were diagnosed with perineal, midline and parastomal hernias, respectively (6.9%, 6.2% and 21.9%). Conclusions It is important to have accurate knowledge of perineal and donor-site morbidity rates to allow an informed consent process.
SummaryHerniation of the liver through an anterior abdominal wall incisional defect has rarely been described. An 81-year-old man presented to our surgical team with acute right upper quadrant abdominal pain. He had undergone coronary artery bypass grafting via a median sternotomy 7 years previously. Examination revealed gallbladder tenderness and a non-tender incisional epigastric hernia. Cholecystitis was confirmed on ultrasound. A CT scan revealed a knuckle of liver (segment II/III) herniating through an upper midline anterior abdominal wall incisional defect. BACKGROUND
SUMMARYGiant basal cell carcinomas (GBCC) are rare, accounting for <1% of BCCs. Those occurring on the anterior chest wall are a very rare subset that brings particular reconstructive challenges. We describe a 75-year-old man whose 13.5 cm diameter ulcerating GBCC on his left anterior chest came to medical attention following a fall. The lesion was resected en-bloc with adjacent ribs, and reconstructed with an omental flap, superiorly pedicled vertical rectus abdominus myocutaneous (VRAM) flap and split skin grafting. While the myriad reasons for delayed presentation of giant cutaneous malignancies are well documented, the complex nature of reconstruction and requirement for an integrated multidisciplinary approach are less so. It is of importance to note that the cicatricial nature of these lesions may result in a much larger defect requiring reconstruction than appreciated prior to resection. Documented cases of anterior chest wall GBCC and the treatment strategies employed are reviewed. BACKGROUND
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