Dr. Spencer

Although the basic surgical tools for dermatologic reconstruction haven't changed in 50 years, exciting new products are available that can dramatically improve surgical results, according to James Spencer, M.D., of Spencer Dermatology and Skin Surgery Center in St. Petersburg, Fla.

Skin cancer is on the rise, and surgical excision has been and remains the treatment of choice. Radiation is an option, but the inconvenience and inferior cosmetic results make it a less attractive option, according to Dr. Spencer. Radiation for any type of cancer produces changes in the appearance of skin that tend to worsen with time, including permanent loss of sweat glands, dyspigmentation and telangiectasias.

Wounds produced

Traditional surgical techniques all produce wounds.

The original Mohs technique made use of zinc chloride paste, applied to the skin cancer, to fix it in situ. The tissue was surgically removed later for use in making microscope slides. Some of the devitalized, black eschar was left behind and had to slough before healing could begin. Thus, immediate reconstruction was not possible.

In the early 1980s, the fresh tissue technique was developed for creation of frozen microscope slides. This technique was an improvement in that the skin cancer was cut out and repaired the same day.

However, Dr. Spencer tells Dermatology Times, since that time, dermatologists have repaired wounds using the same basic fundamentals. The use of flaps and grafts hasn't changed in 20 years.

"Interestingly, a lot of our surgical techniques are based on opinion rather than studies," Dr. Spencer notes. "A lot of what is practiced in this area is anecdotal and experiential. For example, we were taught as residents to suture in two layers, using absorbable suture material in the innermost layer and non-absorbable material in the outside layer. The absorbables were thought to be too inflammatory and (likely to) increase the risk of infection to be used in the outside layer. We now know through studies that this is not the case — the outcome in patients receiving absorbable and non-absorbable outer sutures is identical."

Another example of anecdotal teaching in most dermatology programs is that when closing an elliptical excision, one should never leave a dog ear because it will be permanent. It is now apparent that some dog ears will resolve with time in certain locations, especially the back of the hands.

Smaller refinements

The recent advances have been in smaller refinements in treatment.

One notable example is imiquimod cream, which is Food and Drug Administration-approved for use in warts, superficial basal cell carcinoma and actinic keratoses, but also seems to have an effect on the scarring process. A recent study found that women who had undergone reduction mammoplasty had a significantly improved cosmetic outcome when using imiquimod cream after healing.

Dr. Spencer believes that imiquimod cream will play a significant role in dermatologic oncology.

The cream works to boost the immune system, and offers dual benefits — it acts to clean up cancer that might potentially be left behind after surgery and provides the patient with a better-looking scar.

"I personally did a study in which basal cell carcinoma was treated with curettage and electrodessication; half of patients were given imiquimod cream to apply to the wound," Dr. Spencer reports. "Historically, we know that if we do C&D and then re-examine the area, there is cancer left behind up to 40 percent of the time. As expected, at the end of treatment and a waiting period, 40 percent of the patients receiving the placebo showed cancer. In the imiquimod group, the frequency of residual tumor dropped to only 10 percent. Additionally, the cosmetic quality of the scar was better in the imiquimod group."

Another product is Apligraf (Organogenesis) which acts as a living, artificial skin. Apligraf is developed from neonatal foreskin that does not take as a graft, but acts as a biologic Band-Aid. According to Dr. Spencer, the product definitely facilitates healing and gives a nice cosmetic result.