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Correspondence and communications
includes more perforators to the skin.4 I believe, based my personal experience and the findings of the current study, that a free DIEP flap with a good single “dominant” perforator vessel might have better skin and fat compared to a free TRAM flap with multiple perforators. This is another provoking study that we are looking for in the future!
References 1. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row perforator DIEP flap in breast reconstruction: threedimensional perforasome and clinical results. Plast Reconstr Surg 2010 Sep;126(3):739e51. 2. Garvey PB, Salavati S, Feng L, Butler CE. Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric Artery branch perforators for breast reconstruction. Past Reconstr Surg 2011 Dec;128(6):581ee9e. 3. Losken A, Zenn MR, Hammel JA, Walsh MW, Carlson GW. Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction. Plast Reconstr Surg 2012 Apr;129(4):618ee24e. 4. Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010 May;125(5):1335e41.
Moustapha Hamdi Plastic Surgery Department, Brussels University Hospital, Vrije Universiteit Brussel (VUB), Belgium E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.057
Frozen section in skin cancer surgery: Is the technique obsolete? Dear Sir, In skin cancer surgery, frozen section (FS) has long been used for intraoperative assessment of tumours, particularly squamous cell and basal cell carcinoma. FS is used to help maximise disease clearance and minimise tissue loss in lesions with poorly defined clinical margins, infiltrative growth patterns, recurrences and at critical anatomical sites. But how accurate is it, and how often does the frozen section technique truly alter patient outcome? A range of accuracy of between 71 and 99% has been quoted in the literature for FS in head and neck cancer surgery.1 A true evaluation of the technique’s influence on patient outcome is, however, more difficult to establish. Despite its widespread use, the standard FS sampling technique is now perceived by many to be sub-optimal in
the intra-operative assessment of skin cancer margins. This is due to the increasing popularity and availability of Mohs micrographic surgery.2e4 This is highlighted by recent draft recommendations from the Royal College of Pathologists on the management of BCCs. The College suggests, “Frozen sections should be limited to Mohs micrographic surgery where horizontal sections are used to accurately assess margin status. Vertical frozen sections should not be used to assess margins as they are insufficiently representative of the entire margin”.5 In light of these recent recommendations, we reviewed the use of frozen section in our unit, to determine if there continued to be a place for it in a large tertiary referral centre. This study examined the results of a cohort of patients undergoing excision of malignant skin lesions utilising frozen section ‘control’, in an attempt to evaluate the usefulness of the technique. A retrospective review was performed of all cases of malignant skin tumour excision utilising frozen section in a large Regional Plastic Surgery Unit over a 12 month period (January to December 2011). 67 patients who underwent frozen section analysis were reviewed. 50 patients had prior histological confirmation of their diagnosis. The predominant pathological diagnosis was BCC. The mean number of frozen section specimens analysed for each patient was 5.7 (range 1e11). The mean age of patient was 68 years (range 28e96 years). 10/67 patients had frozen sections that were positive for malignant disease. 9/57 patients with negative frozen sections had definitive paraffin section demonstrating incomplete or close (
Correspondence and communications
includes more perforators to the skin.4 I believe, based my personal experience and the findings of the current study, that a free DIEP flap with a good single “dominant” perforator vessel might have better skin and fat compared to a free TRAM flap with multiple perforators. This is another provoking study that we are looking for in the future!
References 1. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row perforator DIEP flap in breast reconstruction: threedimensional perforasome and clinical results. Plast Reconstr Surg 2010 Sep;126(3):739e51. 2. Garvey PB, Salavati S, Feng L, Butler CE. Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric Artery branch perforators for breast reconstruction. Past Reconstr Surg 2011 Dec;128(6):581ee9e. 3. Losken A, Zenn MR, Hammel JA, Walsh MW, Carlson GW. Assessment of zonal perfusion using intraoperative angiography during abdominal flap breast reconstruction. Plast Reconstr Surg 2012 Apr;129(4):618ee24e. 4. Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010 May;125(5):1335e41.
Moustapha Hamdi Plastic Surgery Department, Brussels University Hospital, Vrije Universiteit Brussel (VUB), Belgium E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.057
Frozen section in skin cancer surgery: Is the technique obsolete? Dear Sir, In skin cancer surgery, frozen section (FS) has long been used for intraoperative assessment of tumours, particularly squamous cell and basal cell carcinoma. FS is used to help maximise disease clearance and minimise tissue loss in lesions with poorly defined clinical margins, infiltrative growth patterns, recurrences and at critical anatomical sites. But how accurate is it, and how often does the frozen section technique truly alter patient outcome? A range of accuracy of between 71 and 99% has been quoted in the literature for FS in head and neck cancer surgery.1 A true evaluation of the technique’s influence on patient outcome is, however, more difficult to establish. Despite its widespread use, the standard FS sampling technique is now perceived by many to be sub-optimal in
the intra-operative assessment of skin cancer margins. This is due to the increasing popularity and availability of Mohs micrographic surgery.2e4 This is highlighted by recent draft recommendations from the Royal College of Pathologists on the management of BCCs. The College suggests, “Frozen sections should be limited to Mohs micrographic surgery where horizontal sections are used to accurately assess margin status. Vertical frozen sections should not be used to assess margins as they are insufficiently representative of the entire margin”.5 In light of these recent recommendations, we reviewed the use of frozen section in our unit, to determine if there continued to be a place for it in a large tertiary referral centre. This study examined the results of a cohort of patients undergoing excision of malignant skin lesions utilising frozen section ‘control’, in an attempt to evaluate the usefulness of the technique. A retrospective review was performed of all cases of malignant skin tumour excision utilising frozen section in a large Regional Plastic Surgery Unit over a 12 month period (January to December 2011). 67 patients who underwent frozen section analysis were reviewed. 50 patients had prior histological confirmation of their diagnosis. The predominant pathological diagnosis was BCC. The mean number of frozen section specimens analysed for each patient was 5.7 (range 1e11). The mean age of patient was 68 years (range 28e96 years). 10/67 patients had frozen sections that were positive for malignant disease. 9/57 patients with negative frozen sections had definitive paraffin section demonstrating incomplete or close (
