Plastic and Reconstructive Surgery • November 2013 wound fluid declined over time as anticipated, but the decline was less precipitous in wound fluid. Wound cotinine levels also decreased at a rate of 0.14 ng/ml for every minute increase in surgery length. Wound fluid cotinine was correlated with urine cotinine (0.85; p < 0.001) but was not significantly correlated with selfreported cigarettes consumed per day (0.53; p = 0.141). Nicotine levels in wound fluid of current smokers were at or below the limit of detection, whereas nicotine levels in urine and blood were appropriate for cigarette consumption. These pilot data demonstrate that cotinine is feasibly measured in wound fluid. Although wound cotinine was significantly less than urine cotinine, these levels correlate, showing that wound cotinine reliably quantifies tobacco exposure. With further study, the measurement of biomarkers of tobacco exposure in wound fluid will potentially provide an innovative means by which to evaluate the effect of smoking on wound healing. DOI: 10.1097/PRS.0b013e3182a4c642
Amy Anne D. Lassig, M.D. Bevan Yueh, M.D., M.P.H. Department of Otolaryngology–Head and Neck Surgery
Sharon E. Murphy, Ph.D. Department of Biochemistry, Molecular Biology, and Biophysics, and Masonic Cancer Center
Patricia G. Fernandes, D.D.S. Kathryn M. Banks, B.A. Department of Otolaryngology–Head and Neck Surgery
Katherine M. Wickham, B.A. Masonic Cancer Center
Anne M. Joseph, M.D., M.P.H. Department of Medicine University of Minnesota Minneapolis, Minn. Correspondence to Dr. Lassig Department of Otolaryngology–Head and Neck Surgery University of Minnesota Minneapolis, Minn. 55419 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENT Funding for this study was graciously provided by a Lions Club Grant (Minneapolis, Minn.). REFERENCES 1. Coon D, Tuffaha S, Christensen J, Bonawitz SC. Plastic surgery and smoking: A prospective analysis of incidence, compliance, and complications. Plast Reconstr Surg. 2013; 131:385–391.
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2. Hawn MT, Houston TK, Campagna EJ, et al. The attributable risk of smoking on surgical complications. Ann Surg. 2011;254:914–920. 3. Sorensen LT. Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy. Ann Surg. 2012;255:1069–1079. 4. Hecht SS, Carmella SG, Chen M, et al. Quantitation of urinary metabolites of a tobacco-specific lung carcinogen after smoking cessation. Cancer Res. 1999;59:590–596. 5. Murphy SE, Villalta P, Ho SW, von Weymarn LB. Analysis of [3’,3’-d(2)]-nicotine and [3’,3’-d(2)]-cotinine by capillary liquid chromatography-electrospray tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2007;857:1–8.
Merkel Cell Carcinoma: Diagnosis, Management, and Outcomes Sir: read with great interest the comprehensive review on Merkel cell carcinoma by Senchenkov and Moran.1 As a plastic surgeon and Merkel cell carcinoma researcher for over a decade now, I feel that the plastic surgical expertise needs to be emphasized in the treatment of Merkel cell carcinoma tumors and patients. Regarding the multidisciplinary treatment of Merkel cell carcinoma, the plastic surgeon has a pivotal role. The majority of Merkel cell carcinoma tumors occur in the head and neck region, and the tumor reaches a considerable size in just months or even weeks. Although there is no solid conclusion regarding the width of the surgical margins, the excision of the fast-grown tumor may result in a large defect, resulting in a functional and aesthetic defect, especially if the tumor occurs in the face. In one of our group’s earlier studies, we achieved a positive impact on the outcome of Merkel cell carcinoma patients if the excision defect was reconstructed with a split-thickness skin graft or a local flap2 instead of an excision and direct closure alone. Recently, our national study reconfirmed the importance of a clear margin excision.3 Considered together, the anatomical location of the tumor should not restrict adequate excision, because of the multiple reconstructive options available. Earlier, all Merkel cell carcinoma cases were deemed to have extremely poor prognoses. However, accumulated knowledge and detailed outcome data stratified by tumor size, nodal status, and distant metastasis4 show that the majority of Merkel cell carcinoma patients have a relatively good 5-year outcome; approximately 60 percent of the node-negative patients are alive after 5 years, and for those who present with positive nodal status by pathologic evaluation, the 5-year survival is over 40 percent.4 Nevertheless, there remains a small subgroup of patients with an extremely poor prognosis, those with distant metastatic dissemination or with extreme immunosuppressive states. Even though Merkel cell carcinoma is principally a disease of the elderly, with current life expectancy, it is likely that an individual Merkel cell carcinoma patient
I
Volume 132, Number 5 • Viewpoints may live 5 to 10 or more years after diagnosis and treatment. The skewed age distribution of Merkel cell carcinoma patients naturally challenges the reconstructive options. However, older age and fragility should not restrict the optimal treatment. In a small clinical series, we showed that a sentinel lymph node biopsy and excision and reconstruction with a local flap are applicable under local anesthesia in elderly head and neck Merkel cell carcinoma patients.5 Our premise should be based on sustaining the patient’s quality of life and the staging and local control of the tumor, at least until this virus-induced malignancy is treated with vaccinations or antibiotics. DOI: 10.1097/PRS.0b013e3182a4c681
Virve Koljonen, M.D., Ph.D. Department of Plastic Surgery Töölö Hospital P.O. Box 266 FIN 0029 HUS Helsinki, Finland [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Senchenkov A, Moran SL. Merkel cell carcinoma: Diagnosis, management, and outcomes. Plast Reconstr Surg. 2013;131:771e–778e. 2. Koljonen V, Böhling T, Granhroth G, Tukiainen E. Merkel cell carcinoma: A clinicopathological study of 34 patients. Eur J Surg Oncol. 2003;29:607–610. 3. Kukko H, Böhling T, Koljonen V, et al. Merkel cell carcinoma: A population-based epidemiological study in Finland with a clinical series of 181 cases. Eur J Cancer 2012;48:737– 742. 4. Edge SB, Byrd DR, Compton CC, eds. Merkel cell carcinoma. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010:315–323. 5. Koljonen V, Suominen S. Sentinel node biopsy in local anaesthesia in patients with head and neck Merkel cell carcinoma. Eur J Plast Surg. 2008;30:205–210.
the use of pigs. Thus, sheep, which are acceptable and accessible, can be used for training instead.2 In addition, sheep heads can be obtained easily at a lower cost or even free of charge after euthanasia following the conclusion of experiments performed on living sheep. On gross examination, sheep eyelids are similar to human eyelids, including the presence of eyelid lashes. The human adult tarsus averages 1 mm in thickness and 11 mm and 4 mm in height for the upper and lower eyelids, respectively. In our study, we used 10 eyelids from cadaver sheep and found an average thickness of 1 mm and an average height of 7 mm and 6.5 mm for the upper and lower eyelids, respectively.3 Approximation of the lacerated edges, periorbital flap design for eyelid reconstruction, and straight lid margin closure were easily simulated (Fig. 1, left). In humans, small “through-and-through” defects of the nasal ala may be managed with composite grafts of the auricular tissue. Sheep nasal ala and ear anatomical structures are similar to those of humans in their thickness and representation of three-layered structures. These similarities allow for their application as a training model for alar rim reconstruction (Fig. 1, right). In addition, the sheep auricle can be used for simulating auricular defect repair, dissection of the auricular cartilage, and scoring and antihelical fold creation with the application of Mustardé sutures (Fig. 2, left). Cleft palate surgery is challenging for surgeons because it is performed in a small cavity, provides limited access, and requires tissue handling and suturing in the deeper tissue regions. There are training models used for this purpose; however, they use artificial materials and cannot simulate the dissection and suturing of real tissues.4,5 Thus, the sheep palate provides a good model for gaining experience with real tissues. Although the sheep model does not have all of the morphologic characteristics of a cleft palate defect in humans, it is still a very useful model because the mucoperiosteal flaps based on the greater palatine artery can be elevated, palatal defects can be created by simple mucosal excision and bone osteotomies, and muscle repair and nasal lining can be performed (Fig. 2, right). In summary, we have found the sheep head cadaver model to be a useful tool for plastic surgery training. DOI: 10.1097/PRS.0b013e3182a4c66d
Sheep Head Model for Plastic Surgery Training Sir:
A
nimal models are believed to be the optimal choice for surgical training. Cadaver sheep heads have been previously used as surgical training models.1 We propose to use the sheep head as a model with which to simulate basic plastic surgery techniques such as eyelid surgery, lip wedge and alar rim repair, cleft palate repair, and external ear procedures. The idea of using animals in the surgical training of basic plastic surgery techniques and lip wedges is not new. Previously, pig models were used for this purpose; however, cultural norms in the Middle East restrict
Safak Uygur, M.D. Can Ozturk, M.D. Grzegorz Kwiecien, M.D. Maria Z. Siemionow, M.D., Ph.D., D.Sc. Department of Plastic Surgery Cleveland Clinic Cleveland, Ohio Correspondence to Dr. Siemionow 9500 Euclid Avenue Cleveland, Ohio 44195 [email protected]
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Amy Anne D. Lassig, M.D. Bevan Yueh, M.D., M.P.H. Department of Otolaryngology–Head and Neck Surgery
Sharon E. Murphy, Ph.D. Department of Biochemistry, Molecular Biology, and Biophysics, and Masonic Cancer Center
Patricia G. Fernandes, D.D.S. Kathryn M. Banks, B.A. Department of Otolaryngology–Head and Neck Surgery
Katherine M. Wickham, B.A. Masonic Cancer Center
Anne M. Joseph, M.D., M.P.H. Department of Medicine University of Minnesota Minneapolis, Minn. Correspondence to Dr. Lassig Department of Otolaryngology–Head and Neck Surgery University of Minnesota Minneapolis, Minn. 55419 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENT Funding for this study was graciously provided by a Lions Club Grant (Minneapolis, Minn.). REFERENCES 1. Coon D, Tuffaha S, Christensen J, Bonawitz SC. Plastic surgery and smoking: A prospective analysis of incidence, compliance, and complications. Plast Reconstr Surg. 2013; 131:385–391.
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2. Hawn MT, Houston TK, Campagna EJ, et al. The attributable risk of smoking on surgical complications. Ann Surg. 2011;254:914–920. 3. Sorensen LT. Wound healing and infection in surgery: The pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy. Ann Surg. 2012;255:1069–1079. 4. Hecht SS, Carmella SG, Chen M, et al. Quantitation of urinary metabolites of a tobacco-specific lung carcinogen after smoking cessation. Cancer Res. 1999;59:590–596. 5. Murphy SE, Villalta P, Ho SW, von Weymarn LB. Analysis of [3’,3’-d(2)]-nicotine and [3’,3’-d(2)]-cotinine by capillary liquid chromatography-electrospray tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci. 2007;857:1–8.
Merkel Cell Carcinoma: Diagnosis, Management, and Outcomes Sir: read with great interest the comprehensive review on Merkel cell carcinoma by Senchenkov and Moran.1 As a plastic surgeon and Merkel cell carcinoma researcher for over a decade now, I feel that the plastic surgical expertise needs to be emphasized in the treatment of Merkel cell carcinoma tumors and patients. Regarding the multidisciplinary treatment of Merkel cell carcinoma, the plastic surgeon has a pivotal role. The majority of Merkel cell carcinoma tumors occur in the head and neck region, and the tumor reaches a considerable size in just months or even weeks. Although there is no solid conclusion regarding the width of the surgical margins, the excision of the fast-grown tumor may result in a large defect, resulting in a functional and aesthetic defect, especially if the tumor occurs in the face. In one of our group’s earlier studies, we achieved a positive impact on the outcome of Merkel cell carcinoma patients if the excision defect was reconstructed with a split-thickness skin graft or a local flap2 instead of an excision and direct closure alone. Recently, our national study reconfirmed the importance of a clear margin excision.3 Considered together, the anatomical location of the tumor should not restrict adequate excision, because of the multiple reconstructive options available. Earlier, all Merkel cell carcinoma cases were deemed to have extremely poor prognoses. However, accumulated knowledge and detailed outcome data stratified by tumor size, nodal status, and distant metastasis4 show that the majority of Merkel cell carcinoma patients have a relatively good 5-year outcome; approximately 60 percent of the node-negative patients are alive after 5 years, and for those who present with positive nodal status by pathologic evaluation, the 5-year survival is over 40 percent.4 Nevertheless, there remains a small subgroup of patients with an extremely poor prognosis, those with distant metastatic dissemination or with extreme immunosuppressive states. Even though Merkel cell carcinoma is principally a disease of the elderly, with current life expectancy, it is likely that an individual Merkel cell carcinoma patient
I
Volume 132, Number 5 • Viewpoints may live 5 to 10 or more years after diagnosis and treatment. The skewed age distribution of Merkel cell carcinoma patients naturally challenges the reconstructive options. However, older age and fragility should not restrict the optimal treatment. In a small clinical series, we showed that a sentinel lymph node biopsy and excision and reconstruction with a local flap are applicable under local anesthesia in elderly head and neck Merkel cell carcinoma patients.5 Our premise should be based on sustaining the patient’s quality of life and the staging and local control of the tumor, at least until this virus-induced malignancy is treated with vaccinations or antibiotics. DOI: 10.1097/PRS.0b013e3182a4c681
Virve Koljonen, M.D., Ph.D. Department of Plastic Surgery Töölö Hospital P.O. Box 266 FIN 0029 HUS Helsinki, Finland [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. REFERENCES 1. Senchenkov A, Moran SL. Merkel cell carcinoma: Diagnosis, management, and outcomes. Plast Reconstr Surg. 2013;131:771e–778e. 2. Koljonen V, Böhling T, Granhroth G, Tukiainen E. Merkel cell carcinoma: A clinicopathological study of 34 patients. Eur J Surg Oncol. 2003;29:607–610. 3. Kukko H, Böhling T, Koljonen V, et al. Merkel cell carcinoma: A population-based epidemiological study in Finland with a clinical series of 181 cases. Eur J Cancer 2012;48:737– 742. 4. Edge SB, Byrd DR, Compton CC, eds. Merkel cell carcinoma. AJCC Cancer Staging Manual. 7th ed. New York: Springer; 2010:315–323. 5. Koljonen V, Suominen S. Sentinel node biopsy in local anaesthesia in patients with head and neck Merkel cell carcinoma. Eur J Plast Surg. 2008;30:205–210.
the use of pigs. Thus, sheep, which are acceptable and accessible, can be used for training instead.2 In addition, sheep heads can be obtained easily at a lower cost or even free of charge after euthanasia following the conclusion of experiments performed on living sheep. On gross examination, sheep eyelids are similar to human eyelids, including the presence of eyelid lashes. The human adult tarsus averages 1 mm in thickness and 11 mm and 4 mm in height for the upper and lower eyelids, respectively. In our study, we used 10 eyelids from cadaver sheep and found an average thickness of 1 mm and an average height of 7 mm and 6.5 mm for the upper and lower eyelids, respectively.3 Approximation of the lacerated edges, periorbital flap design for eyelid reconstruction, and straight lid margin closure were easily simulated (Fig. 1, left). In humans, small “through-and-through” defects of the nasal ala may be managed with composite grafts of the auricular tissue. Sheep nasal ala and ear anatomical structures are similar to those of humans in their thickness and representation of three-layered structures. These similarities allow for their application as a training model for alar rim reconstruction (Fig. 1, right). In addition, the sheep auricle can be used for simulating auricular defect repair, dissection of the auricular cartilage, and scoring and antihelical fold creation with the application of Mustardé sutures (Fig. 2, left). Cleft palate surgery is challenging for surgeons because it is performed in a small cavity, provides limited access, and requires tissue handling and suturing in the deeper tissue regions. There are training models used for this purpose; however, they use artificial materials and cannot simulate the dissection and suturing of real tissues.4,5 Thus, the sheep palate provides a good model for gaining experience with real tissues. Although the sheep model does not have all of the morphologic characteristics of a cleft palate defect in humans, it is still a very useful model because the mucoperiosteal flaps based on the greater palatine artery can be elevated, palatal defects can be created by simple mucosal excision and bone osteotomies, and muscle repair and nasal lining can be performed (Fig. 2, right). In summary, we have found the sheep head cadaver model to be a useful tool for plastic surgery training. DOI: 10.1097/PRS.0b013e3182a4c66d
Sheep Head Model for Plastic Surgery Training Sir:
A
nimal models are believed to be the optimal choice for surgical training. Cadaver sheep heads have been previously used as surgical training models.1 We propose to use the sheep head as a model with which to simulate basic plastic surgery techniques such as eyelid surgery, lip wedge and alar rim repair, cleft palate repair, and external ear procedures. The idea of using animals in the surgical training of basic plastic surgery techniques and lip wedges is not new. Previously, pig models were used for this purpose; however, cultural norms in the Middle East restrict
Safak Uygur, M.D. Can Ozturk, M.D. Grzegorz Kwiecien, M.D. Maria Z. Siemionow, M.D., Ph.D., D.Sc. Department of Plastic Surgery Cleveland Clinic Cleveland, Ohio Correspondence to Dr. Siemionow 9500 Euclid Avenue Cleveland, Ohio 44195 [email protected]
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