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composed of small basaloid cells without atypia in a densely collagenous stroma. Horn cysts and focus of calcification were seen within some of the islands. These features confirmed the diagnosis of DTE (Figure 4A).
Discussion This case not only supports the previously reported dermoscopic, RCM, and histological features of a DTE but also provides novel insights into its morphological features using HD-OCT. The low-reflective dermal tumor islands (slice and en face) correlate with the dark tumor islands seen in RCM and also with the strands of basaloid cells observed in histology.3,4 The surrounding highly reflective collagen and dilated vessels in HD-OCT correspond to the same structures presented in the desmoplastic stroma both in RCM and histopathology. The presence of these features, the connection between some islands and follicles, and also the absence of epidermal disarray, inflammatory cells, and peripheral dark rim, which are usually seen in BCC, allowed to favor the diagnosis of DTE over BCC in HD-OCT.5 In conclusion, this case demonstrated an excellent correlation between HD-OCT, RCM, and histopathology. To the best of the authors’ knowledge, this is the first report of HD-OCT imaging of rare DTE. Recognition of such features may facilitate its in vivo diagnosis, avoiding invasive diagnostic techniques of an otherwise benign tumor frequently located in cosmetically sensitive areas.
References 1. Mamelak AJ, Goldberg LH, Katz TM, Graves JJ, et al. Desmoplastic trichoepithelioma. J Am Acad Dermatol 2010;62:102–6. 2. Boone M, Norrenberg S, Jemec G, Del Marmol V. High-definition optical coherence tomography imaging of melanocytic lesions: a pilot study. Arch Dermatol Res 2014;306:11–26. 3. Khelifa E, Masouyé I, Kaya G, Le Gal FA. Dermoscopy of desmoplastic trichoepithelioma reveals other criteria to distinguish it from basal cell carcinoma. Dermatology 2013;226:101–4. 4. Ardigo M, Zieff J, Scope A, Gill M, et al. Dermoscopic and reflectance confocal microscopy findings of trichoepithelioma. Dermatology 2007; 215:354–8. 5. Boone MALM, Norrenberg S, Jemec GBE, Del Marmol V. Imaging of basal cell carcinoma by high-definition optical coherence tomography: histomorphological correlation. A pilot study. Br J Dermatol 2012;167: 856–64.
André Oliveira, MD Department of Dermatology Hospital de Curry Cabral—Centro Hospitalar de Lisboa Central Lisboa, Portugal Edith Arzberger, MD Iris Zalaudek, MD Rainer Hofmann-Wellenhof, MD Department of Dermatology Medical University of Graz Graz, Austria The authors have indicated no significant interest with commercial supporters.
Preoperative Ultrasound and Photoacoustic Imaging of Nonmelanoma Skin Cancers There is a growing concern over the rising incidence of nonmelanoma skin cancer (NMSC), and higher treatment-related cost may become a burden on the healthcare system. Management of NMSC is usually surgical either by local excision or Mohs micrographic surgery (MMS).1 Tumor recurrence rates, prolonged surgical times, and significant patient morbidity could be improved with tools that would allow for more accurate tumor evaluation and planning before surgery. Several noninvasive imaging modalities have been applied to NMSC. Among them, high-frequency
ultrasound (HFUS) can provide structural information about tumor size with its high resolution (50 mm) and deep penetration depth (>2 mm).1,2 However, the technique relies on mechanical contrast rather than functional contrast. It is desirable to increase tumor contrast for improved tumor demarcation. In this respect, optical contrast can complement ultrasound contrast. Photoacoustic imaging (PAI) can aid HFUS with its high contrast and sensitivity measures. Photoacoustic imaging is based on pulsed laser light being absorbed by chromophores (e.g., hemoglobin in blood), which leads to thermoelastic expansion and generation of sound
41:4:APRIL 2015
525
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
waves.3 Photoacoustic imaging can quantify highresolution vasculature with an achievable spatial resolution of 50 mm at 3 mm depth,3,4 thus being suitable for noninvasive imaging of skin malignancies. This pilot study was designed to validate tumor thickness measurements obtained with HFUS by comparing them with histological thicknesses obtained during MMS. The authors also obtained vascular maps by PAI to enhance contrast for improved tumor demarcation and to help establish these techniques for future clinical trials involving surgery. Experimental Design and Methods An IRB-approved clinical trial (protocol #I226912) was initiated at Roswell Park Cancer Institute.5 Twenty-one patients with biopsy-proven NMSCs, of a minimum diameter of 0.5 to 1 cm, who were scheduled for MMS were enrolled, and written informed consent was obtained from all subjects. A commercial grade HFUS imaging system (40 MHz, Episcan; Longport Inc.) was used because of its capability of providing high spatial resolution (45 mm axial [depth] resolution) with an 5 mm signal penetration depth. Custom clinical PAI system had a tunable laser (5 nanosecond pulse width, 20 Hz pulse repetition rate), a 20 MHz focused ring transducer with a 600 mm multimode fiber so that the laser fiber and transducer were set coaxially in a combined probe. The laser beam was collimated with a beam diameter of 2 mm on the sample. The system had 5 mm signal penetration depth and 80 mm depth resolution. High-frequency ultrasound and PAI
scans were performed sequentially. First, ultrasound gel was applied to the tumor and the HFUS probe was positioned at the center of the tumor. The B-scans were viewed in real time to visualize the tumor, and images were saved to the computer. Then, the PAI probe was positioned at the same HFUS probe position and raw line scans were acquired. Photoacoustic imaging images were obtained by postprocessing with custom software using MATLAB (MathWorks Inc.). The patients then underwent MMS. The excised tumor layer for each NMSC was brought to the laboratory, and frozen sections were prepared and stained with hematoxylin & eosin (H&E) for morphological assessment. Histological tumor thickness measurements were performed by the Mohs surgeon (N.C.Z.). Results Squamous Cell Carcinoma Figure 1 shows results from a patient with a squamous cell carcinoma tumor. The H&E staining image showed a tumor extent with a largest measured thickness of 0.625 mm. The HFUS image showed a hypoechoic area defining a tumor of 0.73 6 0.03 mm thickness (mean 6 standard deviation of 3 independent measurements) (Figure 1A), and the PAI map at 580 nm showed enhanced optical absorption contrast (Figure 1B). The hemoglobin absorption at 580 nm is close isosbestic point (584 nm), thus the PAI signal is mainly originated from blood absorption in the microvasculature and the signal intensity is proportional to the blood volume.
Figure 1. Squamous cell carcinoma case. (A) High-frequency ultrasound image. (B) Photoacoustic imaging map. Scale bar is 2 mm, arrow indicating tumor area.
526
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Basal cell carcinoma case. (A) High-frequency ultrasound image. (B) Photoacoustic imaging map. Scale bar is 2 mm, arrow indicating tumor area.
Basal Cell Carcinoma Figure 2 shows results from a patient with a nodular basal cell carcinoma tumor. The largest tumor thickness measured by the H&E was 0.50 mm, and HFUS image (Figure 2A) indicated a tumor size of 0.53 6 0.02 mm. Figure 2B shows the PAI map, indicating high hemoglobin absorption in the tumor areas supporting the HFUS image. High-Frequency Ultrasound Thickness Versus Histological Thickness: Statistical Results High-resolution HFUS measurements were performed for all patients (N = 21). The statistical analyses were performed using MATLAB software. This analysis showed that there was a strong correlation (r2 = 0.87) between ultrasound thickness and histological thickness, and the paired t-test showed no significant difference (p = .31) between 2 measurement groups.
include involvement of a small number of patients, especially for PAI measurements. Photoacoustic imaging is a relatively new technique, and pilot clinical studies may help increased acceptance in clinical settings. The results suggest that a concurrent multimodal imaging system based on HFUS and PAI can assist surgeons in preoperative assessment of tumor characteristics and provide improved tumor demarcation during surgical planning. Acknowledgments Dedicated to Janet Morgan. The authors thank Anne Paquette and Ken Keymel for the help at the clinic. References 1. Marmur ES, Berkowitz EZ, Fuchs BS, Singer GK, et al. Use of highfrequency, high-resolution ultrasound before Mohs surgery. Derm Surg 2010;36:841–7. 2. Mogensen M, Nurnberg BM, Forman JL, Thomsen JB, et al. In vivo thickness measurement of basal cell carcinoma and actinic keratosis with optical coherence tomography and 20-MHz ultrasound. Br J Dermatol 2009;160:1026–33.
Discussion
3. Maslov K, Stoica G, Wang LV. In vivo dark-field reflection-mode photoacoustic microscopy. Opt Lett 2005;30:625–7.
To better guide surgery and therapy of NMSC, precise information about tumor depth and thickness is desired. Any additional contrast that can complement the structural contrast would be beneficial for improved visualization before management. The authors showed that HFUS provided high-resolution structural images such as thickness of NMSCs, which correlated well with the histological measurements. Photoacoustic imaging provided high optical contrast originated from the hemoglobin absorption. This was a pilot study to establish these techniques and parameters for the future clinical trials. The limitations of the study
4. Wang PH, Luh JJ, Chen WS, Li ML. In vivo photoacoustic microimaging of microvascular changes for Achilles tendon injury on a mouse model. Biomed Opt Express 2011;2:1462–9. 5. Rohrbach D, Muffoletto D, Huihui J, Saager R, et al. Preoperative mapping of nonmelanoma skin cancer using spatial frequency domain and ultrasound imaging. Acad Radiol 2014;21:263–70.
Nathalie C. Zeitouni, MDCM Department of Dermatology University of Arizona Cancer Center Tucson, Arizona Daniel J. Rohrbach, PhD Mehmet Aksahin, PhD
41:4:APRIL 2015
527
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Department of Cell Stress Biology Roswell Park Cancer Institute Buffalo, New York
Department of Biomedical Engineering University at Buffalo Buffalo, New York
Ulas Sunar, PhD Department of Cell Stress Biology Roswell Park Cancer Institute Buffalo, New York
Supported by the American Society for Dermatologic Surgery Cutting Edge Research Grant (CERG) and by NCI P30CA16056. The authors have indicated no significant interest with commercial supporters.
Successful Treatment of a Large Solitary Nasal Tip Trichoepithelioma Using the 10,600-nm Carbon Dioxide Laser
Trichoepitheliomas are benign cutaneous neoplasms that occur mostly on the face. There are 2 presentations—a hereditary multiple form affecting the nasolabial sulci, nose, and forehead of young adults (Brooke–Spiegler syndrome) and a nonhereditary solitary form affecting adults. Other than surgery, treatments such as electrocautery, cryotherapy, dermabrasion, trichloroacetic acid, retinoic acid, radiation therapy, and carbon dioxide (CO2) laser1,2 have all been used for the palliation of the trichoepitheliomas in Brooke– Spiegler syndrome.
from the columella to the nose bridge (Figure 1). The distorted nasal architecture was distressing, and he wanted improved cosmesis without undergoing a surgical resection. The objective was to reduce the lesion and recontour the nose while minimizing downtime. Although the CO2 laser has been used on subcentimeter trichoepitheliomas in Brooke–Spiegler syndrome, 3,4 it has not been used on large solitary trichoepitheliomas.
The authors report a 67-year-old Chinese man with a recurrent disfiguring large solitary trichoepithelioma on his nasal tip, which was successfully treated with the 10,600-nm CO2 laser. As solitary trichoepitheliomas are rare, there have been few case reports of large trichoepitheliomas involving the nose, all of which were excised.3,4 This patient first underwent excision of a small nasal tip nodule by a plastics surgeon in 1996. Histology returned as a trichoepithelioma. In 2010, a 20· 15 mm nodule recurred. A shave biopsy was performed with plans for further surgery including a paramedian forehead flap reconstruction. The patient was however not keen for more extensive surgery. In 2011, recurrence was noticed, and by 2014, a 35 · 15 mm lobulated plaque extended up the nasal tip
528
Figure 1. Extensive skin-colored nodular lesion extending up the nasal tip from the columella to the nasal bridge. This caused distortion of the nasal contours and was distressing to the patient.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
composed of small basaloid cells without atypia in a densely collagenous stroma. Horn cysts and focus of calcification were seen within some of the islands. These features confirmed the diagnosis of DTE (Figure 4A).
Discussion This case not only supports the previously reported dermoscopic, RCM, and histological features of a DTE but also provides novel insights into its morphological features using HD-OCT. The low-reflective dermal tumor islands (slice and en face) correlate with the dark tumor islands seen in RCM and also with the strands of basaloid cells observed in histology.3,4 The surrounding highly reflective collagen and dilated vessels in HD-OCT correspond to the same structures presented in the desmoplastic stroma both in RCM and histopathology. The presence of these features, the connection between some islands and follicles, and also the absence of epidermal disarray, inflammatory cells, and peripheral dark rim, which are usually seen in BCC, allowed to favor the diagnosis of DTE over BCC in HD-OCT.5 In conclusion, this case demonstrated an excellent correlation between HD-OCT, RCM, and histopathology. To the best of the authors’ knowledge, this is the first report of HD-OCT imaging of rare DTE. Recognition of such features may facilitate its in vivo diagnosis, avoiding invasive diagnostic techniques of an otherwise benign tumor frequently located in cosmetically sensitive areas.
References 1. Mamelak AJ, Goldberg LH, Katz TM, Graves JJ, et al. Desmoplastic trichoepithelioma. J Am Acad Dermatol 2010;62:102–6. 2. Boone M, Norrenberg S, Jemec G, Del Marmol V. High-definition optical coherence tomography imaging of melanocytic lesions: a pilot study. Arch Dermatol Res 2014;306:11–26. 3. Khelifa E, Masouyé I, Kaya G, Le Gal FA. Dermoscopy of desmoplastic trichoepithelioma reveals other criteria to distinguish it from basal cell carcinoma. Dermatology 2013;226:101–4. 4. Ardigo M, Zieff J, Scope A, Gill M, et al. Dermoscopic and reflectance confocal microscopy findings of trichoepithelioma. Dermatology 2007; 215:354–8. 5. Boone MALM, Norrenberg S, Jemec GBE, Del Marmol V. Imaging of basal cell carcinoma by high-definition optical coherence tomography: histomorphological correlation. A pilot study. Br J Dermatol 2012;167: 856–64.
André Oliveira, MD Department of Dermatology Hospital de Curry Cabral—Centro Hospitalar de Lisboa Central Lisboa, Portugal Edith Arzberger, MD Iris Zalaudek, MD Rainer Hofmann-Wellenhof, MD Department of Dermatology Medical University of Graz Graz, Austria The authors have indicated no significant interest with commercial supporters.
Preoperative Ultrasound and Photoacoustic Imaging of Nonmelanoma Skin Cancers There is a growing concern over the rising incidence of nonmelanoma skin cancer (NMSC), and higher treatment-related cost may become a burden on the healthcare system. Management of NMSC is usually surgical either by local excision or Mohs micrographic surgery (MMS).1 Tumor recurrence rates, prolonged surgical times, and significant patient morbidity could be improved with tools that would allow for more accurate tumor evaluation and planning before surgery. Several noninvasive imaging modalities have been applied to NMSC. Among them, high-frequency
ultrasound (HFUS) can provide structural information about tumor size with its high resolution (50 mm) and deep penetration depth (>2 mm).1,2 However, the technique relies on mechanical contrast rather than functional contrast. It is desirable to increase tumor contrast for improved tumor demarcation. In this respect, optical contrast can complement ultrasound contrast. Photoacoustic imaging (PAI) can aid HFUS with its high contrast and sensitivity measures. Photoacoustic imaging is based on pulsed laser light being absorbed by chromophores (e.g., hemoglobin in blood), which leads to thermoelastic expansion and generation of sound
41:4:APRIL 2015
525
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
waves.3 Photoacoustic imaging can quantify highresolution vasculature with an achievable spatial resolution of 50 mm at 3 mm depth,3,4 thus being suitable for noninvasive imaging of skin malignancies. This pilot study was designed to validate tumor thickness measurements obtained with HFUS by comparing them with histological thicknesses obtained during MMS. The authors also obtained vascular maps by PAI to enhance contrast for improved tumor demarcation and to help establish these techniques for future clinical trials involving surgery. Experimental Design and Methods An IRB-approved clinical trial (protocol #I226912) was initiated at Roswell Park Cancer Institute.5 Twenty-one patients with biopsy-proven NMSCs, of a minimum diameter of 0.5 to 1 cm, who were scheduled for MMS were enrolled, and written informed consent was obtained from all subjects. A commercial grade HFUS imaging system (40 MHz, Episcan; Longport Inc.) was used because of its capability of providing high spatial resolution (45 mm axial [depth] resolution) with an 5 mm signal penetration depth. Custom clinical PAI system had a tunable laser (5 nanosecond pulse width, 20 Hz pulse repetition rate), a 20 MHz focused ring transducer with a 600 mm multimode fiber so that the laser fiber and transducer were set coaxially in a combined probe. The laser beam was collimated with a beam diameter of 2 mm on the sample. The system had 5 mm signal penetration depth and 80 mm depth resolution. High-frequency ultrasound and PAI
scans were performed sequentially. First, ultrasound gel was applied to the tumor and the HFUS probe was positioned at the center of the tumor. The B-scans were viewed in real time to visualize the tumor, and images were saved to the computer. Then, the PAI probe was positioned at the same HFUS probe position and raw line scans were acquired. Photoacoustic imaging images were obtained by postprocessing with custom software using MATLAB (MathWorks Inc.). The patients then underwent MMS. The excised tumor layer for each NMSC was brought to the laboratory, and frozen sections were prepared and stained with hematoxylin & eosin (H&E) for morphological assessment. Histological tumor thickness measurements were performed by the Mohs surgeon (N.C.Z.). Results Squamous Cell Carcinoma Figure 1 shows results from a patient with a squamous cell carcinoma tumor. The H&E staining image showed a tumor extent with a largest measured thickness of 0.625 mm. The HFUS image showed a hypoechoic area defining a tumor of 0.73 6 0.03 mm thickness (mean 6 standard deviation of 3 independent measurements) (Figure 1A), and the PAI map at 580 nm showed enhanced optical absorption contrast (Figure 1B). The hemoglobin absorption at 580 nm is close isosbestic point (584 nm), thus the PAI signal is mainly originated from blood absorption in the microvasculature and the signal intensity is proportional to the blood volume.
Figure 1. Squamous cell carcinoma case. (A) High-frequency ultrasound image. (B) Photoacoustic imaging map. Scale bar is 2 mm, arrow indicating tumor area.
526
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 2. Basal cell carcinoma case. (A) High-frequency ultrasound image. (B) Photoacoustic imaging map. Scale bar is 2 mm, arrow indicating tumor area.
Basal Cell Carcinoma Figure 2 shows results from a patient with a nodular basal cell carcinoma tumor. The largest tumor thickness measured by the H&E was 0.50 mm, and HFUS image (Figure 2A) indicated a tumor size of 0.53 6 0.02 mm. Figure 2B shows the PAI map, indicating high hemoglobin absorption in the tumor areas supporting the HFUS image. High-Frequency Ultrasound Thickness Versus Histological Thickness: Statistical Results High-resolution HFUS measurements were performed for all patients (N = 21). The statistical analyses were performed using MATLAB software. This analysis showed that there was a strong correlation (r2 = 0.87) between ultrasound thickness and histological thickness, and the paired t-test showed no significant difference (p = .31) between 2 measurement groups.
include involvement of a small number of patients, especially for PAI measurements. Photoacoustic imaging is a relatively new technique, and pilot clinical studies may help increased acceptance in clinical settings. The results suggest that a concurrent multimodal imaging system based on HFUS and PAI can assist surgeons in preoperative assessment of tumor characteristics and provide improved tumor demarcation during surgical planning. Acknowledgments Dedicated to Janet Morgan. The authors thank Anne Paquette and Ken Keymel for the help at the clinic. References 1. Marmur ES, Berkowitz EZ, Fuchs BS, Singer GK, et al. Use of highfrequency, high-resolution ultrasound before Mohs surgery. Derm Surg 2010;36:841–7. 2. Mogensen M, Nurnberg BM, Forman JL, Thomsen JB, et al. In vivo thickness measurement of basal cell carcinoma and actinic keratosis with optical coherence tomography and 20-MHz ultrasound. Br J Dermatol 2009;160:1026–33.
Discussion
3. Maslov K, Stoica G, Wang LV. In vivo dark-field reflection-mode photoacoustic microscopy. Opt Lett 2005;30:625–7.
To better guide surgery and therapy of NMSC, precise information about tumor depth and thickness is desired. Any additional contrast that can complement the structural contrast would be beneficial for improved visualization before management. The authors showed that HFUS provided high-resolution structural images such as thickness of NMSCs, which correlated well with the histological measurements. Photoacoustic imaging provided high optical contrast originated from the hemoglobin absorption. This was a pilot study to establish these techniques and parameters for the future clinical trials. The limitations of the study
4. Wang PH, Luh JJ, Chen WS, Li ML. In vivo photoacoustic microimaging of microvascular changes for Achilles tendon injury on a mouse model. Biomed Opt Express 2011;2:1462–9. 5. Rohrbach D, Muffoletto D, Huihui J, Saager R, et al. Preoperative mapping of nonmelanoma skin cancer using spatial frequency domain and ultrasound imaging. Acad Radiol 2014;21:263–70.
Nathalie C. Zeitouni, MDCM Department of Dermatology University of Arizona Cancer Center Tucson, Arizona Daniel J. Rohrbach, PhD Mehmet Aksahin, PhD
41:4:APRIL 2015
527
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Department of Cell Stress Biology Roswell Park Cancer Institute Buffalo, New York
Department of Biomedical Engineering University at Buffalo Buffalo, New York
Ulas Sunar, PhD Department of Cell Stress Biology Roswell Park Cancer Institute Buffalo, New York
Supported by the American Society for Dermatologic Surgery Cutting Edge Research Grant (CERG) and by NCI P30CA16056. The authors have indicated no significant interest with commercial supporters.
Successful Treatment of a Large Solitary Nasal Tip Trichoepithelioma Using the 10,600-nm Carbon Dioxide Laser
Trichoepitheliomas are benign cutaneous neoplasms that occur mostly on the face. There are 2 presentations—a hereditary multiple form affecting the nasolabial sulci, nose, and forehead of young adults (Brooke–Spiegler syndrome) and a nonhereditary solitary form affecting adults. Other than surgery, treatments such as electrocautery, cryotherapy, dermabrasion, trichloroacetic acid, retinoic acid, radiation therapy, and carbon dioxide (CO2) laser1,2 have all been used for the palliation of the trichoepitheliomas in Brooke– Spiegler syndrome.
from the columella to the nose bridge (Figure 1). The distorted nasal architecture was distressing, and he wanted improved cosmesis without undergoing a surgical resection. The objective was to reduce the lesion and recontour the nose while minimizing downtime. Although the CO2 laser has been used on subcentimeter trichoepitheliomas in Brooke–Spiegler syndrome, 3,4 it has not been used on large solitary trichoepitheliomas.
The authors report a 67-year-old Chinese man with a recurrent disfiguring large solitary trichoepithelioma on his nasal tip, which was successfully treated with the 10,600-nm CO2 laser. As solitary trichoepitheliomas are rare, there have been few case reports of large trichoepitheliomas involving the nose, all of which were excised.3,4 This patient first underwent excision of a small nasal tip nodule by a plastics surgeon in 1996. Histology returned as a trichoepithelioma. In 2010, a 20· 15 mm nodule recurred. A shave biopsy was performed with plans for further surgery including a paramedian forehead flap reconstruction. The patient was however not keen for more extensive surgery. In 2011, recurrence was noticed, and by 2014, a 35 · 15 mm lobulated plaque extended up the nasal tip
528
Figure 1. Extensive skin-colored nodular lesion extending up the nasal tip from the columella to the nasal bridge. This caused distortion of the nasal contours and was distressing to the patient.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
