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19. Edwards JD, Sadeghi N, Najam F, et al. Craniocervical necrotizing fasciitis of odontogenic origin with mediastinal extension. Ear Nose Throat J 2004;83:579Y582 20. Fenton CC, Kertesz T, Baker G, et al. Necrotizing fasciitis of the face: a rare but dangerous complication of dental infection. J Can Dent Assoc 2004;70:611Y615 21. Wong CH, Kurup A, Wang YS, et al. Four cases of necrotizing fasciitis caused by Klebsiella species. Eur J Clin Microbiol Infect Dis 2004; 23:403Y407 22. Stamenkovic I, Lew PD. Early recognition of potentially fatal necrotizing fasciitis. The use of frozen-section biopsy. N Engl J Med 1984;310:1689Y1693 23. McHenry CR, Piotrowski JJ, Petrinic D, et al. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg 1995;221:558Y563

Wide Excision and Anterolateral Thigh Perforator Flap Reconstruction for Dermatofibrosarcoma Protuberans of the Face Benedetto Longo, MD, PhD,* Guido Paolini, MD, PhD,* Evaristo Belli, MD,Þ Brando Costantino, MD,* Marco Pagnoni, MD,* Fabio Santanelli, MD, PhD* Abstract: Dermatofibrosarcoma protuberans is a rare cutaneous malignant tumor associated with a high cure rate but with a high incidence of local recurrence. Because of its tentacle-like subcutaneous infiltrating pattern that extends far beyond the clinically visible skin lesion, a wide resection margin is recommended. Hence, its localization to the head-and-neck regions, although rare, represents a real challenge for both the oncologic surgeon and the reconstructive surgeon, who aim to achieve a radical resection of the tumor with the best possible aesthetic outcome. A case of a 21-year-old Mediterranean man who presented with a 7-month history of a slowly growing subcutaneous lesion of the left preauricular region is reported. A diagnosis of dermatofibrosarcoma protuberans CD34+ was confirmed through surgical biopsy, and the patient subsequently underwent a wide en bloc local surgical resection, followed by anterolateral thigh perforator free flap reconstruction. Healing was uneventful. Initially, there was some facial nerve neurapraxia; however, this completely subsided within 3 months after the surgery. At the 13-month follow-up, the patient was completely well and free from the disease.

From the *Plastic Surgery Unit, and †Maxillofacial Surgery Unit, Department of Neuroscienze, Salute Mentale e Organi di Senso, Sant’Andrea Hospital, School of Medicine and Psychology, Sapienza University of Rome, Rome, Italy. Received April 4, 2013. Accepted for publication June 23, 2013. Address correspondence and reprint requests to Dr. Fabio Santanelli, Via di Grottarossa 1035-39, 00189, Rome, Italy; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a238c1

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Key Words: Dermatofibrosarcoma protuberans, ALT perforator flap, facial tumor, head-neck tumor, skin tumor

D

ermatofibrosarcoma protuberans (DFSP) is a slowly growing but locally aggressive malignant skin tumor that can affect any region of the body, mostly the trunk (42%Y72%) and the extremities (16%Y30%) and, less frequently, the region of the head and neck (10%Y16%).1 The high tendency of the lesion for local relapse2 due to its peculiar branching pattern of infiltration within all the surrounding tissues, the large oncologically safe excision, and the preservation of the physiognomic important structure of the face with aesthetically acceptable reconstruction all together represent one of the most challenging tasks for the surgeon to deal with. Although DFSP behaves as a nonYaggressive malignancy, complete surgical resection of the affected area is mandatory because the recurrence rate strictly depends on it. We report the use of anterolateral thigh (ALT) perforator flap after a wide local excision (WLE) for DFSP of the face.

CLINICAL REPORT A 21-year-old Mediterranean man with an uneventful medical history presented with a slowly growing (7 mo) painless dermal-subcutaneous mass localized at the left gonial region. A 2.5  1.5- cm erythematous, slightly protruding dermal lesion, which was apparently independent and mobile from the deeper structures, with no facial nerve involvement was found during clinical examination (Fig. 1). The results of magnetic resonance imaging revealed a squared, well-vascularized,

FIGURE 1. Upper left, Preoperative lateral view. Upper right, The 12-month postoperative lateral view. Lower left, Preoperative oblique view. Lower right, The 12-month postoperative oblique view.

* 2013 Mutaz B. Habal, MD

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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FIGURE 2. Left, Preoperative markings of the surgical resection with 4 cm of grossly disease-free skin margin. Right, Intraoperative view of the recipient site showing a 10  10-cm soft tissue defect with preserved facial nerve branches.

31  23  6.5-mm lesion extending from the skin plane toward the parotid fascia and the fascia of the posterior border of the masseter muscle, which it appeared to be adherent to. A preoperative computed tomographic scan showed no regional or distant lymph node involvement, or metastases. Wide en bloc resection of the mass was planned, ensuring at least 4 cm of grossly disease-free skin margin (Fig. 2). Given the preoperative evidence of parotid fascia involvement, superficially combined centrifugal (anterograde) and centripetal (retrograde) facial nerveYsparing parotidectomy was performed (Figs. 2, 3). The plastic surgeon (B.L.) performed the reconstruction with a free ALT perforator flap (Fig. 4) using the superior left thyroid artery and vein as recipient vessels and an external jugular vein as the tributary to receive the second vein anastomosis. The frozen section of a pretragic specimen was negative; hence, via excision of a Burow triangle on the posterior aspect of the flap to create an inset, the earlobe was correctly repositioned. Despite the flap’s dimension, the primary donor-site closure was achieved (Fig. 5). The results of the histopathologic examination revealed a complete mass excision with disease-free resection margins and disease-free intraparotid, jugulodigastric lymph nodes. The results of the immunohistochemical analysis showed no fibrosarcomatous transformation of the DFSP, so adjuvant radiation therapy was not indicated. Healing was uneventful. Initially, there was some facial nerve neurapraxia; however, this completely subsided within 3 months after the surgery. At the 13-month follow-up, the patient was completely well and free from the disease.

FIGURE 4. Intraoperative view of the harvested ALT perforator flap before its transfer to the recipient site. The red and blue vessel loops identify the 2 perforators and vascular pedicle.

with fibrosarcomatous transformation (5% of cases).3 Prognosis is generally good, but advanced tumors and their trend for recurrence lead to significant morbidity and social costs. The precise rate of recurrence is, nowadays, still unclear. Data from peer-reviewed articles show widely variable results: the older the study, the higher the incidence. During the last 20 years, data pooled from various studies that published DFSP recurrence rate highlighted a 7.3% recurrence rate in 1443 patients treated with WLE versus a 1% recurrence rate in patients that underwent Mohs micrographic surgery (MMS). These data are somewhat difficult to interpret. Historically, head-and-neck DFSP localization (24.7% incidence) seems to be a negative prognostic indicator. Tumors of this area tend to have much of a higher recurrence rate compared with their trunk-and-extremities equivalents. This looks like an underestimation of the disease in the region of the head and neck and a suboptimal preoperative resection planning. The main surgical concern, in our opinion, is the safe resection margin. The strict anatomopathologic features of the DFSP, its tentacle-like random infiltrating pattern, demand a need for a standardized width to dictate the removal area. Although the term wide is not very well defined in the literature, most authors consider a 1- to

DISCUSSION Dermatofibrosarcoma protuberans is a low-grade, slowly progressing, locally aggressive tumor that rarely metastasizes, with an estimated rate between 0.5% and 5%; distance spread seems to be associated

FIGURE 3. Intraoperative view of the resected tumor comprising the superficial muscular aponeurotic system, superficial parotid lobe, and a strip of the posterior edge of the masseter muscle and the fascia.

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FIGURE 5. Left, Preoperative ALT flap markings. Right, The 12-month postoperative view of the donor site.

* 2013 Mutaz B. Habal, MD

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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4-cm margin as wide4,5 and so does the National Comprehensive Cancer Network.6 Nevertheless, some authors reported a high rate of local recurrence (71%) after close tumor resection with the need to perform wider surgical revisions of the margins.4 Ratner et al’s microscopic review of 58 patients with DFPS (treated with MMS) demonstrated that 70% of the tumors extended 1 cm beyond the macroscopically visible lesion, that 15% extended at least 3 cm, and that 5% extended at least 5 cm.7 These data led us to our assumption that this tumor can and must be treated in the area of head and neck in the same way that it is treated in its trunk and extremities localization. The problem of obtaining postprocedural oncologic radicality and a near-to-zero recurrence rate seems to be related to the possibility of thoroughly including this peculiar tumor within the specimen. The surgeon should not be reluctant to sacrifice important structures such as the main arteries, nerves or bony structures, and aesthetic subunits if needed. A single-stage, radical, disease-freeing procedure will end up in much of a less disfiguring outcome and morbidity if compared with multiple attempts to contain such disease’s recurrences. It is thus clear that preoperative surgical planning plays a key role in establishing the most correct approach for every single patient. We do believe that a combined approach with 4 cm of grossly disease-free skin margin and a three-dimensional analysis of the planned defect allows the oncologic surgeon to obtain a safe oncological resection and the reconstructive surgeon to restore as much as possible the anatomic continuity, given his arsenal of composite flaps. In this perspective, there are almost no limits to how aggressive the demolition can be. Careful flap selection, guided by the like with like concept, will lead to satisfactory results. In our case, the resection specimen was a 10  10-cm skin paddle, including the superficial muscular aponeurotic system, the superficial parotid lobe, as well as a strip of the posterior edge of the masseter muscle and its fascia. An ALT perforator flap was selected to replace the entire aesthetic unit of the left cheek. Because of the need to reconstruct the soft tissue only, this thin (and can be further thinned), pliable, hair-bearing, and color-matching free flap best suited our goals.8,9 The final results were a healthy and satisfied patient, no donor-site morbidity, and an aesthetically pleasant result with a harmonic and symmetric facial contour. We do believe that WLE should be the appropriate surgical approach for facial DFSP because the MMS technique represents a costly and time-consuming outpatient procedure that could force both the surgeon and the patient to a lengthy time span in the operating room or office, often requiring multiple procedures, until the frozen section of specimen results to freedom from the disease. Even if some authors reported safe results with MMS,10 this technique may compromise the choice for an ideal and aesthetically pleasant reconstructive procedure, especially in complex cases such as that presented in our study, where a perforator free flap for facial reconstruction is required. The MMS may thus become more expensive and less cost-effective than other routine treatment measures such as 1-stage WLE and ALT perforator flap reconstruction. Nevertheless, future objective studies to investigate on the effectiveness of WLE compared with MMS for DFSP are required to come to a standardized surgical approach to this locally aggressive tumor in the craniofacial area.

REFERENCES 1. Lemm D, Mu¨gge LO, Mentzel T, et al. Current treatment options in dermatofibrosarcoma protuberans. J Cancer Res Clin Oncol 2009;135:653Y665 2. Angouridakis N, Kafas P, Jerjes W, et al. Dermatofibrosarcoma protuberans with fibrosarcomatous transformation of the head and neck. Head Neck Oncol 2011;3:5 3. Bogucki B, Neuhaus I, Hurst EA. Dermatofibrosarcoma protuberans: a review of the literature. Dermatol Surg 2012;38:537Y551

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4. Thiele OC, Seeberger R, Bacon C, et al. Recurrent craniofacial dermatofibrosarcoma protuberans: long-term prognosis after close surgical removal. J Craniofac Surg 2009;20:844Y846 5. Farma J, Ammori J, Zager J, et al. Dermatofibrosarcoma protuberans: how wide should we resect? Ann Surg Oncol 2010;17:2112Y2118 6. National Comprehensive Cancer Network (NCCN) guidelines. Available at: http://www.nccn.org. Accessed February 1, 2013 7. Ratner D, Thomas C, Johnson T, et al. Mohs micrographic surgery for the treatment of dematofibrosarcoma protuberans. Results of a multiinstitutional series with an analysis of the extent of microscopic spread. J Am Acad Dermatol 1997;37:600Y613 8. Agostini T, Lazzeri D, Agostini V, et al. Anterolateral thigh flap as the ideal flap to full-thickness cheek reconstruction. J Craniofac Surg 2010;21:1897Y1898 9. Liu SC, Chiu WK, Chen SY, et al. Comparison of surgical result of anterolateral thigh flap in reconstruction of through-and-through cheek defect with/without CT angiography guidance. J Craniomaxillofac Surg 2011;39:633Y638 10. Simman R, DeFranzo A, Sanger C, et al. Dermatofibrosarcoma protuberans of the face: surgical management. J Craniofac Surg 2005;16:439Y443

Occupational Safety Threats Among Dental Personnel and Related Risk Factors M. Kezban Gurbuz, MD,* Tolgahan C¸atli, MD,Þ Cemal Cingi, MD,* Aytekin Yaz, MD,þ Cengiz Bal, PhD§ Abstract: Occupational diseases are primarily considered to be important health problems for individuals with occupations in heavy industry fields. Although dentists work in very clean and elegant offices, they are frequently exposed to various chemicals and highintensity, sound-producing instruments, such as compressors and aerators. In our study, we aimed to investigate the risk for occupational hearing loss of dental personnel, by performing pure-tone audiometry in 40 dentists and comparing the results with those of healthy individuals. We also sampled the nasal mucosa to investigate the effects of occupational chemicals on the nasal mucosa of the dentists. The pure-tone audiometric thresholds at 5 different frequencies (1000, 2000, 4000, 6000, and 8000 Hz) and working time were evaluated as potential risk factors. The pure-tone audiometric results (as decibels) at each frequency and the median values for each side (right and left ears) were significantly higher for dentists than for the control group (P G 0.05). The pure-tone audiometric results did not significantly differ between the women and men in the study group (P 9 0.05). From the *Department of Otorhinolaryngology, Osmangazi University, Medical Faculty, Eskisehir; †ENT Clinic, Ministry of Health, Bozyaka Training and Reserch Hospital, Izmir; ‡ENT Clinic, Ministry of Health, Gaziantep Sehit Kamil State Hospital, Gaziantep; and §Department of Biostatistics, Medical Faculty, Eskisehir Osmangazi University Eskisehir, Turkey. Received March 21, 2013. Accepted for publication May 27, 2013. Address correspondence and reprint requests to Tolgahan C ¸ atli, MD, Bozyaka Teaching and Research Hospital, Saim C ¸ ikrik0i Street, Bozyaka/Izmir 35170 Turkey; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a28b80

* 2013 Mutaz B. Habal, MD

Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Wide excision and anterolateral thigh perforator flap reconstruction for dermatofibrosarcoma protuberans of the face.

Dermatofibrosarcoma protuberans is a rare cutaneous malignant tumor associated with a high cure rate but with a high incidence of local recurrence. Be...
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