Burak Kaya

Objectives: To compare preoperative diagnostic concordance and histopathological margin outcomes between two pathways for clinically suspected nonmelanoma skin cancer: assessment and margin marking by dermatologists using clinical examination and dermoscopy versus assessment and marking by plastic surgeons using clinical examination and guideline-based risk stratification. All excisions were performed by the same plastic surgery team.Materials and Methods: This single-center, nonrandomized, prospective cohort study included patients presenting independently to Dermatology or to Plastic Surgery from December 2023 through December 2024 for primary excision of clinically suspicious lesions. After exclusions, 184 patients were analyzed: 100 in the dermatology pathway and 84 in the plastic surgery pathway. Comparisons used the Mann–Whitney U, chi-square, or Fisher exact test. Multivariable logistic regression adjusted margin positivity for age, tumor type, and anatomical site.Results: Diagnostic concordance was higher in dermatology pathway (63/70, 90.0%) than in plastic surgery pathway (41/60, 68.3%; risk difference 21.7 percentage points, 95% CI 8.0–35.4; OR 4.17, 95% CI 1.61–10.80; p=0.004). Positive margins occurred in 11/100 (11.0%) and 11/84 (13.1%), respectively (OR 0.82, 95% CI 0.34–2.00; p=0.820), with no association after adjustment (OR 0.86, 95% CI 0.34–2.16; p=0.747). The nearest lateral margin was wider in dermatology pathway (median 3.20 vs. 2.70 mm; p=0.027), but the difference became non-significant after excluding involved margins (p=0.053). Deep margins and tumor thickness were similar.Conclusion: Dermatologist-led preoperative assessment incorporating dermoscopy was associated with greater diagnostic concordance and in the primary analysis, wider lateral histopathological margins but not with a lower positive-margin rate. Because all excisions were performed by one surgical team, specialist preoperative assessment contributes principally to lesion characterization rather than to surgical clearance.

Background: Malignant proliferating trichilemmal tumor is a rare adnexal malignancy derived from the outer root sheath. It most often affects the scalp and may be mistaken for squamous cell carcinoma because of overlapping clinical and histopathological features. As a result, management is largely informed by small case series and case reports. Methods: We retrospectively reviewed 11 consecutive patients with histopathologically confirmed malignant proliferating trichilemmal tumor managed at two tertiary referral centers between January 2020 and May 2024. Demographic, clinicopathological, operative, immunohistochemical, and follow-up data were analyzed. To place our cohort in context, we also performed a focused narrative review of the recent literature on malignant proliferating trichilemmal tumor and related trichilemmal malignancies. Results: The mean age was 64.1 ± 5.7 years (range, 55–74 years), and 7 patients were female. Mean tumor diameter was 27.5 ± 9.1 mm. Five patients (45.5%) had coexisting trichilemmal cysts. All patients underwent wide local excision with planned 1–2 cm clinical margins; 6 patients (54.5%) required local or free flap reconstruction. p53 showed diffuse nuclear positivity in 10 of 11 tumors (90.9%), and Ki-67 exceeded 20% in 8 of 11 (72.7%). Two patients (18.2%) had compromised deep margins on the index excision specimen and underwent re-excision. No local recurrence, nodal disease, or distant metastasis was identified during a mean follow-up of 16.3 ± 5.4 months. Conclusions: In this cohort, malignant proliferating trichilemmal tumor behaved primarily as a locally aggressive scalp malignancy in which adequate deep clearance was critical to definitive surgical management. Achieving histologically clear margins—particularly at the deep plane—and performing prompt re-excision when margins were compromised were the decisive factors for local control. Misinterpretation as squamous cell carcinoma remains a diagnostic pitfall on limited biopsy material and the reconstructive burden is notable, with more than half of patients requiring complex reconstruction. Mohs micrographic surgery is a reasonable option in selected cases, though the supporting data come largely from trichilemmal carcinoma and should not be applied to malignant proliferating trichilemmal tumor without caution. Careful pathological review and long-term follow-up are necessary for all patients.

Background: The free fibula flap is the gold standard for reconstructing mandibular defects caused by trauma, tumors, dysplastic diseases, osteoradionecrosis, and atrophy. However, it has not yet been shown to be the ideal method for condylar reconstruction. This anatomical study proposes a surgically pragmatic approach to temporomandibular joint and condylar reconstruction by defining the vascularity of the chondrocostal joint. Methods: One fresh frozen and six fixed cadavers were dissected to assess the suitability of the 4th rib for the planned procedure. Bilateral internal thoracic vessels and branches surrounding chondrocostal joints were identified. The 4th chondrocostal joint flap was dissected with care to preserve the joint surface and perichondral vascularity. Digital calipers were used for precise measurements of maximal flap and pedicle length. The vascular anatomy was further explored in a fresh frozen cadaver through fluoroscopic imaging by radiopaque latex injection. The flap's suitability for temporomandibular joint reconstruction was tested by surgically removing the original temporomandibular joint from the cadaveric skull and positioning the chondrocostal joint flap in the resultant defect. Results: The dominant pedicle to the fourth chondrocostal joint was shown to be the perforators of the internal thoracic vessels. The mean pedicle length was 4.7 cm, which was sufficient to reach recipient vessels in the neck. The compatibility between the fourth chondrocostal joint and the glenoid fossa was confirmed. Conclusion: This study demonstrates that the fourth chondrocostal joint flap is a promising free flap for temporomandibular joint and condylar reconstruction. It offers ideal pedicle positioning, length, and vascular size match at the anastomosis, making it a suitable technique for reconstructing the challenging temporomandibular region. This approach adds a new option to the reconstructive surgeon's armamentarium, addressing previous limitations in condylar reconstruction.

Purpose There are few studies searching for possible perforator flap donor sites on the arm. This study aimed to identify the locations of cutaneous perforators of the arm according to anatomical landmarks. Methods Thirteen Thiel-fixed and latex-filled upper extremities of bodies donated to science were used. The distance between the acromion and medial or lateral epicondyle of the humerus was defined as the Y-axis, and the axis that cut the Y-axis perpendicularly through the epicondyles of the humerus was identified as the X-axis. The Y-axis was then divided into three parts Cutaneous arterial perforators were found using surgical dissection. The locations of the perforators were determined according to the defined lines and regions. Results On the lateral side, there were 6.00 ± 2.08 perforators per arm, of which 56.4% were septocutaneous and 43.6% muscular. In all extremities, with in the distal 1/3 of the lateral arm, there were 1–4 radial collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.16 ± 0.53 cm. On the medial side, there were 5.05 ± 1.44 perforators per arm, which were all septocutaneous perforators. In 85% of the extremities, within the middle 1/3 of the medial arms, there were 1–2 superior ulnar collateral artery-based perforators. The mean distance of these perforators to the Y-axis was 1.53 ± 0.61 cm. Conclusion There are always perforators from the radial collateral artery with in the distal third of the lateral arm. Within the middle third of the medial arm, it is usually possible to find a perforator from the superior ulnar collateral artery.