Richard is away this week so here are 2 cases which offer “something completely different”

CASE 1

A quick diagnostic case to get started. 55 yrold lady came in for a skin check has these longstanding lesions on her body. They change with time and are asymptomatic. What are they?

CASE 2

78 yrold “old timer” who lives alone and has these three neglected nodular BCC’s on his  nose.  His neighbour has persuaded him to come in and be looked at. He states “Can you fix me Doc?”

The largest BCC involves 75% of the nasal tip subunit and excision of this lesion  left only a thin layer of perichondrium at the base. Full thickness skin grafts sometimes can have a hard time healing on perichondrium only wound beds and in my opinion flaps on the central nose look  cosmetically superior to grafts.

I will point out that he  has a  low hairline (see below) so a paramedian forehead flap may involve transfer of hair to the nasal tip.

So what options have we?  And what would you do surgically to the other 2 BCC on the left nasal sidewall and nasal root?

So how do you “Fix me Doc?”  Give me your surgical plan for this mans nose.

My solution was 2 -stage cheek /nose interpolation flap with the excised flap pedicle taken as FTSG for the other BCC defects. At 2 weeks the flap looks better than the grafts.

A. Dermatoscopy: Ladies’ Thigh Highs

A couple of lesions on the thighs of two ladies. Are we in dangerous territory? Are things as they seem? Further images of these cases will be added at about midday.

Case 1 – Posterior thigh

This 75 year-old patient had no idea about this lesion – do you? Pass it over as a seb k / lentigo? Why or why not?

Below: The histology of this one…. (images courtesy Dr Duncan Lambie, IQ Pathology Brisbane)

Case 2 – Anterior thigh

This 50 year-old patient had noticed this pink lesion enlarge over 5-6 months. Her GP has seen it and reassured her.

B. Surgical: Lip-reading

This was a solid BCC on an upper lip. What would you countenance as a repair? Any specific considerations?

Below: Most of the options as described (and as I could understand them) …..

Below: What I did. This fellow is a sweaty fast-whisker-growing fellow who is very outdoorsy and is really a bit of a problem with wound hygiene. I thought that I would do the flap that had the most robust blood supply, require the least undermining and not pull on or push on the vermilion lip whilst respecting the melolabial groove.

Gallery

66 yo commercial pilot, skin phototype 2, PHx of having a SSM with a Breslow’s depth 0.73mm taken off his back by me 35 yrs ago. Also, PHx of previous NMSCs and cryotherapy for actinic keratoses.
He has had a longstanding dark mole on the thenar eminence on his left palm for many years.Photographs attached. Recent change. Three weeks ago he noticed some dryness and peeling of the skin around the mole and now the mole is much lighter in colour and looks like it is going to disappear.It has developed a white halo around the nevus.This was really only obvious when the clinical photograph was taken.
What do you think is going on here? Should we be concerned?
Photos from 2009:

Above photos were taken with my new toy, my ipad and dermoscopy photos taken using dermlite pro 2.
Then decided to use my old faithfuls- Canon EOS 450D and my Heine Delta 20 with oil emersion.

I don’t know if my neologism is excellent.
Well, you understand the meaning of the question!

Case 1, courtesy of Dr François Guilbert, Palaiseau

This case is from my friend Dr François Guilbert. Who is a keen dermoscopist and a great singer and guitar player (frenc accoustic repertoire, like Georges Brassens).
A slowly enlarging lesion on the cheek. Was is it?

Case 2.

Thanks to Photoshop and its merge function, here is a large lesion of the wrist in an 80 years old lady. Slow enlargement.
Funny vascular pattern. Polarized view.

Clinical view.

Gallery

Cliff is in the U.S.A. lecturing at the moment and has asked me to fill in for this posting. Big shoes to fill!! Anyway, here are two cases, one is LIVE!! (I like live cases as it kind of takes the psychology out of the equation!)

Case 1:

46 yr old man presenting for the first time. No PH of note. Wasn’t really aware of the pinkish lesion on the shoulder.

Case 2:

64 yr old lady. No PH of note. Right neck pigmented lesion noted at skin check.