Repeatable acute rhabdomyolysis with multiple organ dysfunction because of interferon α and dacarbazine treatment in metastatic melanoma

Sir, Dr Telfer's comments on the management of cutaneous squamous cell carcinoma (SCC) of the skin using Mohs' surgery were prompted by our paper on the use of formalinfixed tissue sections in Mohs' surgery. He has expressed concerns about the resulting delay between excision and closure that occurs as a result of using this method and has drawn some conclusions about the management of periocular tumours that are incorrect and not based on published evidence. We would like to clarify these points. We reported that the median delay between SCC excision and reconstruction was 4 days (range 2±28). The few cases that had long delays relate to the time when it was only possible to perform Mohs' surgery once a week in our department. In order to be able to do this type of surgery satisfactorily, experience has taught us that the dermatologist must have access to two (Tuesday and Thursday) or, better still, three (Monday, Wednesday and Friday) operating sessions per week. With these resources, 90% of the SCCs we treat can be excised and closed within 8 days. We agree that a delay lasting several weeks between excision and closure will make the final repair more difficult and will inconvenience the patient. However, we have previously shown, in a study not quoted by Dr Telfer, that a few days' delay has no discernible effect. Defects around the eye are particularly sensitive to the excellence of the closure technique employed. Our own experience of using the formalinfixed tissue technique to treat 123 periocular basal cell carcinomas showed that, on average, clearance was achieved after 1 ́6 excision stages and the mean delay between excision and closure was 80 h. We have found repeatedly that, with the aid of a simple wound dressing, full-thickness eyelid defects can be left for up to 3 days before closure and good cosmetic results can still be obtained. Long delays make wound closure more difficult but short delays do not; given sufficient resources, only short delays result from the use of the formalin-fixed tissue technique. We believe that there is still scope for useful practical developments using this type of alternative approach, and that this should not be rejected simply because is appears to be at variance with current dogma.