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Hindawi Publishing Corporation Journal of Skin Cancer Volume 2011, Article ID 181093, 8 pages doi:10.1155/2011/181093 Clinical Study 1 1 1 2 2 2 A. C. Salgarelli, P. Bellini, A. Multinu, C. Magnoni, M. Francomano, F. Fantini, 1 2 U. Consolo, and S. Seidenari Department of Head and Neck Surgery, Unit of Maxillofacial Surgery, Modena and Reggio Emilia University, Via del Pozzo 71, 41100 Modena, Italy Department of Dermatology, Head and Neck Skin Cancer Service, Modena and Reggio Emilia University, Via del Pozzo 71, 41100 Modena, Italy Correspondence should be addressed to A. C. Salgarelli, email@example.com Received 17 January 2011; Accepted 12 April 2011 Academic Editor: Arash Kimyai-Asadi Copyright © 2011 A. C. Salgarelli et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Reconstruction of nasal defects must preserve the integrity of complex facial functions and expressions, as well as facial symmetry and a pleasing aesthetic outcome. The reconstructive modality of choice will depend largely on the location, size, and depth of the surgical defect. Individualized therapy is the best course, and numerous ﬂaps have been designed to provide coverage of a variety of nasal-speciﬁc defects. We describe our experience in the aesthetic reconstruction of nasal skin defects following oncological surgery. The use of diﬀerent local ﬂaps for nasal skin cancer defects is reported in 286 patients. Complications in this series were one partial ﬂap dehiscence that healed by secondary intention, two forehead ﬂaps, and one bilobed ﬂap with minimal rim necrosis that resulted in an irregular scar requiring revision. Aesthetic results were deemed satisfactory by all patients and the operating surgeons. The color and texture matches were aesthetically good, and the nasal contour was distinct in all patients. All scars were inconspicuous and symmetrical. No patient had tenting or a ﬂat nose. 1. Introduction specimen sections to view the entire surgical margin. The disadvantages of the Mohs technique are that it is labor Themost common siteof facial skin cancer isthe nose intensive, time consuming, and quite dependent on the (25.5%), because of its cumulative exposure to sunlight [1– skills of not only the Mohs surgeon/pathologist but also the 3]. When dealing with primary non-melanoma nasal skin histotechnician who prepares the specimens. In addition, cancers, the most important goal is to obtain a tumor-free high cost has been a criticism of Mohs surgery in the patient. Several studies have outlined the surgical parameters literature . After tumor-free margins on frozen section necessary for the excision of primary nonmelanoma skin have been established, reconstruction of the surgical wound cancers [4–6]. Well-deﬁned primary basal cell carcinomas can be performed with conﬁdence. (BCCs) less than 2 cm in diameter should be excised with Given the vital functions of the nose in everyday life, 4.0-mm margins to obtain a 95% cure rate . Primary it is extremely important that the reconstruction of facial squamous cell carcinomas (SCCs) require 4.0-mm margins defects preserves the integrity of complex facial functions for low-risk tumors and 6.0 mm margins for high-risk and expressions, as well as facial symmetry and a pleasing tumors (≥2.0 cm; >II histological grade; nose, lip, scalp, ears, aesthetic outcome. When planning the reconstruction of eyelids; invasion into the subcutaneous tissue) to obtain a surgical defects, a surgeon must carefully consider a number of characteristics unique to the nose, including the inherent 95% cure rate [4, 6]. For these tumors, Mohs micrographic surgery oﬀersimprovedcure rates, asit isatechnique that structural complexity of the nose, with convex and concave allows for complete microscopic control of tumor removal in surfaces in close proximity, the symmetry of the nose, addition to superior tissue preservation. The Mohs technique the limited laxity of the nasal skin, and the sebaceous described in 1941 is based on the concept of excising composition of distal nasal skin. Finally, the function of the skin cancer layer by layer and examining horizontally cut nose must be maintained by preserving or replacing the bony 2 Journal of Skin Cancer and cartilaginous framework and the mucosal lining and deep, because placement that is too superﬁcial may leave by never compromising a patent airway. Re-establishing the permanent dimples. The buried sutures should approximate framework in nasal reconstruction is critical to achieving the edge closely enough that the top layer of the running both form and function. As the options for producing these cuticular sutures is under no tension. Owing to its advantages results may be limited in some cases, familiarity with a of simplicity, fewer suture lines, and fewer complications, variety of ﬂaps is essential [8, 9]. primary closure has long been used to avoid the limitations Here, we review our experience with nasal reconstruc- inherent in reconstruction using ﬂaps or grafts. However, the tions. Surgical defects in each subunit were usually repaired skin over the lower third of the nose has limited mobility in a predictable and reproducible fashion. The results of and cannot readily be recruited for closure of anything a review of 286 patients with surgical defects of the nose but small defects. Therefore, if primary closure will lead to following excision of skin malignancies are presented. unacceptable results, more complex wound reconstruction should be considered. 2. Patients and Methods 4. Bilobed Flap Consecutive patients (n = 286) referred for excision of nonmelanoma skin cancers on the nose, from 2002 to 2009, The Zitelli’s bilobed ﬂap is one of the most useful ﬂaps were included. They comprised 167 males and 119 females, for nasal reconstruction [10, 11]. It is a simple double aged 42 to 92 years, who were followed for between 6 months transposition ﬂap (Figure 3) and is designed to move more and 7 years. The most common skin cancers of the nose skin, without deformation, over a larger distance than would in these patients were basal cell carcinomas (190 cases) and be possible with a single transposition ﬂap in the same squamous cell carcinomas (96 cases). After a shave biopsy location. This is the repair of choice for defects located conﬁrmed a malignancy, all patients underwent excision between 0.5 and 1.5 cm of the distal and lateral aspect of the of the skin cancer with margins appropriate for the type, nose, particularly defects involving the lateral tip, supratip, behavior, and size of the lesion. All specimens underwent or tissue near the tip [10, 14, 16]. On the lower third of histological examination. Frozen histological sections were the nose, where the skin is least mobile, the bilobed ﬂap examined for lesions of more than 1 cm in diameter. All allows the surgical site to be ﬁlled with nearby skin and patients underwent primary reconstruction after excision matched for color and texture; it then allows for repair of of the malignancy. Immediately after tumor excision, all the secondary defect with another well-matched ﬂap from a wounds were managed by primary closure; local skin ﬂaps, nearby donor site. The initial lobe should be the same size including bilobed double transposition ﬂap, nasolabial ﬂap, as the defect, but the secondary lobe may be slightly smaller modiﬁed nasalis ﬂap, or forehead ﬂap; or a combination of to allow for donor site closure with minimal distortion. reconstructive modalities to preserve the nasal topographic The angle of transposition is approximately 45–50 for each aesthetic subunits [10–15]. The excisions were performed lobe. The defect, ﬂap, and donor site should be widely under local anesthesia or local anesthesia plus intravenous undermined in the periosteal and perichondrial planes to sedation, except in those patients whose wounds were closed facilitate transposition without distortion of the nasal tissue with a forehead ﬂap, who received general anesthesia and and to reduce pin cushioning. An adequate Burow’s triangle constant monitoring of ﬂap vascularity by the surgeon. must be removed from the pivot point to eliminate bunching The cosmetic outcome was evaluated at 6 months after and dog-ear formation. It can be designed with its base surgery. The location, depth, and size of the skin defect; the medial or lateral. Flaps based laterally on the side wall of quality of the adjacent skin; the reconstruction choice; and the nose are most useful for reconstruction of defects near the cosmetic result were recorded. the nasal tip, whereas medially based ﬂaps are more useful The reconstructive modality of choice depends largely on for repair of alar defects. Bilobed ﬂaps are the best for small the location, size, and depth of the surgical defect. defectsin the tip orala [17, 18]. In cases with defects located between 1.5 and 2.0 cm of the distal and lateral aspect of the nose, particularly those involving the nasal tip or alar lobules, 3. Direct Closure more complex wound reconstructions should be considered. Direct elliptical closure undermining the supraperichondrial or supraperiosteal plane was usually used for defects up to 5. Modiﬁed Nasalis Flap 1 cm in diameter. Upper nonsebaceous nasal areas were most amenable to direct closure. Aesthetic reconstruction of the nasal tip and supratip areas Wide undermining is crucial for suﬃcient skin laxity following skin tumor excision is a challenge. The tip is the and must be extended to the nasal facial junction. When aesthetic focal point of the nose, and irregularities in color, signiﬁcant advancement has been achieved, the margins texture, and thickness are easily noted . The modiﬁed of the surgical defect may be readily approximated under nasalis ﬂap provides an additional option for reconstruction minimal tension. The resulting surgical defect is then closed of this diﬃcult area (Figure 1) and has been extremely useful with 5-0 Vicryl buried vertical mattress sutures, keeping the for the closure of central and lateral nasal tip and supratip sutures within the subcutaneous tissue and deep reticular defects of up to 2.0 cm in diameter . It is a simple dermis . Special care should be taken to keep the sutures transposition ﬂap based on the angular artery that rotates Journal of Skin Cancer 3 (a) (b) (c) (d) (e) Figure 1: (a) BCC involving nasal tip: ﬂap design. (b) Tumour resection. (c) Intraoperative view: modiﬁed bilateral nasalis ﬂap. (d) Interpositional ﬂap from the alar groove. (e) Nasal appearance before and one year after surgery. toward the midline and nasal tip and leaves donor scars the donor defect in the nasojugal fold in order to minimize located in the nasojugal and alar creases. scarring for closure of wider defects and to maintain the Owing to our dissatisfaction with the original technique deﬁnition of the nasojugal fold . Donor scars are well as presented in the literature, we prefer using a modiﬁed concealed, and the nasal contour is minimally altered. The nasalis ﬂap as a bilateral ﬂap for coverage of central tip wide ﬂap base minimizes postoperative edema and has defects, even when they are not large . In this way, prevented the pincushion deformity common to small local we minimize nasal distortion and create symmetrical scars, transposition and advancement ﬂaps. The ﬂap can be raised providing better aesthetic results . Following tumor in a single stage under local anesthesia, and late revisions excision, anincisionismade inthe superior alar sulcus, have not been required. extending to the nasojugal fold. A backcut is then made in the nasojugal fold, parallel to the nasolabial fold. The transposition ﬂap, including the nasalis muscle, and an 6. Nasolabial Flap interpositional ﬂap from the lateral alae are elevated com- pletely at the perichondrial and deep subcutaneous levels, In the case of defects with diameters between 1.5 and 2.0 cm respectively. The arterial branches of the nasalis muscle and involving the alar lobules, a nasolabial transposition ﬂap should be identiﬁed and preserved during elevation of the is useful for reconstruction in this diﬃcult area (Figure 2) transposition ﬂap. As the nasalis ﬂap is transposed in an [12, 13, 17]. The nasolabial ﬂap is a superiorly based anterior and caudal direction, a midline dog-ear that requires transposition ﬂap that makes use of the abundant cheek resection is created. The interpositional ﬂap from the alar skin. A small amount of excess tissue that matches the groove rotates in an opposite and cephalad direction to ﬁll nose in color and texture lies near the melolabial fold, but 4 Journal of Skin Cancer (a) (b) (c) (d) Figure 2: (a) Nasolabial ﬂap design. (b) Tumour resection. (c) The ﬂap is transferred to the recipient site. (d) Nasal appearance two years after surgery. its underlying fat has a strong tendency to contract. The nose, thereby facilitating subsequent closure of the primary melolabial fold can supply enough skin to resurface the ala, defect with minimal wound closure tension. and the contractility of the nasolabial ﬂap can be used to Three weeks later, the ﬂap inset is partially elevated, simulate the round, expected bulge of the normal ala [17, 20]. and excess subcutaneous and scar tissue are sculpted from Abundant tissue is usually available in the melolabial area, the alar base, lip, and cheek join; in the same procedure, and the maximum width of the ﬂap is limited only by the cartilage grafts to prevent scar contraction can be performed amount of cheek tissue that can be used in the ﬂap and still as necessary. The normal concavity of the nasofacial sulcus eﬀect primary closure of the donor site in the melolabial can be re-established, using an absorbable suspension suture sulcus. placed between the undersurface of the dermis of the ﬂap and Furthermore, the skin is usually free of hair and has an the periosteum of the nasal bone or maxilla. After further excellent blood supply from the branches of the facial artery. 3 weeks, the pedicle is divided. The residual pedicle, which As the ﬁrst step in this procedure, the exact pattern of served as a vascular carrier, is discarded, and the cheek is the contralateral normal ala is determined just superior to closed by advancement, so that the ﬁnal scar lies exactly in the melolabial sulcus. The ﬂap is designed as an interpolation the alar facial sulcus and melolabial sulcus. ﬂap in which the ﬁnal scar of donor site closure lies exactly in the melolabial sulcus. The ﬂap is traced 1 mm larger in all dimensions to allow for postoperative contraction. The inset 7. Forehead Flap is thinned distally, leaving only 1-2 mm of subcutaneous tissuein the area of theinset. The donor siteisclosed by In general, defects greater than 2.5–3 cm in diameter are undermining adjacent cheek skin and advancing it, inferiorly diﬃcult to close with a nasolabial ﬂap. Local transposition and medially. Closure of the donor defect before closure of ﬂaps are precluded, and distant tissue such as a forehead the primary defect brings the base of the ﬂap closer to the ﬂap will usually be required (Figure 4)[13, 15, 21]. In our Journal of Skin Cancer 5 (a) (b) (c) (d) (e) Figure 3: (a) BCC involving the lateral tip of the nose. (b) Zitelli’s ﬂap design. (c) Tumour resection. (d) Intraoperative view: double trans- position ﬂap. (e) Nasal appearance two years after surgery. experience, the pedicle ﬂap most commonly used on the before suturing it into the wound. Forehead skin is used only nose is the median forehead ﬂap. It is a two-stage, advanced for nasal coverage and not for adjacent lip or cheek defects. procedure for reconstruction of large and deep surgical The central vertical component is employed to resurface the defects of the distal nose, especially where the cartilage dorsum, tip, and columella, and its lateral wings are used framework has been sacriﬁced. Its base lies close to the defect, to wrap around the ala and curve into the nostril ﬂoor and between the medial brow and medial canthus. First, an exact alar sill, in cases requiring total nasal resurfacing. Redundant three-dimensional pattern is made of the defect. Typically, tissue is removed from the forehead in both the horizontal this is designed on the contralateral normal side or on an and vertical directions when closing the donor site. This ideal model. Forehead skin does not contract, and so the facilitates primary closure of the vertical component as an pattern is designed exactly. The forehead ﬂap is excised to inconspicuous vertically oriented paramedian scar and the the periosteum at the base of the ﬂap, to the upper parts lateral wings as scars that lie in the natural transverse wrinkle of the subcutaneous tissue, in order to avoid the axially and lines of the forehead. vertically oriented feeding arteries. Three weeks later, the ﬂap inset is partially elevated, The success of this ﬂap depends on the preservation and excess subcutaneous and scar tissue are sculpted; in the of its vascular pedicle, the supratrochlear artery, and the same procedure, cartilage grafts to prevent scar contraction thinning of the subcutaneous tissue from the distal ﬂap can be performed as necessary. The pedicles remain intact 6 Journal of Skin Cancer (a) (b) (c) (d) Figure 4: (a) Multifocal nasal skin cancer: ﬂap design. (b)Skin defect after tumour resection. (c) Nasal appearance one year after surgery: frontal view. (d) Nasal appearance one year after surgery: lateral view. for approximately 3 weeks, allowing the ingrowth of blood nasalis ﬂaps, 15 nasolabial transposition ﬂaps, 71 forehead vessels from the recipient site. Then, it is divided, and the ﬂaps, 6 combinations of reconstructive modalities, and 83 unused part is returned to the forehead. cases of direct elliptical closure (Table 1). The bilobed ﬂap Techniques for the reconstruction of larger defects was the most commonly used ﬂap on the nose; of the 203 involving multiple subunits and the adjoining cheeks remain wounds repaired with a local ﬂap, 94 were repaired with a a matter of debate. In these cases, a combination of bilobed double transposition ﬂap, and most of these were reconstructive modalities is necessary to preserve the nasal located in the lower third of the nose. topographic aesthetic subunits . Defects in all nasal topographic units were treated, with some patients having defects involving multiple subunits. In such cases, a combination of reconstructive modalities are necessary to preserve the nasal topographic aesthetic 8. Results subunits. The mean age of the patients at the time of surgery was 67.3 years. There were 167 men and 119 women. A total of 286 patients who underwent nasal reconstruction after ablative skin cancer surgery (190 basal cell carcinomas, The follow-up period ranged from 6 months to 7 years 96 squamous cell carcinomas) were treated with the proce- (mean, 38.5 months). Comorbidities included diabetes, hypertension, smok- dures described above. The nasal reconstruction distribution for the 286 patients included 94 bilobed ﬂaps, 17 modiﬁed ing, and previous histories of nasal skin cancer ablation. In Journal of Skin Cancer 7 Table 1: Surgical wound management of the nose ( 286 cases). of nasal-speciﬁc defects. We recommend that reconstructive techniques be selected according to the anatomical nasal Mode Patients %Treated subunits to be restored, whenever possible . Direct Direct elliptical closure 83 29,1% elliptical closure with undermining in a supraperichondrial Bilobed ﬂap 94 32,9% or supraperiosteal plane was typically used for defects up to 1 cm in diameter. Upper nonsebaceous nasal areas were most Modiﬁed nasalis ﬂap 17 5,9% amenable to direct closure. Nasolabial transposition ﬂap 15 5,2% A skin graft is generally not considered the ideal replace- Forehead ﬂap 71 24,8% ment for nasal skin, in particular for the thick, sebaceous skin Forehead ﬂap + nasolabial ﬂap 6 2,1% of the nasal tip, ala, lower sidewalls, or dorsum. The basic concern with using a skin graft is the resultant patchwork appearance caused by color mismatch and contour defects. the 83 patients who underwent direct elliptical closure there Nevertheless, superﬁcial defects larger than 1 cm will be were 12 minor complications such as superﬁcial infection or treated with full-thickness skin graft successfully . hematoma with secondary healing. In the 203 patients who When peripheral concerns such as prior skin history and underwent nasal reconstruction with a local ﬂap, there was smoking are minimal and the only desire is an excellent no ﬂap failure. Complications in this series were one case of cosmetic result, ﬂaps are a superior way to close defects. partial ﬂap dehiscence that healed by secondary intention, Esser designed the ﬁrst bilobed ﬂap in 1918 and applied it two forehead ﬂaps, and one bilobed ﬂap with minimal rim to the reconstruction of defects of the nasal tip . In 1989, necrosis that resulted in an irregular scar requiring revision. Zitelli adapted the design of Esser’s bilobed ﬂap by reducing Aesthetic results were deemed satisfactory by all patients its rotation angles, and then it is one of the most useful ﬂaps and the operating surgeons.The color and texture matches for nasal reconstruction [10, 11]. were aesthetically good and the nasal contour was distinct in It is designed to move more skin over a larger distance all patients. All scars were inconspicuous and symmetrical. than would be possible with a single transposition ﬂap No patienthad tentingora ﬂatnose. We hada total of in the same location. Thus, it is the repair of choice for 9 (0.32%) recurrences on 286 patients: two on 83 direct defects located within 0.5 and 1.5 cm of the distal and lateral elliptical closure, three on 94 bilobed ﬂaps, one on 15 aspects of the nose, particularly those involving the lateral nasolabial ﬂap and three on 71 isolated forehead ﬂaps. tip, supratip, or ala near the tip [10, 15, 18]. In the lower third of the nose, where the skin is least mobile, a bilobed ﬂap allows the surgical site to be ﬁlled with nearby skin that 9. Discussion is matched for color and texture, and then allows for repair Aesthetic and functional reconstruction of full-thickness of the secondary defect with another well-matched ﬂap from soft-tissue nasal defects involves many options. Although the a nearby donor site. The nose tip is the aesthetic focal point topographic nasal subunit principle of Burget and Menick of the nose, and irregularities in color, texture, and thickness  is important in preoperative analysis and planning of are easily noted [8, 9, 12, 17]. The modiﬁed nasalis ﬂap provides an additional option the reconstruction, other aesthetic considerations such as skin texture, color, and contour are also crucial [9, 21]. A for reconstruction of this diﬃcult area [14, 19]. This ﬂap balance must be achieved among these various factors and has proven to be extremely useful for the closure of central and lateral nasal tip and supratip defects of up to 2.0 cm in the patient’s medical condition, adjacent tissue availability, skin history, and expectations [9, 22]. diameter . A patient’s medical history can signiﬁcantly aﬀect the In cases of defects with a 1.5- to 2.0-cm diameter that reconstruction plan, by forcing all treatment into a moni- involve the alar lobules, a nasolabial transposition ﬂap is tored operating room environment. Diabetics and smokers useful for reconstruction of this diﬃcult area [12, 13]. The nasolabial ﬂap is a superiorly based transposition ﬂap that should be warned about potential skin necrosis, and a diﬀerent plan of reconstruction or the delay of ﬂaps may be makes use of abundant cheek skin. necessary in these patients. Skin history is important, and A small amount of excess tissue that matches the nose in color and texture lies near the melolabial fold, and patients with scars from previous nasal cancers may require a modiﬁed treatment plan. In these patients, a ﬂap may be its underlying fat has a strong tendency to contract. The used to incorporate a past scar; on the other hand, scar melolabial fold can supply enough skin to resurface the ala, and the contractility of the nasolabial ﬂap can be used to tissue may impede the blood supply to a ﬂap. Finally, patient expectations can inﬂuence reparative concerns. For example, simulate the round, expected bulge of the normal ala . a young woman may want optimal cosmetic results, whereas The donor site scar from the melolabial transposition ﬂap is an older man may not have as many cosmetic concerns . relatively easy to camouﬂage in the natural expression lines The reconstructive modality of choice will depend largely of the face. Larger defects often require a forehead ﬂap. Forehead on the location, size, and depth of the surgical defect. Nevertheless, reconstructive plans should be customized and skin with a width of 4 or more cm can be harvested without not be based solely on the size or location of the defect. tissue expansion [7, 15, 26]. The pedicle ﬂap most commonly used on the nose is the median forehead ﬂap. It is a two- Individualized therapy is the best course, and numerous ﬂaps have been designed to provide coverage of a variety stage advanced procedure for the reconstruction of large 8 Journal of Skin Cancer and deep surgical defects of the distal nose, especially where grafts and implications of patients’ contentment,” Oral and Maxillofacial Surgery, vol. 13, no. 1, pp. 15–19, 2009. the cartilage framework has been sacriﬁced. The depth of  J. A. Zitelli, “The bilobed ﬂap for nasal reconstruction,” the defect governs the choice of material for reconstruction. 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Bremerich, “Complications after nasal skin repair with local ﬂaps and full-thickness skin MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014
Journal of Skin Cancer – Hindawi Publishing Corporation
Published: Jun 7, 2011
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