LEARNING OBJECTIVES:After studying this article, the participant should be able to: 1. List important prognostic features that affect cutaneous squamous cell carcinoma risk. 2. Summarize the changes to the AJCC Cancer Staging Manual, Eighth Edition, staging system for cutaneous squamous cell carcinoma. 3. Evaluate the draining nodal basin with appropriate imaging modalities. 4. Recommend adjuvant radiation therapy in the correct clinical setting for high-risk tumors. 5. Recognize the currently available treatments for advanced cutaneous squamous cell carcinoma.SUMMARY:This continuing medical education article reviews the features, management, and prognosis of cutaneous squamous cell carcinoma with an emphasis on high-risk squamous cell carcinoma and data from the past 3 years. This review will discuss the primary tumor management, high-risk features of a squamous cell carcinoma, changes to the American Joint Committee on Cancer staging system, and the utility of sentinel lymph node biopsy, and critically review the evidence regarding adjuvant therapy.

BACKGROUND:Not all women undergo post-mastectomy breast reconstruction due to medical comorbidities or personal preference. An aesthetically pleasing closure and contour of the chest wall is still desired, though may be technically difficult to achieve in some patients. By combining techniques and lessons learned from breast reductions and female-to-male mastectomies (FTTM), we present a technical approach to aesthetic primary closure post-mastectomy that can be utilized in patients regardless of preoperative breast size.METHODS:After mastectomy, excess cranial/caudal tissue is determined and the lower flap is de-epithelialized to allow for bulk in the reconstructed breast. Excess tissue in the horizontal plane is assessed, and axillary, nonbreast tissue is medialized. Excess skin in the horizontal plane is removed with a small lateral incision similar to a wise-pattern closure.RESULTS:We have performed this technique with good aesthetic results and satisfied patients postoperatively.CONCLUSION:When performing post-mastectomy closure without reconstruction, attention to tissue excess, medialization of axillary tissue and providing bulk with lateral and caudal tissue allows for an easy, reproducible, and aesthetic closure.

Summary: The sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, which are at risk for injury or loss during mastectomy. Providing reinnervation after mastectomy was introduced almost 20 years ago, but it is not widely performed, perhaps because of the difficulty of locating a recipient nerve. The authors have performed cadaveric dissections to allow for precise anatomical localization of the lateral intercostal branch providing breast sensation. Bilateral chest dissections were performed on 10 female cadavers. The lateral intercostal nerve providing sensation to breast tissue was identified. The distances from the sternum, the midclavicular line, and the lateral pectoralis minor—in addition to nerve diameter—were measured. The nerve was successfully identified bilaterally in all cadavers. The majority of nerves (16 of 20) exited from under the fourth rib. The average distance from the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm) and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). The nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border for all cadavers. The diameter of the nerve was consistently 2 mm. The nerve traveled under the thoracodorsal vessels, aiding in identification. The authors identified the predictable location of the lateral intercostal nerve providing sensation to the breast. The authors hope that by enabling surgeons to locate this nerve, more well-conducted studies will be performed investigating techniques and outcomes for breast reinnervation.