Search

Background: Mohs micrographic surgery may be discontinued with positive margins as an anticipated strategy for multidisciplinary care or as an unanticipated occurrence. Management of primary tumors has not been compared after anticipated versus unanticipated incomplete Mohs micrographic surgery (iMMS)., Objective: To compare rates and timing of adjuvant surgery after iMMS and final margin status when iMMS is anticipated versus unanticipated. Secondary outcomes were preoperative and intraoperative clinicopathologic factors associated with iMMS., Methods: Cases of iMMS of keratinocyte carcinomas at a tertiary academic center between 2005 and 2022 were classified as anticipated (preoperative assembly of multidisciplinary teams) or unanticipated (ad hoc management of positive margins). Rate, timing, and final margin status of adjuvant surgery was compared between anticipated and unanticipated iMMS cohorts using χ2/Fisher exact test for categorical variables and t-test for continuous variables., Results: Of 127 iMMS cases, 51.2% (65/127) were anticipated. Anticipated iMMS cases were more likely to undergo additional resection (98.5% vs 72.6%, p < .001), with fewer delays (3.9 vs 13.2 days, p < .001) and higher rates of final margin clearance (84.6% vs 59.7%, p < .001)., Conclusion: When iMMS is anticipated as part of multidisciplinary care, patients are more likely to undergo additional resection, with fewer delays to next surgery and higher final margin clearance rates., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Dermatologists perform most interpolated flaps after skin cancer resection. Prospective, multicenter data on complications after interpolated flap repair in this setting are limited., Objective: To determine the rate of physician-reported complications after interpolated flap repair of the nose., Methods: Multicenter, prospective cohort study of 169 patients undergoing 2-stage interpolated flap repair of post-Mohs nasal defects. Frequency of bleeding, infection, dehiscence, necrosis, hospitalization, and death in the 30 days after flap placement and flap takedown are reported., Results: Patients experienced 23 complications after flap placement (13.61%) and 6 complications after flap takedown (3.55%) that were related to the surgical procedure. The most frequent complication after flap placement was bleeding (9, 5.33%, 95% confidence interval [CI]: 2.83%-9.82%). The most frequent complication after flap takedown was infection (5, 2.96%, 95% CI: 1.27%-6.74%). There was one hospitalization related to an adverse reaction to antibiotics. There were no deaths., Conclusion: Most complications after interpolated flap repair for post-Mohs defects of the nose are minor and are associated with flap placement. Interpolated flap repair for post-Mohs defects can be performed safely in the outpatient setting under local anesthesia., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The relationship of postoperative facial scar assessments among patients, physicians, and societal onlookers is not clearly defined., Objective: To identify differences in perceived scar outcomes by different stakeholders., Methods and Materials: Retrospective cohort study at a single Mohs micrographic surgery (MMS) center during which scars were assessed by: patients, physicians, and medical student observers not involved in patients' care using the Patient and Observer Scar Assessment Scale (v.2). Eighty-one patients graded their scars at 2 visits: 1 to 2 weeks post-MMS and 3 months post-MMS. Deidentified patient photographs were taken at each visit and graded by 4 physicians and 12 observers., Results: At week 1, there was a significant difference in overall opinion of scar appearance between patient and physicians (p = .001) and medical student observers and physicians (p < .001). Physicians graded scars more favorably. At 3 months, there remained a difference in scar evaluations between patient and physicians (p = .005), whereas medical student observers rated scars more similarly to physicians (p = .404)., Conclusion: Postoperative scar perceptions differ among stakeholders. Physicians must be mindful of this disparity when counseling patients in the perioperative setting to align patient expectations with realistic scar outcomes., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood., Objective: To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions., Materials and Methods: Multi-center, prospective discrete choice experiment (DCE)., Results: Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics., Conclusion: Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons., Objective: To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics., Materials and Methods: This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members., Results: The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention., Conclusion: Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antibiotic use associated with Mohs surgery is increasing., Objective: To understand variation in practice patterns and factors associated with antibiotic use., Materials and Methods: The authors conducted a retrospective cohort study of antibiotic use among patients treated with Mohs micrographic surgery between July 1, 2013, and June 30, 2017, at an academic medical center. Multivariate logistic regression was used to evaluate for associations between antibiotic prescribing and the surgeon, site, reconstruction, and patient characteristics., Results: The odds of prescribing antibiotics differed significantly between each surgeon evaluated; 3.35-fold variation in postoperative antibiotic use was observed. Increasing number of surgical sites (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.09-1.41), number of Mohs stages required (OR 1.18; 95% CI 1.08-1.28), and defect area (OR 1.31; 95% CI 1.25-1.37), as well as patient female sex (OR 1.14; 95% CI 1.03-1.27), were associated with increased postoperative antibiotic use, whereas age >80 was associated with decreased use (OR 0.75; 95% CI 0.64-0.87) compared with age <60., Conclusion: Antibiotics are more commonly prescribed for repairs that are considered higher risk for infection. However, significant variation exists between surgeons, even within a single institution, suggesting a need for prospective trials and consensus guideline development.

Background: The V-Y island advancement flap is a useful reconstruction technique for nasal alar defects, but flap mobility is limited by the insertion of the muscles of facial expression into the dermis of the alae., Objective: To describe a V-Y muscle sling myocutaneous island advancement flap (SMIAF) for improved mobility and intrasubunit reconstruction of alar defects., Materials and Methods: A retrospective review of patient records and preoperative and postoperative photographs was performed on all patients with alar defects repaired with the SMIAF between April 2008 and October 2017. Patients and physicians rated aesthetic outcomes with the Patient and Observer Scar Assessment Scale (POSAS)., Results: A total of 18 nasal alar defects were repaired with the SMIAF after Mohs micrographic surgery. All defects were located on the anterior two-thirds of the alar lobule and had a mean surface area of 0.42 ± 0.19 cm. No patients experienced flap necrosis. Patients and 3 independent dermatologic surgeons rated favorable aesthetic outcomes., Conclusion: The SMIAF is a reliable reconstruction option with good aesthetic outcomes for small defects on the anterior two-thirds of the nasal ala.

Background: Few data exist to guide surgical management and counseling about local recurrence after surgery of primary male genital melanoma., Objective: To compile all available data on local recurrence rates after surgery of primary cutaneous melanoma of the penis and scrotum., Materials and Methods: A systematic review of PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Excerpta Medica database (EMBASE), and Web of Science identified all surgically treated penile and scrotal melanomas that reported local recurrence status and follow-up time., Results: One hundred twenty-seven melanomas from 74 manuscripts were included. Eighty-six percent of melanomas were located on the penis, and 14% were located on the scrotum. Average follow-up time was 35.7 months. Scrotal melanomas were predominantly treated with organ-sparing surgeries (16/18, 88.9%), whereas penile melanomas were treated more often with amputation (61/109, 56.0%). Overall, local recurrence rate was 15.7% (20/127). Local recurrence rates for penile cases were 18.8% (9/48) after organ-sparing surgery versus 13.1% (8/61) for amputative surgery. Local recurrence rates were 66.7% (4/6) after positive surgical margins versus 10.2% (5/49) after negative surgical margins., Conclusion: Local recurrence rates are high after both organ-sparing and amputative surgery of primary cutaneous melanoma of the penis and scrotum. There is a need to standardize reporting for this rare tumor, as more complete data are necessary to develop consensus guidelines for surgical management of male genital melanoma.

Background: Extramammary Paget's disease (EMPD) is a rare intraepithelial malignancy with high recurrence rates following standard surgical treatments, ranging from 22% to 60% in large retrospective reviews., Objective: To evaluate the local recurrence rate of Mohs micrographic surgery (MMS) supplemented with intraoperative immunohistochemistry for cytokeratin-7 (MMS + CK-7) for primary and recurrent EMPD., Materials and Methods: Retrospective, multi-center, cross-sectional study of patients treated using MMS + CK-7. Demographic, clinicopathologic, treatment, and follow-up data were obtained by chart review., Results: The observed local recurrence rate for MMS + CK-7 is 3.3% (2/61 tumors) with a mean follow-up of 43.5 months (1-120 months). Local recurrence occurred in 2.3% (1/43) of primary tumors and 5.6% (1/18) of recurrent tumors. Kaplan-Meier 5-year tumor-free rates are 94.6% overall, 97.1% for primary tumors, and 80.0% for recurrent tumors. The Kaplan-Meier 5-year tumor-free rates for all EMPD tumors treated with MMS + CK-7 versus a historical cohort of MMS alone are 94.6% versus 72.0% (p = .012)., Conclusion: MMS + CK-7 is an effective treatment for EMPD, demonstrating improved outcomes compared with historical controls.

Background: Atypical intraepidermal melanocytic proliferation (AIMP) is a histopathologic diagnosis with uncertain malignant potential and presents a surgical management dilemma for clinicians., Objective: To identify the associated clinical and histopathologic factors and the frequency of diagnostic change to melanoma after conventional excision of AIMP., Methods: Retrospective cross-sectional study of 306 AIMPs treated by conventional excision., Results: Diagnostic change to melanoma occurred in 4.2% (13/306) of AIMP lesions after histopathologic review of the excision specimen; melanomas were in situ in 85% (11/13) and invasive in 15% (2/13) of cases. Factors associated with diagnostic change to melanoma included anatomic location on the head and neck (Odds ratio [OR] 8.49, 95% confidence interval [CI] 2.17, 33.19; p = .001) and acral areas (OR 9.24, 95% CI 2.18, 39.24; p = .001), lesion extension to the base of the biopsy specimen (OR 13.07, 95% CI 2.98, 57.31; p = .001), biopsy using the punch technique (OR 6.06, 95% CI 1.95, 18.86; p = .013), and melanoma in the initial biopsy's histopathologic differential diagnosis (OR 13.29, 95% CI 1.71, 103.57; p = .001)., Conclusion: Preoperative counseling and surgical planning for AIMP should be individualized to account for potential diagnostic change to melanoma, especially when specific risk factors are present.

Background: Published appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) for melanoma are based on consensus opinion., Objective: To evaluate whether published AUC identify melanomas for which MMS may benefit patients by detecting subclinical spread or confirming clear microscopic margins before flap or graft reconstruction., Materials and Methods: Retrospective cohort study of 591 melanomas in 556 patients evaluating the correlation between current AUC (anatomic location, recurrent status, and tumor stage) and subclinical spread or reconstruction with a flap or graft., Results: Anatomic location on the head, neck, genitalia, hands, feet, or pretibial leg was associated with a significantly higher frequency of subclinical spread (odds ratio (OR) 1.89, p = .0280) and flap or graft reconstruction (OR 10.3, p = .0001). Compared with primary lesions, recurrent melanomas had a higher frequency of subclinical spread (OR 1.78, p = .0104) and reconstruction with a flap or graft (OR 1.67, p = .0217). The frequencies of subclinical spread and flap or graft reconstruction did not differ between in situ and invasive melanomas., Conclusion: Anatomic location and recurrent status are useful criteria to identify melanomas that may benefit from MMS. Tumor stage is not a useful criterion, as MMS has similar benefits for subsets of both invasive and in situ melanomas.

Background: Many surgeons recommend postoperative scar massage to improve aesthetic outcome, although scar massage regimens vary greatly., Objective: To review the regimens and efficacy of scar massage., Methods: PubMed was searched using the following key words: "massage" in combination with "scar," or "linear," "hypertrophic," "keloid," "diasta*," "atrophic." Information on study type, scar type, number of patients, scar location, time to onset of massage therapy, treatment protocol, treatment duration, outcomes measured, and response to treatment was tabulated., Results: Ten publications including 144 patients who received scar massage were examined in this review. Time to treatment onset ranged from after suture removal to longer than 2 years. Treatment protocols ranged from 10 minutes twice daily to 30 minutes twice weekly. Treatment duration varied from one treatment to 6 months. Overall, 65 patients (45.7%) experienced clinical improvement based on Patient Observer Scar Assessment Scale score, Vancouver Scar Scale score, range of motion, pruritus, pain, mood, depression, or anxiety. Of 30 surgical scars treated with massage, 27 (90%) had improved appearance or Patient Observer Scar Assessment Scale score., Conclusions: The evidence for the use of scar massage is weak, regimens used are varied, and outcomes measured are neither standardized nor reliably objective, although its efficacy appears to be greater in postsurgical scars than traumatic or postburn scars. Although scar massage is anecdotally effective, there is scarce scientific data in the literature to support it., (© 2011 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)