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Background: Conventional excision of female genital skin cancers has high rates of local recurrence and morbidity. Few publications describe local recurrence rates (LRRs) and patient-reported outcomes (PROs) after Mohs micrographic surgery (MMS) for female genital skin cancers., Objective: To evaluate LRRs, PROs, and interdisciplinary care after MMS for female genital skin cancers., Methods: A retrospective case series was conducted of female genital skin cancers treated with MMS between 2006 and 2021 at an academic center. The primary outcome was local recurrence. Secondary outcomes were PROs and details of interdisciplinary care., Results: Sixty skin cancers in 57 patients were treated with MMS. Common diagnoses included squamous cell cancer (n = 26), basal cell cancer (n = 12), and extramammary Paget disease (n = 11). Three local recurrences were detected with a mean follow-up of 61.1 months (median: 48.8 months). Thirty-one patients completed the PROs survey. Most patients were satisfied with MMS (71.0%, 22/31) and reported no urinary incontinence (93.5%, 29/31). Eight patients were sexually active at follow-up and 75.0% (6/8) experienced no sexual dysfunction. Most cases involved interdisciplinary collaboration 71.7% (43/60)., Limitations: Limitations include the retrospective single-center design, heterogeneous cohort, and lack of preoperative function data., Conclusions: Incorporating MMS into interdisciplinary teams may help achieve low LRRs and satisfactory function after genital skin cancer surgery., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2023 American Academy of Dermatology, Inc. Published by Elsevier 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.)

Objective: To describe local recurrence rates and patient-reported outcomes when Mohs micrographic surgery with cytokeratin-7 immunostains (MMS-CK7) is included in the interdisciplinary management of extramammary Paget's disease (EMPD) METHODS: A retrospective study was conducted of EMPD treated with MMS-CK7 as part of an interdisciplinary team at an academic medical center between 2009 and 2016. Local recurrence rates and patient-reported outcomes were determined by record review and patient surveys., Results: Twenty tumors in 19 patients were treated using MMS-CK7. After MMS-CK7 defined clear microscopic margins, 75% (15/20) of tumors underwent excision or reconstruction by a surgical colleague. Internal malignancy screening was performed by multiple specialties in 17 patients, with 1 associated malignancy of prostate cancer detected. No local recurrence was detected with a mean follow-up of 75.2 months. Most patients were satisfied with appearance (18/19, 95%) and function (16/19, 84%) after surgery., Conclusion: Interdisciplinary teams that include MMS-CK7 can treat EMPD with low local recurrence rates, high patient satisfaction, and thorough internal malignancy screening., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: To curtail the opioid epidemic, physicians have been advised to limit opioid prescriptions., Objective: To characterize the frequency and changes over time (2009-2020) of opioid prescriptions following Mohs micrographic surgery., Design, Setting, and Participants: This cross-sectional study using Optum Clinformatics DataMart (Optum CDM), a nationally representative insurance claims database, included patients aged 18 years and older who had Mohs micrographic surgery insurance claims in the Optum CDM database from 2009 to 2020. Data were analyzed from November 11, 2020, to March 30, 2021., Exposures: Opioid prescription following Mohs surgery., Main Outcomes and Measures: The primary outcome was the proportion of patients who underwent Mohs surgery and obtained an opioid prescription within 2 days of surgery. Secondary outcomes included type and opioid quantity prescribed., Results: Among 358 012 patients with Mohs micrographic surgery claims (mean [SD] age, 69 [13] years; 205 609 [57.4%] were men), the proportion of patients obtaining an opioid prescription after Mohs micrographic surgery increased from 2009 (34.6%) to 2011 (39.6%). This proportion then declined each year, reaching a low of 11.7% in 2020 (27.9% absolute decrease from 2011 to 2020). Hydrocodone, codeine, oxycodone, and tramadol were the 4 most commonly prescribed opioids. By 2020, hydrocodone was obtained less (2009: 47.5%; 2011: 67.1%; 2020: 45.4%; 21.7% absolute decrease from 2011 to 2020) and tramadol was obtained more (2009: 1.6%; 2020: 27.9%; 26.3% absolute increase from 2009 to 2020)., Conclusions and Relevance: In this cross-sectional study of Mohs micrographic surgery claims, patients obtained fewer postsurgery opioid prescriptions over the study period, suggesting responsiveness of patients and dermatologic surgeons to public health concerns regarding the opioid epidemic. During this decline, prescriptions for hydrocodone decreased and tramadol increased.

Background: On the basis of high-local recurrence risk features and tissue-rearranging reconstruction, consensus guidelines recommend microscopic margin control for keratinocyte carcinomas (KCs) but not for cutaneous melanoma., Objective: To compare high-local recurrence risk features and frequency of tissue-rearranging reconstruction for head and neck KC with those for melanoma., Methods: Retrospective cohort study of KC versus melanoma treated at the Hospital of the University of Pennsylvania with Mohs micrographic surgery., Results: A total of 12,189 KCs (8743 basal cell carcinomas and 3343 squamous cell carcinomas) and 1475 melanomas (1065 melanomas in situ and 410 invasive melanomas) were identified from a prospectively updated Mohs micrographic surgery database. Compared with KCs, melanomas were significantly more likely to have high-local recurrence risk features, including larger preoperative size (2.10 cm vs 1.30 cm [P < .0001]), recurrent status (5.08% vs 3.91% [P = .031]), and subclinical spread (31.73% vs 26.52% [P < .0001]). Tissue-rearranging reconstruction was significantly more common for melanoma than for KCs (44.68% vs 33.02% [P < .0001]; odds ratio, 1.98 [P < .0001])., Limitations: This was a retrospective study, and it did not compare outcomes with those of other treatment methods, such as slow Mohs or conventional excision., Conclusion: Melanomas of the head and neck have high-local recurrence risk features and require tissue-rearranging reconstruction more frequently than KCs do., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Local recurrence rates (LRRs) after Mohs micrographic surgery (MMS) for male genital cancers have been reported in only a few small case series, and patient-reported outcomes (PROs) have not been studied., Objective: To determine the LRR and PROs after MMS for male genital skin cancers., Methods: Retrospective review of all male genital skin cancers removed with MMS between 2008 and 2019 at an academic center. LRR was determined by chart review and phone calls. PROs were assessed by survey., Results: A total of 119 skin cancers in 108 patients were removed with MMS. Tumors were located on the penis (90/119) and scrotum (29/119). Diagnoses included squamous cell carcinoma in situ (n = 71), invasive squamous cell carcinoma (n = 32), extramammary Paget disease (n = 13), melanoma (n = 2), and basal cell carcinoma (n = 1). The LRR was 0.84% (1/119), with a mean follow-up time of 3.25 years (median, 2.36 years). The majority of survey respondents reported no changes in urinary (66%) or sexual functioning (57.5%) after surgery., Limitations: Retrospective single-center experience; short follow-up time; low survey response rate; no baseline functional data., Conclusion: MMS for male genital skin cancer has a low LRR and high patient-reported satisfaction with urinary and sexual function., Competing Interests: Conflicts of interest None disclosed., (Copyright © 2020. Published by Elsevier Inc.)

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.

Importance: Patients are satisfied when surgical outcomes meet their expectations. Dissatisfaction with surgical scars is one of the most common reasons that patients sue surgeons who perform Mohs micrographic surgery (MMS)., Objective: To measure the accuracy of patient and physician estimations of scar length prior to skin cancer removal with MMS., Design, Setting, and Participants: This cross-sectional study was conducted between December 1, 2017, and February 28, 2018, at the MMS clinic of a single tertiary referral center health system. A total of 101 adults presenting for MMS for treatment of facial skin cancers volunteered for this study, and 86 surgeons who performed the MMS procedure participated., Main Outcomes and Measures: Patients and physicians independently drew the anticipated scar length on the patients' skin prior to surgery. Preoperative estimates by patients and surgeons were compared with actual postoperative scar length., Results: Of the 101 patients who participated, 57 patients (56.4%) were men and 57 patients (56.4%) were aged 65 years or older. Eighty-four patients (83.2%) underestimated scar length, whereas 67 of the 86 surgeons (77.9%) correctly estimated the scar length (P < .001). The actual postoperative scar length was 2.2 (interquartile range, 1.5-3.6) times larger than the patients' preoperative estimate but only 1.1 (interquartile range, 1.0-1.2) times larger than the surgeons' preoperative estimate (P < .001). Preoperative consultation with the surgeon, a personal history of MMS, or patient-directed research about MMS were not associated with improvement of patients' estimations of scar length., Conclusions and Relevance: This study's findings suggest that patients with facial skin cancers have unrealistic expectations regarding scars that measure, on average, less than half the length of the actual postoperative scars. Surgeons appear to accurately estimate the length of most surgical scars and have an opportunity to set realistic patient expectations about scar length before surgery.

Background: Changes in patient perceptions of quality of life (QOL) after Mohs micrographic surgery (MMS) may benefit from different counseling or treatment., Objective: To measure QOL before and after MMS and to identify risk factors associated with impaired QOL., Methods: Prospective observational study of 727 patients with skin cancer who self-reported QOL via the Skin Cancer Index immediately before and at 1 to 2 weeks and 3 months after MMS., Results: QOL fluctuated after MMS. At 1 to 2 weeks after surgery, overall QOL remained unchanged compared with before MMS. Patients reported reduced anxiety about skin cancer but had increased distress about social interactions and physical appearance. At 3 months after surgery, patients reported an overall improvement in QOL compared with before MMS (P = .0007). Age younger than 65 years (P = .0001), female sex (P = .0001), and tobacco use (P = .03) were associated with lower QOL scores at all assessment points., Limitations: Single-site observational study. Significant loss to follow-up at both time points after MMS., Conclusion: Patients with skin cancer had persistent concerns about social interactions and physical appearance 1 to 2 weeks after MMS, but all aspects of their QOL improved by 3 months after surgery. Patients who underwent MMS that were younger than 65 years, were female, or smoked were at increased risk for longitudinally impaired QOL., (Copyright © 2018 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

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: Many factors influence anxiety and satisfaction of patients undergoing Mohs micrographic surgery (MMS)., Objective: We sought to determine the effect of a preoperative educational telephone call on anxiety and satisfaction for patients undergoing same-day office consultation and MMS., Methods: Patients with skin cancer (N = 104) scheduled for same-day office consultation and MMS were randomly assigned to receive or not to receive an educational telephone call during the week before surgery. All patients rated their anxiety levels immediately before and after the same-day office consultation and MMS by completing the State-Trait Anxiety Inventory and an anxiety visual analog scale. Patients also rated satisfaction immediately after MMS by completing the Visit-Specific Patient Satisfaction Questionnaire., Results: Patients undergoing same-day office consultation and MMS reported similar levels of increased anxiety and high satisfaction, regardless of whether they received a preoperative educational telephone call., Limitations: Lack of control for patients' prior surgery or self-education is a limitation., Conclusion: Preoperative educational telephone calls did not relieve anxiety or improve satisfaction for patients undergoing same-day office consultation and MMS. Preoperative education and counseling has uncertain benefits to anxiety and satisfaction of patients undergoing MMS., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: No evidence-based surgical guidelines exist for atypical intraepidermal melanocytic proliferation (AIMP), a descriptive histopathologic diagnosis with uncertain malignant potential., Objective: We sought to identify the frequency of and risk factors associated with positive or equivocal margins after conventional excision., Methods: We conducted a retrospective cross-sectional study of 413 AIMPs treated by conventional excision., Results: Positive or equivocal margins were seen in 2.9% (12/413) of conventional excisions of AIMP. Risk factors associated with positive or equivocal margins included anatomic location on the head and neck (5/51, 9.8%; odds ratio 6.91, 95% confidence interval 1.93-24.80) (P = .012) and a preoperative biopsy specimen that included melanoma in situ in the differential diagnosis (11/214, 5.1%; odds ratio 10.73, 95% confidence interval 1.37-83.88) (P = .006). The frequency of positive or equivocal margins did not differ significantly with surgical margins greater than or less than 5 mm (odds ratio 0.61, 95% confidence interval 0.18-2.07) (P = .457)., Limitations: This was a single-site, retrospective observational study., Conclusion: AIMP has a significantly increased risk for incomplete excision when it is located on the head and neck or has a preoperative histologic differential diagnosis that includes melanoma in situ. These subsets of AIMP may benefit from Mohs micrographic surgery or staged surgical excision to confirm clear margins before reconstruction., (Copyright © 2016 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

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: Various methods of tissue processing have been used to treat melanoma with Mohs micrographic surgery (MMS)., Objective: We describe a method of treating melanoma with MMS that combines breadloaf frozen sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation, allowing detection of upstaging and comprehensive pathologic margin assessment before reconstruction., Methods: We conducted a retrospective cohort study evaluating for local recurrence and upstaging in 614 invasive or in situ melanomas in 577 patients treated with this MMS tissue processing methodology using frozen sections with melanoma antigen recognized by T cells 1 (MART-1) immunostaining. Follow-up was available in 597 melanomas in 563 patients., Results: Local recurrence was identified in 0.34% (2/597) lesions with a mean follow-up time of 1026 days (2.8 years). Upstaging occurred in 34 of 614 lesions (5.5%), of which 97% (33/34) were detected by the Mohs surgeon before reconstruction., Limitations: Limitations include retrospective study, intermediate follow-up time, and that the recurrence status of 39.6% of patients was self-reported., Conclusion: Treating melanoma with MMS that combines breadloaf sectioning of the central debulking excision with complete peripheral and deep microscopic margin evaluation permits identification of upstaging and consideration of sentinel lymph node biopsy before definitive reconstruction and achieves low local recurrence rates compared with conventional excision., (Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)