Search

Background: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature., Objective: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature., Methods: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors., Results: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%)., Conclusion: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

One benefit of Mohs micrographic surgery (MMS) is maximal tissue sparing compared to standard excisional surgery techniques. It also has the highest statistical cure rate for appropriately selected nonmelanoma skin cancers (NMSCs) in cosmetically sensitive areas, making it a preferred choice for many self-referred patients or their referring physicians. Patients and nondermatologist physicians may be unaware of how frequently Mohs surgeons perform complex surgical repairs compared to other specialists. Our objective was to compare the quantity and characteristics of flap or graft repairs on the nose or ears following skin cancer extirpation performed by either a fellowship-trained Mohs surgeon or plastic surgeons at 1 academic institution. A retrospective chart review of all skin cancer surgeries was performed to collect data on all flap or graft repairs on the nose or ears at Baylor Scott and White Health (Temple, Texas) from October 1, 2016, to October 1, 2017. We collected secondary data on final defect size prior to the repair, skin tumor type, referring specialty for the procedure, and patient demographics. We found that Mohs surgeons performed a larger number of complex repairs on cosmetically sensitive areas compared to plastic surgeons following skin cancer removal, which may be unrecognized in several specialties that refer patients for management of skin cancers, creating a possible practice gap. More data may aid referring providers in optimally advising and managing patients with cutaneous malignancies.

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: Dermatologists are experts in skin cancer treatment. Their experience with cutaneous reconstruction may be underrecognized., Objective: We sought to determine the percentage of skin reconstruction claims submitted to Medicare by dermatologists relative to other specialists., Methods: The Medicare Physician Supplier Procedure Master File from 2004 to 2009 was accessed to determine the proportion of layered closures, grafts, and flaps by specialty., Results: In 2009, dermatologic surgeons' (DS) claims accounted for 60.8% of intermediate closures, 75.1% of complex repairs, 55.5% of local tissue rearrangements, and 57.5% of full-thickness skin grafts in the Medicare population. DS billed for the majority of skin reconstructions except simple repairs, split-thickness skin grafts, and interpolation flaps. DS claims represented far more reconstructions of aesthetically important regions of the head and neck-including ears, eyes, nose, and lips-than other fields including plastic surgery and otolaryngology. Over the study period, DS increased the percentage of skin reconstructions in nearly every category relative to other specialists., Limitations: This analysis is limited to the Medicare population and addresses claim volumes only. Cosmetic outcomes or appropriateness of closure selection or coding cannot be addressed., Conclusions: DS perform the highest volumes of repairs in the Medicare population. DS play a primary role in routine and advanced cutaneous reconstructive surgery, especially of aesthetically important regions., (Copyright © 2013 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Background: There are few data to indicate whether the type of final wound defect is associated with the type of post-Mohs repair., Objective: To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics., Methods: Statistical analysis of procedure logs of 20 representative young to mid-career Mohs surgeons., Results: The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43-55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98-2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99)., Conclusions: Most post-Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: Mohs micrographic surgery (MMS) is the criterion standard treatment for high-risk skin cancers. Few data on current MMS Utilization are available., Objective: To better understand current trends in MMS use in the Medicare population., Methods and Materials: The 2009 Medicare Limited Data Set Standard Analytic File (LDSSAF), carrier claims, 5% sample and the Physician Supplier Procedure Master File (PSPMF) 100% summary were analyzed., Results: In 2009, 558,447 Medicare MMS cases were performed, with an average of 1.75 stages per case. In the 5% claims sample, 0.3% and 1.3% of MMS cases were performed for melanoma and carcinoma in situ, respectively. Total annual volume predictions for 1,777 providers showed a left-shifted curve. 65.8% of LDSSAF cases had same-day MMS repairs: 48.7% of repairs were complex, 9.8% intermediate, 32.4% flaps, and 7.4% full-thickness skin grafts., Conclusions: The 5% LDSSAF is highly predictive of total claim volumes and is useful for modeling practice trends. There is wide variation in MMS provider annual case volume. These data reflect only Medicare Part B enrollees in 2009; 5% LDDSAF extrapolations are predictions based on sampling., (© 2012 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

Background: The bilobed and hatchet flaps are well-accepted reconstructive options for the correction of defects of the lower third of the nose. Optimal utilization of these flaps depends on understanding the characteristics of each flap as well as anatomic considerations related to the distal nasal area. Disregarding the limitations of either method may lead to flap failure and unacceptable aesthetic results., Objective: We present three original ideas: 1) a bilobed flap may be considered as a hatchet flap with a Z-plasty; 2) the trap door deformity (TDD) associated with a bilobed flap can be used as an advantage; and 3) an easy method for preoperative planning of a bilobed flap., Methods: We collected data from patients who underwent excision of basal cell carcinoma (BCC) of the distal third of the nose and reconstruction with a hatchet or a bilobed flap within the last 20 years., Results: Favorable cosmetic results were achieved when a hatchet flap was used to reconstruct defects of the inferior third of the nasal side wall, above or bordered with the alar crease, and when a bilobed flap was used to reconstruct nasal tip para-medial defects above the lower lateral cartilage convexity., Conclusions: We suggest choosing between the hatchet and bilobed flaps for nasal reconstruction according to the defect location as outlined by our findings.

Background: Mohs micrographic surgery is the preferred treatment for certain skin cancers. It had already been considerably refined prior to its introduction into Australia in 1978, refinement has continued since. Documenting the work practices of Australian Mohs surgeons serves to clarify the current role of Mohs surgery and may help tailor future Mohs fellowship programs., Methods: A survey was conducted to investigate the characteristics and clinical practices of Australian Mohs surgeons, particularly as they relate to skin cancer management and aesthetic dermatology., Results: The typical Australian Mohs surgeon is male (90%), works in a group private practice (70%), and is aged 40-44 years (37%). Mohs surgery is generally reserved for tumours that are located on the head, neck, digits or genitals (98%), and flap reconstructions are the commonest repair types performed (48%). Laser and cosmetic injectable treatments form part of many Mohs surgeon's repertoires., Conclusion: Australian Mohs surgeons make an important contribution to the management of skin cancer in Australia and many are skilled in laser and cosmetic procedures. The increasing number of cases performed annually and the familiarity with laser and cosmetic therapies reinforces Australian dermatologists as leaders in these important areas of dermatology., (© 2011 The Authors. Australasian Journal of Dermatology © 2011 The Australasian College of Dermatologists.)

Background: Mohs micrographic surgery (MMS) provides a combination of high cure rate and tissue conservation. Epidemiologic factors and changes in techniques may affect the way MMS is performed., Objective: We sought to evaluate changes over time in the type of patients and skin cancers that are treated using MMS, and the repairs used to close the defects., Methods: We conducted a retrospective study on patients treated with MMS at the Skin and Cancer Foundation Australia, Westmead, in 1997 against those treated in 2007. Patient demographics (age, sex), pathology of tumor, anatomic site of the tumor, preoperative tumor size, postoperative defect size, and repair method were analyzed., Results: There was a 260% increase in the number of procedures (596 in 1997 vs 1587 in 2007). The 2007 cohort was a little older (62 vs 64 years), but there were no differences in sex, anatomic site, rate of basal/squamous cell carcinoma, squamous cell carcinoma histologic subtypes, or preoperative tumor size. However, there were fewer superficial basal cell carcinomas, and the postoperative defect size was smaller in 2007 (P < .0001). There was also a decrease in the use of grafts and second-intention healing to close the defects and an increase in the number of side-to-side closures (P < .0001)., Limitations: Retrospective study at one institution is a limitation., Conclusion: Although tumor size and the percentage of tumors in each anatomic site did not change over 10 years, the size of the defect created after MMS has become smaller. This reduction in defect size may explain why more defects are now repaired by side-to-side closure and flap repairs whereas fewer defects are repaired by skin grafting., (Copyright © 2009 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Objective: To describe changing patterns of skin cancer surgery by Australian general practitioners and make comparisons with specialists., Design and Setting: Analysis of Medicare Australia item number reports for skin cancer excisions and for flap and graft repairs between 2001 and 2005., Main Outcome Measures: GPs' and specialists' rates of non-melanoma skin cancer (NMSC) excisions, melanoma excisions, flap repairs and graft repairs; excision to flap ratios., Results: NMSC excisions in Australia increased from 338 712 (2001) to 451 628 (2005), a mean annual increase of 1.11/1000 population (P = 0.04); GPs did 51.1% of excisions in 2001, increasing to 54.4% in 2005, representing a higher mean annual rate increase than in specialists (P = 0.003). Nationally, melanoma excisions increased from 20 414 (2001) to 25 580 (2005); GPs did 34.3% of excisions in 2001, increasing to 35.8% in 2005--a similar mean annual rate increase to that in specialists (P = 0.25). Total flap repairs increased from 58 550 (2001) to 80 742 (2005); GPs did 21.3% of flap repairs in 2001, increasing to 26.9% in 2005--a similar mean annual rate increase to that in specialists (P = 0.83). Nationally, the excision to flap ratio for GPs fell from 14 : 1 (2001) to 12 : 1 (2005); in Queensland the ratio fell from 14 : 1 to 9 : 1 over the same period., Conclusion: GPs excise the majority of skin cancers, and the proportion excised by GPs is increasing. GPs are increasingly using skin flaps for repair, suggesting substantial changes to patterns of treatment, especially in Queensland.

Background: Because the probability of basal cell carcinoma (BCC) recurrence was thought to be 30% to 50%, surgical tradition became not to perform additional resection when the margin was positive., Objective: To determine whether there is an association among age or sex of the patient, anatomic location, histologic type, or reconstructive procedures and the signs and symptoms of the recurrence, interval between incomplete resection and Mohs micrographic surgery (MMS), or extent of MMS resection., Design: During 20 years, all patients with incompletely excised BCC of the head referred for MMS were sequentially prospectively accrued into the cohort., Setting: An outpatient MMS practice., Patients: Nine hundred ninety-four patients., Main Outcome Measures: Interval to tumor recurrence, interval to MMS, and extent of MMS as determined by mean surface area resected, depth of resection, and number of tumor nests., Results: The interval to signs or symptoms of recurrence and to MMS from incomplete resection was greater for men, patients older than 65 years, those having a tumor on the nose or cheek, those with aggressive or fibrosing BCC, and those who underwent flap reconstruction (P =.001). The extent of MMS resection was greater for those with flap and split-thickness skin graft repairs. The number of tumor nests identified by MMS was significantly greater in those treated with split-thickness skin graft and flap (P =.001)., Conclusion: Because it is more difficult to control recurrent BCC, treating tumor remaining at the margin of resection in the immediate postoperative period could result in less extensive surgery.