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Melanoma is a malignant tumour with a poorer prognosis in stage III and IV patients. Development of effective therapies for the treatment of advanced melanoma has led to an improvement in survival. Furthermore, the French population is ageing, and treatment of melanoma in this population has several specific limitations. This descriptive, retrospective, single-centre study collected data on the diagnostic and therapeutic management of patients with melanoma of Breslow ≥ 1 mm or of unknown primary and metastatic spread, at Limoges University Hospital, between 2018 and 2022, and compared the results obtained between 2 groups: under 80 and over 80 years of age; 344 patients were included. The extension work-up was more frequently complete and the sentinel lymph node technique more frequently performed in patients under 80. Wide excision was more frequently in accordance with guidelines in patients over 80. Adjuvant or first-line metastatic treat-ment was more frequently instituted in patients under 80, but no difference was found as regards the second and third lines, the frequency of adverse events, and the reason for stopping treatment. Our study supports similar management of elderly and young subjects, given the safety profile and efficacy of treatments.

It may be necessary for patients to undergo (dermato-)surgical procedures during pregnancy or lactation. Often, there are no drug approvals or guidelines in this context. The following article describes the most common dermatologic surgical conditions during pregnancy and lactation, as well as the special therapeutic considerations and risks to be aware of during treatment. Dermatosurgical procedures are subject to strict indications. Most of these procedures can be performed during pregnancy, but the risks to the mother and fetus must be carefully weighed against the disadvantages of nonsurgical therapy. Although surgery can be performed safely in any trimester, the second trimester and immediate postpartum period are optimal. Surgery should not be delayed for melanoma or high-risk skin cancer. Perioperative positioning and choice of analgesics, antiseptics, anesthetics and antibiotics must be considered carefully to avoid risks to the patient, fetus and infant., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Patients are often advised to keep the initial postoperative dressings dry and undisturbed for 24 to 72 hours. However, these requirements may result in significant disruption of patients' activities of daily living, such as bathing, leisure, and exercise., Objective: Compare standard management of keeping wounds dry and covered (48 hours) with early (6 hours) postoperative water exposure., Methods: Investigator-blinded, randomized (1:1), controlled trial evaluating rate of infection and additional outcomes of interest., Results: Overall, 437 patients were randomized to either the early (6-hour) water exposure (n = 218) intervention group or the standard cohort (n = 219). The incidence of culture-proven infection in the intervention group (1.8%) was similar to the standard group (1.4%) (P > .99). There was also no difference in rates of bleeding or bruising. Scar assessment using the Patient and Observer Scar Assessment Scale revealed similar scar outcomes., Limitations: Single site, academic center., Conclusion: Surgical wounds can be allowed to get wet in the immediate postoperative period with no increased incidence of infection or other complications and with similar cosmesis., Competing Interests: Conflicts of interest Dr Kirby has served as a consultant for AbbVie, Incyte, Janssen, Novartis, and UCB; has received honoraria from AbbVie, Incyte, InsMed, and Viela Bio; and has served on the speakers bureau for AbbVie., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Keloids are excessive formations of scar tissue that develop at the site of a skin injury. Due to their invasive nature, they have a negative impact on the skin's appearance and are prone to recurrence, making them a challenging condition to treat with regard to skin aesthetics., Objectives: The objective of this article was to compare the long-term effects of dermatologic trephination with nonsurgical treatments for scars and evaluate the clinical value of the treatments., Methods: A retrospective analysis was conducted of 48 patients who received keloid treatment in the Department of Dermatology and Department of Thoracic Surgery at our hospital from January 2021 to October 2023. Twenty-four patients received dermatologic trephination, and 24 patients received nonsurgical treatment. Outcome measures included scar appearance, scar healing time, pain and itching levels, and patient satisfaction., Results: The healing time of patients receiving dermatologic trephination was significantly shorter than that of patients in the nonsurgical group. The degree of itching in patients undergoing dermatologic trephination was significantly lower than that of patients in the nonsurgical group. The satisfaction of patients who received dermatologic trephination was significantly higher than that of patients in the nonsurgical group., Conclusions: In this study we demonstrated that trephination achieves better long-term results in keloid revision, including improved keloid appearance, itching symptoms, and patient satisfaction., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Pinch grafting has experienced a resurgence in interest in recent years, stemming from its simplicity, safety, and potential in restoring tissue integrity. While historically employed for chronic nonhealing wounds, pinch grafts have shown promise following surgical procedures, particularly those involving the lower extremities., Objective: To systematically review the literature and present an updated overview of the current applications of pinch grafting., Methods: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In collaboration with a medical reference librarian, the PubMed, Embase, Scopus, and Web of Science databases were searched for studies reporting on the use of pinch grafting from 2000 onward. The references of each included article were also screened., Results: Ten articles met final inclusion criteria. In total, 300 patients underwent pinch grafting for treatment of skin ulceration, while an additional 35 cases were performed as an alternative to primary closure following skin cancer resection. Overall, pinch grafting was safe and well tolerated, with minimal adverse outcomes reported., Conclusion: Pinch grafting is a safe, straightforward, and effective technique to promote the healing of chronic wounds. While the procedure shows early promise in emerging applications within dermatologic surgery, only about 10% of the reported cases involved this indication, reflecting a need for further research in this area., (Copyright © 2024 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Dermatosurgical procedures are predominantly performed under local anesthesia, yet there are few studies on perioperative pain management for extensive or staged procedures under local anesthesia. The purpose of this study was to assess pain during dermatologic surgery, describe perioperative pain management, and identify factors that influence pain perception., Patients and Methods: This prospective, monocentric study included inpatients undergoing dermatologic surgery under local anesthesia from April to December 2021. Preoperative demographic data, a pain questionnaire, and four psychometric questionnaires (PCS, LOT-R, SFQ, PHQ-9) were collected. Postoperative pain and analgesic use during the first 24 hours were recorded., Results: A total of 120 patients (with a total of 191 interventions) were included in the study. Mean postoperative pain was reported to be very low (NRS < 2). Preoperative pain and expected postoperative pain were found to be predictive of postoperative pain. There was a strong correlation between catastrophizing and preoperative anxiety (r = 0.65) and a moderate correlation between depression and preoperative anxiety (r = 0.46)., Conclusions: Dermatologic surgery under local anesthesia is generally considered painless. During preoperative counseling and assessment, attention should be paid to patients who fear surgery, report pain, or anticipate postoperative pain, as they have an increased risk of experiencing postoperative pain., (© 2024 The Author(s). Journal der Deutschen Dermatologischen Gesellschaft published by Wiley‐VCH GmbH on behalf of Deutsche Dermatologische Gesellschaft.)

Introduction: Fast gut cutaneous sutures have become more prominent due to their low tissue reactivity, rapid absorption, and elimination of suture removal visits. It is not known how fast gut sutures compare to other closure modalities., Methods: A comprehensive literature review was conducted to identify randomized controlled trials comparing fast gut sutures to alternative closure methods during dermatologic surgery. Data collected included patient and physician assessed cosmetic outcome as well as standardized complication rates., Results: Six studies were included in final analysis and reported on 208 patients. Fast gut sutures were associated with lower physician opinions of final scar when compared to polypropylene sutures (SMD 0.438; 95% CI 0.082 to 0.794). No differences existed between physician opinion of fast gut sutures and cyanoacrylate tissue adhesive (SMD - 0.024; 95% CI - 0.605 to 0.556). Complications with fast gut suture placement were rare, and included infection, dehiscence, and hematomas. Fast gut sutures were less likely to experience wound dehiscence than tissue adhesive (p = 0.01)., Conclusion: If no contraindications to polypropylene sutures exist, they may provide superior cosmetic outcomes compared to fast gut sutures. Further research is required to better quantify cosmetic outcomes and optimal use of fast gut sutures., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The optimal treatment of acne scarring is challenging because several factors need to be considered, including the type and number of scars, Fitzpatrick skin type, and the amount of downtime permissible to the patient. This second article in the continuing medical education series discusses the procedural treatments available for acne scarring, including the use of chemical peels, fillers, radiofrequency microneedling, lasers, and surgical procedures. The indications for each modality, evidence for its benefits, and the adverse effects are discussed. This section aims to help guide the reader select and implement the most appropriate treatment based on the patient's preferences, acne scarring, and skin type., Competing Interests: Conflict of interest None disclosed., (Copyright © 2022 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Understanding patient non-adherence to prescribed antibiotics can inform clinical practices, patient counseling, and antibiotic efficacy study design in dermatology. The primary objective was to determine the rate of and reasons for antibiotic non-adherence in the dermatologic surgery setting. The secondary objective was to test the applicability of previously studied survey questions for antibiotic non-adherence screening in the dermatologic surgery setting. Five academic outpatient dermatologic surgery centers across the United States conducted one multicenter prospective cohort study. Dermatologic surgery patients ≥ 18 years of age who were prescribed an antibiotic were included as part of this study. 15.2% (42/276) of patients did not adhere to their antibiotic regimen after dermatologic surgery. Most common reasons for incomplete antibiotic courses included forgotten antibiotics (42.9%,18/42) and side effects (28.6%, 12/42). Previously evaluated questions to identify and predict non-adherence had modest performance in the dermatologic surgery setting (Area under the curve of 0.669 [95% CI (0.583-0.754)]). Antibiotic non-adherence after skin surgery is prevalent and commonly due to reasons that physicians can address with patients., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The use of ointments can be beneficial for dry, chapped, or cracked skin and also for supporting wound healing. We describe the results of 2 studies with an over-the-counter healing ointment (HO) to evaluate the effects on skin hydration and in the setting of wound healing after dermatologic procedures.&nbsp; Methods: Study 1 was a single-center, in-use study using HO on qualified areas at least once daily for 4 weeks in subjects with dry, cracked body skin and self-perceived sensitive skin. Study 2 was a multi-center study of wound healing in subjects using HO on a daily basis after having dermatologic surgical procedures.&nbsp; Results: In Study 1, there was a significant reduction in skin dryness after 1 and 4 weeks of HO use (P&lt;0.05). Image analysis of the skin revealed a significant increase in skin smoothness after the first application of HO in 100% of subjects (P&lt;0.05). Tolerability and safety were excellent, and HO was well-perceived by subjects throughout the study. In Study 2, HO improved clinical assessments at all time points compared with baseline with a decrease in erythema, edema, scabbing/crusting, and an improvement in overall wound appearance (P&lt;0.05). There was no worsening or significant increase in measures for tolerability parameters at any study visits. Additionally, HO achieved a favorable perception by study subjects.&nbsp; Conclusions: HO has a well-established safety profile and has been shown to improve both skin hydration and the overall wound healing process after dermatologic surgical procedures. J Drugs Dermatol. 2024;23(5):360-365. doi:10.36849/JDD.8224.

Competing Interests: Conflicts of interest Dr Tolkachjov is a speaker/investigator for CASTLE Biosciences and Bioventus/LifeNet. Dr Lauck, Author Cho, and Dr Rickstrew have no conflicts of interest to declare.

Background: Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations., Objective: To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis., Materials and Methods: A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors., Results: The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures., Conclusion: These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations., (Copyright © 2024 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Many patients undergoing cutaneous surgery are prescribed at least one anticoagulant or antiplatelet agent. With the recent emergence of direct oral anticoagulants (DOACs), there is a deficit of knowledge regarding optimal perioperative management. This review aims to evaluate the evidence and risk surrounding management of DOACs in patients undergoing skin surgeries., Methods: Systematic review of EMBASE, Scopus, and PubMed, with inclusion of studies that detailed perioperative management of DOACs in those undergoing skin surgery. Primary outcome measures were perioperative hemorrhagic and thromboembolic complications., Results: Seven thousand seven hundred and forty-one abstracts were identified, with 13 articles meeting inclusion criteria. Two studies investigated complication risk associated with DOAC continuation in skin surgery and found an average rate of hemorrhagic complications of 1.74%. Two studies evaluated complications associated with DOAC cessation prior to skin surgery, with a pooled thromboembolic complication rate of 0.15%. Articles comparing continuation and cessation discovered no decreased risk of bleeding with DOAC cessation prior to surgery (P = 0.93). Seven of the 13 articles compared complications in a control vs a DOAC group undergoing cutaneous procedures. Evidence was conflicting but may have suggested a small increase in bleeding risk in those on DOAC therapy., Conclusion: Optimal management of anticoagulants perioperatively is difficult because of conflicting information, complicated by advent of novel agents. Risk of hemorrhagic complications with both continuation and interruption of DOAC therapy was low. Perioperative DOAC management can be guided by procedural bleeding and patient clotting risk and can often be continued in minor dermatologic procedures., (© 2023 The Authors. International Journal of Dermatology published by Wiley Periodicals LLC on behalf of the International Society of Dermatology.)

Antithrombotic medication is taken by 14-22% patients undergoing skin surgery, with more patients now taking direct oral anticoagulants (DOACs). The latest evidence suggests that the risk of stopping DOACs perioperatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidelines suggest that clinicians could consider stopping DOACs in patients for 24-48 h, based on individual bleeding risk. We surveyed BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. The results demonstrated that there is consistency among clinicians in the management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher-risk procedures such as larger flaps or grafts with DOACs vs. other antithrombotics postoperatively. Stopping DOACs perioperatively for 24-48 h for higher-risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Association of Dermatologists.)

Background: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy of the posterior tibial nerve. Surgery can be performed less invasively under local anesthesia. We adopted zig-zag skin incision to prevent postoperative wound complications., Methods: Between July 2022 and June 2023, we operated on 19 legs of 14 consecutive TTS patients (5 males, 11 females; average age 73.3 years). We made a 2- to 3-cm zig-zag skin incision on the tarsal tunnel. After posterior tibial nerve decompression by posterior tibial artery (PTA) transposition, the subcutaneous layer was tightly sutured with 4-0 PDS and the skin was closed with Dermabond Advanced. We investigated adverse events that developed during the first 30 postoperative days and recorded surgical outcomes at the final visit., Results: In all patients the nerves were successfully decompressed with PTA transposition. There were no intraoperative complications. During the 30 postoperative days there were no adverse events, including wound complications, and patients' symptoms improved significantly., Conclusion: Zig-zag skin incision was easy and convenient for surgical TTS treatment and may be useful for preventing postoperative wound complications.

In addition to prevention of surgical site infections after skin surgery, perioperative antibiotic prophylaxis (PAP) aims to prevent the occurrence of other postoperative infectious complications, especially bacterial endocarditis and hematogenous joint prosthesis infections. This article discusses specific indications for the use of PAP. For example, patients who have undergone any type of heart valve replacement, including transcatheter valve replacement or use of prosthetic material to correct the heart valve, or patients who have experienced bacterial endocarditis, require PAP during skin surgery on mucosal membranes or ulcerated tumors. The use of PAP in special situations such as secondary wound healing, septic dermatosurgery or ulcer surgery is also presented and discussed in detail in this paper based on the current scientific literature. This paper represents the second part of the position paper of the Antibiotic Stewardship Working Group of the German Society for Dermatologic Surgery (DGDC) and summarizes evidence-based recommendations for the administration of PAP during skin surgery for special indications and situations. This is particularly important because, as detailed in Part 1 of this position paper, PAP can and usually should be avoided in skin surgery., (© 2023 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft.)

The aim of perioperative antibiotic prophylaxis (PAP) is to prevent the occurrence of surgical site infections (SSIs) or other infectious complications (especially bacterial endocarditis or septic arthritis). PAP is effective in surgeries where overall infection rates are high even without considering patient-related risk factors (such as orthopedic surgery or fracture repair). Surgery on airways, gastrointestinal, genital, or urinary tract is also considered to be associated with a risk of infection and may require PAP. Overall, SSIs in skin surgery are relatively rare and vary between 1% and 11% depending on the localization, complexity of the wound closure and patient cohort. Therefore, the general surgical recommendations regarding PAP only partially reflect the needs of dermatologic surgery. In contrast to the USA, where recommendations on the use of PAP in skin surgery already exist, there are currently no guidelines for the use of PAP specifically designed for dermatologic surgery in Germany. In the absence of an evidence-based recommendation, the use of PAP is guided by the experience of the surgeons and leads to a heterogeneous use of antimicrobial substances. In this work, we summarize the current scientific literature on the use of PAP and make a recommendation depending on procedure- and patient-related risk factors., (© 2023 The Authors. Journal der Deutschen Dermatologischen Gesellschaft published by John Wiley & Sons Ltd on behalf of Deutsche Dermatologische Gesellschaft.)

Background: Dermatologists perform a variety of procedures including excisions, biopsies, and other minor surgical procedures. Patients can experience anxiety in anticipation of their surgeries or may develop anxiety during the procedure. Since most dermatologic procedures occur with the patient awake and alert, the physician can offer comforting methods to alleviate some of that anxiety., Aims: We wanted to provide a review of available methods that dermatologists can use to reduce patient anxiety., Materials & Methods: In this paper, we review the current literature on methods that can be used in dermatology offices to reduce overall patient anxiety levels., Results: In the preoperative stage, providers can offer educational content to explain the procedure to their patients. Whether it be through telephone calls, educational videos, or utilization of visual models, educating the patient regarding their procedure may reduce their anxiety. Intraoperatively, there are multiple methods that can be used such as music, guided imagery, coloring books, medications, hypnosis, and distraction techniques., Discussion & Conclusion: There is a variety of approaches that can be easily implemented in the office and can help in reducing the anxiety of the patients to allow for a pleasant patient experience and an overall satisfactory procedure outcome., (© 2023 the International Society of Dermatology.)

Purpose: Create a practical step-by-step guide to harvesting this flap, highlighting the critical points that can create problems during surgery and the postoperative period., Methods: The tips and tricks to harvesting the scapula tip-free flap are described in different points, describing the patient preparation and skin incision, identification of the anterior border of the latissimus dorsi, dissection of the pedicle, bone osteotomy, flap inset, and closure., Results: As the scapula tip-free flap provides skin, muscle, and bone tissue, it is a valid option for the reconstruction of the defects maxillary and mandibular region for facial reconstruction. The complications are minimal, with some cases of seroma and postoperative shoulder pain., Conclusion: Thanks to the surgical technique described, harvesting the scapula tip-free flap with the patient in the supine position makes it a valid option for working in 2 fields, shortening surgical time and being a very interesting option for maxillofacial reconstruction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

This article in the series «Safety in Dermatologic Procedures» deals with the accidental laceration of major blood vessels and nerve structures during surgery. We first look at the anatomic location and course of the blood vessels and nerve structures that are most at risk of injury and then describe the possible outcomes in each case. We finally offer some recommendations on how to avoid damage to structures in danger zones and how to repair them if they are accidentally compromised., (Copyright © 2023 AEDV. Publicado por Elsevier España, S.L.U. All rights reserved.)

The use of perioperative antibiotic prophylaxis in cutaneous surgery is controversial due to unclear efficacy and, thus, potentially unnecessary side-effects. This prospective observational study analysed the efficacy of oral perioperative antibiotic prophylaxis in preventing surgical site infections. Adult patients undergoing cutaneous surgery between August 2020 and May 2021 at Ludwig-Maximilian University Hospital Munich, Germany, without prior signs of infection were eligible. Propensity score weighting was used for covariate adjustment to account for non-randomized treatment assignment. Of 758 included patients, 23 received perioperative antibiotic prophylaxis (3.0%). In this group, a surgical site infection occurred in 1 of 45 lesions (2.2%) compared with 76 of 1,189 lesions (6.5%) in the group without perioperative antibiotic prophylaxis (735 patients, 97.0%). With covariate adjustment, the odds ratio for the occurrence of a surgical site infection in patients receiving perioperative antibiotic prophylaxis was 0.114 (95% confidence interval 0.073-0.182; p <0.001) on a per lesion level. The number of lesions needed to treat to prevent 1 surgical site infection was 17.6 (95% confidence interval 16.8-19.2). This prospective observational study shows a reduction in the incidence of surgical site infection in cutaneous surgery performed with perioperative antibiotic prophylaxis. The large size difference between the 2 study groups limits the study.

Dermatologic surgeons are encountering more patients on antithrombotic agents. There are no established consensus guidelines for managing antithrombotic agents in the perioperative period. We provide an updated overview of antithrombotic agents in dermatologic surgery and management of such agents in the perioperative period with additional unique perspectives from cardiology and pharmacy. A literature search of PubMed and Google Scholar was performed to review the English-language medical literature. The landscape of antithrombotic therapy is changing with a notable rise in the use of direct oral anticoagulants (DOACs.) While no consensus guidelines exist, most studies recommend continuing antithrombotic therapy in the perioperative period with appropriate lab monitoring, when applicable. However, recent data suggest it is safe to hold DOACs in the perioperative period. As antithrombotic therapy evolves, the dermatologic surgeon needs to remain current with the most recent available data. Where data are limited, a multidisciplinary approach to managing these agents in the perioperative period is essential. J Drugs Dermatol. 2023;22(5): doi:10.36849/JDD.7456.

Competing Interests: Conflicts of interest None disclosed.

Background: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery., Methods: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression., Results: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications., Conclusion: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed., (© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The CAPER Registry is a voluntary, national safety reporting program that gathers patients' adverse events encountered during dermatologic procedures. This registry is intended as an aid for practitioners, patients, industry, and government regulators, and aims to facilitate safety monitoring for the specialty by identifying resource, process, education, and other systemic gaps associated with adverse events, as well as any potential risk factors for adverse events. CAPER will provide new or corroborating information to help dermatologists improve clinical practices, improve safety and effectiveness, and treat and prevent adverse events. The data generated will also help industry partners and regulatory bodies prevent adverse events from going unnoticed., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: Conflicts of interest None disclosed.

Background: Dermatologic surgeons are faced with a dilemma when counseling actively smoking patients who require dermatologic surgery: recommend total cessation of all nicotine that is associated with extremely high rates of cessation failure or recommend nicotine replacement therapy (NRT)., Objective: To determine the safety of NRT in dermatologic surgery., Materials and Methods: PubMed was queried: [(nicotine OR electronic cigarettes) AND (flap OR wound healing)]., Results: Smoking tobacco is detrimental to wound healing, supported by ample evidence (1A). Perioperative smoking cessation reduces risk (1B). Basic science demonstrates both a benefit and detriment of nicotine depending on the factor studied (2A). Human studies suggest no detrimental effect of nicotine on perioperative complications (1B). Nicotine may be detrimental to flaps, but evidence is limited to basic science (2A)., Conclusion: Dermatologists should consider recommending nicotine replacement for smokers in the perioperative period. Evidence is lacking to determine safety in flaps. It is presumed based on animal studies that nicotine has a negative effect on flaps; however, it is likely less than tobacco. Weighing the risk of cessation failure without nicotine replacement versus nicotine replacement after flap is challenging. Electronic cigarettes should be discouraged as a means of NRT., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Ibrutinib, an irreversible Bruton tyrosine kinase inhibitor, has been associated with an increased risk of bleeding. There is a paucity of data on the risk of bleeding in patients on ibrutinib undergoing dermatologic surgery., Objective: To determine the frequency of bleeding complications associated with ibrutinib in patients undergoing dermatologic surgery., Materials and Methods: A retrospective, single-center, case-control study of patients on ibrutinib undergoing skin surgery between January 2013 and March 2020 compared with sex, disease, and age-matched control patients undergoing cutaneous surgeries., Results: A total of 75 surgeries performed on 37 case patients and 116 surgeries performed on 64 control patients were included. Ibrutinib was associated with a statistically significant increased rate of bleeding events (6/75 [8%] vs 1/116 [0.8%], p -value = .02). Compared with ibrutinib patients who did not have a bleeding event, those on ibrutinib who suffered bleeding were all men, older (mean age 82.7 vs 73.0, p -value= .01), and had lower mean platelet counts (104.0 vs 150.5 K/μL, p -value = .03)., Conclusion: Ibrutinib may be associated with increased risk of bleeding in patients with hematologic malignancies, particularly older men with lower platelet levels and on multiple anticoagulants. Transient discontinuation of ibrutinib should be considered for dermatologic surgeries., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Undermining is thought to improve wound outcomes; however, randomized controlled data regarding its efficacy are lacking in humans. The objective of this randomized clinical trial was to determine whether undermining low to moderate tension wounds improves scar cosmesis compared to wound closure without undermining. Fifty-four patients, 18 years or older, undergoing primary linear closure of a cutaneous defect with predicted postoperative closure length of ≥ 3 cm on any anatomic site were screened. Four patients were excluded, 50 patients were enrolled, and 48 patients were seen in follow-up. Wounds were divided in half and one side was randomized to receive either no undermining or 2 cm of undermining. The other side received the unselected intervention. Three months, patients and 2 masked observers evaluated each scar using the Patient and Observer Scar Assessment Scale (POSAS). A total of 50 patients [mean (SD) age, 67.6 (11.5) years; 31 (64.6%) male; 48 (100%) white] were enrolled in the study. The mean (SD) sum of the POSAS observer component scores was 12.0 (6.05) for the undermined side and 11.1 (4.68) for the non-undermined side (P = .60). No statistically significant difference was found in the mean (SD) sum of the patient component for the POSAS score between the undermined side [15.9 (9.07)] and the non-undermined side [13.33 (6.20)] at 3 months. For wounds under low to moderate perceived tension, no statistically significant differences in scar outcome or total complications were noted between undermined wound halves and non-undermined halves.Trail Registry: Clinical trials.gov Identifier NCT02289859. https://clinicaltrials.gov/ct2/show/NCT02289859 ., (© 2021. The Author(s).)

Backgrounds: Surgical site infections (SSIs) represent one of the most common and potentially preventable sources of morbidity and healthcare cost escalation associated with skin cancer surgery. There is a lack of data reporting organisms cultured from SSIs in skin surgery, with guidelines for antibiotic prophylaxis based on common skin pathogens rather than actual cultured organisms. In this study, we sought to define the cultured microbiology of SSIs specific to skin cancer surgery and test these against empiric treatment guidelines., Methods: All consenting patients presenting to the Auckland regional skin cancer treatment centre over a 6-month period were included. Patients receiving any form of antibiotics within a week prior to surgery were excluded. All wounds were assessed postoperatively, with clinically significant infections identified as those with a standardized wound infection score of 4 (range 0-7) and/or prescribed post-operative antibiotics within 3 weeks of surgery. Wound cultures were recorded., Results: About 104 clinically significant SSIs were identified from 333 lesions treated, with cultures available in 27%. Cultured organisms included MSSA (79%), MRSA (14%), coagulase-negative Staphylococci (11%), and 'skin flora' (14%). Empiric guidelines inaccurately predicted effective treatment in 14% of cases, exclusively due to MRSA., Conclusion: To our knowledge this is the first comprehensive report of SSI microbiology following skin cancer surgery. The overwhelmingly predominant organisms were Staphylococcus sp. (76%), with the rate of MRSA approaching prevalence warranting empiric first-line treatment. These data help inform effective rationalized empiric antibiotic treatment, when indicated, for optimal outcome following skin surgery., (© 2022 Royal Australasian College of Surgeons.)

Competing Interests: Conflicts of interest None disclosed.

Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Despite increasing cross-collaboration between providers who perform cutaneous surgery, a disparity still exists in the current practices regarding perioperative management. This could lead to treatment delays, patient confusion, and increased morbidity, such as clotting, infection, and discomfort of patients., Objective: To characterize the management practices of different providers in regards to perioperative anticoagulation and antiplatelet therapy for cutaneous surgery., Methods and Materials: This study used an electronic survey to assess current perioperative management practices of dermatologic surgeons and plastic and reconstructive surgeons., Results: 177 physicians (115 dermatologic surgeons and 62 plastic and reconstructive surgeons) responded to the survey. For all therapeutic agents, dermatologic surgeons were significantly more likely than their plastic and reconstructive surgery colleagues to continue all anticoagulant and antiplatelet agents perioperatively for cutaneous surgery (vitamin K antagonists, antiplatelets, LMWH, direct Xa inhibitors, direct thrombin inhibitors, NSAIDS: P&lt;0.001; fish oil, vitamin E: P&lt;0.01)., Conclusion: Our data highlight the significant practice gaps that exist between dermatologic surgeons and plastic and reconstructive surgeons. Reducing this disparity will facilitate improved continuity of care, especially when patients are referred from dermatologic surgeons to plastic and reconstructive surgeons for more complex repairs, and potentially reduce morbidity and mortality associated with medication discontinuation. J Drugs Dermatol. 2022;21(7):766-772. doi:10.36849/JDD.6726.

Antibiotics have been used as a prophylaxis for dermatologic procedures. We will review the various procedures that specific antibiotics with dosages are used for, depending on the procedure, diagnosis, and circumstance of the patient. We will examine the current and updated guidelines used in dermatologic surgery and the overlapping guidelines across other fields. Physicians must consider the side effects of antibiotics and the resistance that may occur as a result before using the class or level of prophylaxis. Initial evaluation for alcohol, chlorhexidine, or iodine should be measured as well. Updated guidelines aim to address the contraindications of antibiotics, yet further research is needed to avoid antibiotic resistance and to explore alternative methods of antibiotic application, such as intranasal and intravenous., (© 2022 Wiley Periodicals LLC.)

Introduction: Identifying risk factors for wound infection may guide clinical practice for optimal use of perioperative antibiotic prophylaxis in dermatologic surgery., Objective: To summarize the current evidence whether specific body sites have higher risks for surgical site infections (SSI)., Methods: The systematic literature search included MEDLINE, Embase, CENTRAL, and trial registers. Only observational studies qualified for inclusion and meta-analysis. We assessed the risk of bias according to the Newcastle-Ottawa Scale., Results: Eighteen studies with 33,086 surgical wounds were eligible. Eight studies were of good, 4 of fair, and 6 of poor quality. The mean infection rate was 4.08%. Meta-analysis showed that the lips had significantly higher infection rates. The lower extremity and ears had or tended toward a higher risk for infection, but studies were clinically heterogeneous. A large prospective trial found that surgical wounds on the hands were at higher risk for infection. The trunk showed the lowest infection rate. The risk for SSI in other body locations was not different or remained uncertain because of substantial heterogeneity among studies., Conclusion: Lips, lower extremities, and probably ears and hands may have a higher risk for wound infection after skin surgery. The trunk showed the lowest infection rate., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pain assessment plays an important role in dermatologic surgery. The numeric rating scale (NRS), visual analog scale (VAS), verbal rating scale (VRS), and Faces Pain Scale (FPS) are commonly used scales for pain measurement. Conflicting evidence exists regarding the use of each. Prompt pain recognition and treatment during procedures result in higher patient satisfaction., Objective: Determine the most applicable scale for acute pain measurement in dermatologic surgery., Materials and Methods: This systematic review was performed in accordance with PRISMA-Supplemental Digital Content 4, http://links.lww.com/DSS/A976 (PROSPERO; CRD42018091058). PubMed, Cochrane, EMBASE, Scopus, and Web of Science were searched between April 24, 2018, and May 06, 2018. The search query consisted of pain, pain measurement (NRS, VAS, VRS, and FPS), and assessment/comparison. The inclusion criteria included English language literature with primary/secondary outcome objectives directly comparing ≥2 pain scales in acute pain (age: 13+). Study end points included interscale correlations, patient preferences, provider preferences, study author recommendations, and failure rates., Results: Eight hundred seven studies were retrieved: A total of 42 studies were included. The visual analog scale (n = 42) was most studied, followed by NRS (n = 29), VRS (n = 27), and FPS (n = 11). 93.1% studies showed a high statistical correlation between VAS and NRS. Patients preferred NRS (n = 8/11), followed by FPS (n = 3/11), VRS (n = 2/11), and VAS (n = 1/11). Study authors recommended NRS/VAS (n = 8/19), VRS (n = 6/19), and FPS (n = 1/19). Providers preferred NRS (n = 2/3) and VRS (n = 1/3). The visual analog scale had the highest failure rate (n = 11/12)., Conclusion: The numeric rating scale is most applicable for dermatologic surgery because of reported patient and provider preferences, lowest failure rates, and most frequent study author recommendations., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

In this study, a soft-tissue-anchored, percutaneous port used as a mechanical continence-preserving valve in reservoir ileo- and urostomies was functionally and morphologically evaluated in eight dogs. During follow-up, the skin failed to attach to the implant, but the intestine inside the stoma port appeared to be attached to the mesh. After reaching adequate reservoir volume, the urostomies were rendered continent by attaching a lid to the implant. The experiments were ended at different time intervals due to implant-related adverse events. In only one case did the histological evaluation reveal integration at both the implant-intestine and implant-skin interfaces, with a low degree of inflammation and the absence of bacterial colonisation. In the remaining cases, integration was not obtained and instead mucosal downgrowth and biofilm formation were observed. The skin-implant junction was characterised by the absence of direct contact between the epidermis and the implant. Varying degrees of epidermal downgrowth, granulation tissue formation, inflammatory cell infiltration and bacterial growth and biofilm formation were prominent findings. In contrast, the subcutaneously located anchor part of the titanium port was well integrated and encapsulated by fibrous tissue. These results demonstrate the opportunity to achieve integration between a soft-tissue-anchored titanium port, skin and intestine. However, predictable long-term function could not be achieved in these animal models due to implant- and non-implant-related adverse events. Unless barriers at both the implant-skin and implant-intestine junctions are created, epidermal and mucosal downward migration and biofilm formation will jeopardise implant performance., (© 2021. The Author(s).)

Background: Brachioplasty procedures have experienced a surge in popularity over the past decade, mirroring the rise in bariatric procedures and growing population of massive weight loss patients. The authors estimated the incidence of associated complications and identify possible patient- or procedure-related predictive factors., Methods: A systematic review was performed using the PubMed, Cochrane, and Embase databases; extracted data were synthesized through a random-effects meta-analysis of proportions and a multivariate meta-regression., Results: Twenty-nine studies were included in the meta-analysis, representing 1578 patients; all studies followed an observational design. The incidence of adverse outcomes assessed included aberrant scarring, 9.9 percent (95 percent CI, 6.1 to 15.6 percent); ptosis or recurrence, 7.79 percent (95 percent CI, 4.8 to 12.35 percent); wound dehiscence, 6.81 percent (95 percent CI, 4.63 to 9.90 percent); seroma, 5.91 percent (95 percent CI, 3.75 to 9.25 percent); infection, 3.64 percent (95 percent CI, 2.38 to 5.53 percent); nerve-related complications, 2.47 percent (95 percent CI, 1.45 to 4.18 percent); lymphedema or lymphocele formation, 2.46 percent (95 percent CI, 1.55 to 3.88 percent); skin necrosis or delayed healing, 2.27 percent (95 percent CI, 1.37 to 3.74 percent); and hematoma, 2.06 percent (95 percent CI, 1.38 to 3.06 percent). The operative reintervention rate for aesthetic purposes was 7.46 percent (95 percent CI, 5.05 to 10.88 percent), and the operative reintervention rate for nonaesthetic purposes was 1.62 percent (95 percent CI, 1.00 to 2.61 percent). Multivariate meta-regression demonstrated that medial incision placement was associated with a higher risk of complications, whereas the incidence of certain complications was lowered with adjunctive liposuction (p < 0.05)., Conclusion: In the absence of large clinical trials, the present meta-analysis can serve to provide plastic surgeons with an evidence-based reference to improve informed consent and guide procedure selection with respect to the complication profile of brachioplasty., (Copyright © 2021 by the American Society of Plastic Surgeons.)