Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection

SUMMARY

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery

Background

Reconstruction of nasal lesions is complex due to the topography, mobile free margins and borders of anatomical subunits. Reconstructive challenges can lead to multiple revisional surgeries to achieve the final aesthetic result. This study aimed to evaluate risk factors and predictors of revisional surgery in patients undergoing reconstruction after Mohs micrographic surgery for nasal tumours.

Methods

This was a prospective cohort study from April 2, 2008 to February 26, 2019. The study population included all consecutive patients who underwent Mohs micrographic surgery for nasal skin cancer. Resection and reconstruction of nasal skin cancer was performed by the Mohs team.

Results

A total of 988 cases met our study inclusion criteria with 64 (6.5%) cases requiring unplanned surgical revision. Revision rates were highest in the ala (9.0%, p < 0.05) and complex anatomical subunits (16.7%, p < 0.0001). In contrast, revision rates for dorsum lesions were lowest (1.8%, p < 0.001). In terms of reconstructive modalities, local flaps resulted in significantly higher rates of revision when compared to grafts (relative risk, 2.37; 95% CI, 1.15–5.0; p < 0.01). In terms of histological diagnosis, squamous cell carcinoma had significantly higher revision rates when compared to basal cell carcinoma (p < 0.05).

Conclusions

To our knowledge, this is the first study to report the risk factors and predictors of revision surgery in patients undergoing MMS for nasal tumours. This study highlights that the reconstructive modality utilised affects the functional and cosmetic outcome of MMS. We note that ala complex subunit lesions, squamous cell carcinoma and flap reconstruction were associated with an increased risk of revision after Mohs reconstruction of nasal lesions.

Level of evidence: Level III, risk/prognostic; therapeutic study.

Trial registration number

(Ref: PLA-19-20_A03) 04/02/2020.

Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations

Mohs micrographic surgery is a specialized form of skin cancer surgery that has the highest cure rates for several cutaneous malignancies. Certain skin cancers can have small extensions or “roots” that may be missed if an excised tumor is serially cross-sectioned in a “bread-loaf” fashion, commonly performed on excision specimens. The method of Mohs micrographic surgery is unique in that the dermatologist (Mohs surgeon) acts as both surgeon and pathologist, from the preoperative considerations until the reconstruction. Since Dr. Mohs’s initial work in the 1930s, the practice of Mohs micrographic surgery has become increasingly widespread among the dermatologic surgery community worldwide and is considered the treatment of choice for many common and uncommon cutaneous neoplasms. Mohs micrographic surgery spares the maximal amount of normal tissue and is a safe procedure with very few complications, most of them managed by Mohs surgeons in their offices. Mohs micrographic surgery is the standard of care for high risks basal cell carcinomas and cutaneous squamous cell carcinoma and is commonly and increasingly used for melanoma and other rare tumors with superior cure rates. This review better familiarizes the dermatologists with the technique, explains the difference between Mohs micrographic surgery and wide local excision, and discusses its main indications.

Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older

BACKGROUND

As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients.

OBJECTIVE

To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications.

METHODS

A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics.

RESULTS

This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19-6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08-5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05-4.90; p = .036).

CONCLUSION

Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.

Reappraising Elements of the Aseptic Technique in Dermatology: A Review

Dermatologic procedures are performed under varying degrees of antisepsis, and no clear guidelines exist regarding the role of the aseptic technique in dermatology. This review aims to clarify the terminology surrounding surgical asepsis and examines the importance of various components of the aseptic technique in cutaneous surgery. Included are studies examining optimal glove type, surgical instruments, skin antisepsis, and cost-reducing protocols. Our review highlights that most dermatology procedures are not performed under completely sterile conditions due to the lack of environmental and foot traffic controls in dermatology offices. In addition, for some outpatient procedures, such as for minor excisions and Mohs surgery before reconstruction, elements of the clean technique can be used without increasing infection rates. However, data on the feasibility of a clean protocol for Mohs reconstruction is conflicting. Future prospective, randomized trials analyzing various components of the aseptic technique in dermatology are greatly needed so that guidelines can be established for practicing dermatologists.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

The Use of Chlorhexidine as a Skin Preparation on the Head and Neck: A Systematic Review of Ocular and Ototoxicity

BACKGROUND

Chlorhexidine gluconate is one of the most effective surgical preparations, but it has known potential ocular and ototoxicity.

OBJECTIVE

To review reported cases of ocular and ototoxicity caused by chlorhexidine and summarize the clinical situations in which chlorhexidine toxicity occurred.

METHODS

We performed a systematic review of PubMed and the Web of Science.

RESULTS

Fourteen cases reported sensorineural hearing loss from chlorhexidine instilled into the ear. Of the 38 cases of ocular toxicity, 8 cases were caused by direct instillation in the eye and 17 involved periocular surgical preparation. In the remaining cases, the area prepped was less defined. Seven cases involved preparation of the face, 1 for the scalp, 2 cases were drips from distant sites, and 3 cases did not specify the means of exposure.

CONCLUSION

The vast majority of toxicity occurred in patients undergoing general anesthesia and was rarely seen in situations where surgery was performed by dermatologists. Ultimately, it should be up to the individual physician to decide whether chlorhexidine is the best choice for a particular outpatient procedure.

Patient Concerns in the Immediate Postoperative Period After Mohs Micrographic Surgery

BACKGROUND

Postoperative concerns after Mohs micrographic surgery (MMS) are not well characterized.

OBJECTIVE

To better define patient concerns and contributing characteristics in the immediate postoperative period after MMS.

MATERIALS AND METHODS

A standardized telephone encounter template was implemented to better assess patient concerns in the 24-hour postoperative period. A review was then performed of patients undergoing MMS from October 2016 to July 2017 to assess for the most common patient concerns and association with clinical characteristics.

RESULTS

We included 307 patients. Overall, 60.6% of patients reported a concern. Fifty-four percent of patients reported pain. Most pain was characterized as "a little" (67.7%). On univariate analysis, flap repairs, location on the upper extremities, and swelling were associated with higher mean postoperative pain. Tumor type was not associated with increased pain. On multivariate analyses, patients with larger defects and associated edema were statistically significantly associated with higher degrees of pain.

CONCLUSION

Over half of patients experience postoperative concerns after MMS, most commonly pain. The immediate postoperative period may be an optimal time to identify patient concerns allowing for reassurance or early intervention when necessary.

The effect of antibiotic prophylaxis on infection rates in mohs micrographic surgery: a single-institution retrospective study

As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint.

A case of streptococcal surgical site infection following Mohs surgery

Group A β-hemolytic Streptococcal (GAS) cellulitis is an uncommon surgical site infection that presents with rapid onset of pain and swelling in the first few days after a procedure. Unlike staphylococcal cellulitis, GAS cellulitis lacks purulence and spreading erythema. The absence of these classic signs may delay the diagnosis of GAS cellulitis and lead to severe complications. We present the case of an immunosuppressed 49-year-old patient who developed swelling and severe pain at his incision site two days after undergoing Mohs micrographic surgery on his forehead. He was clinically diagnosed with GAS cellulitis and recovered with intravenous antibiotics. Unfortunately, there is a paucity of information about GAS cellulitis in the dermatologic literature and clinicians need to recognize and aggressively treat this rare but serious complication of Mohs micrographic surgery.

Update and Review of Bleeding Considerations in Dermatologic Surgery: Anticoagulants and Antiplatelets

BACKGROUND

Bleeding is an unavoidable risk of dermatologic surgery. The risk may be higher in patients taking agents that affect hemostasis.

OBJECTIVE

The aim of this study was to provide an updated review of current anticoagulant and antiplatelet therapy available in the market and their associated risk of bleeding complications in cutaneous surgery.

MATERIALS AND METHODS

A review of PubMed and MEDLINE was performed to review the English-language medical literature.

RESULTS

Many anticoagulant and antiplatelet therapies exist. Several studies recommend the continued use of antiplatelet and anticoagulant medications in the perioperative period. Combination regimens and novel oral anticoagulants may be associated with an increased risk of bleeding.

CONCLUSION

An updated understanding of antiplatelet and anticoagulant agents is critical for the surgeon. Current evidence does not support the discontinuation of antiplatelet and anticoagulant agents in the perioperative period under most circumstances. However, relevant data on novel oral anticoagulant agents are still sparse, suggesting that a precautionary approach is warranted.

Three-dimensional modeling and comparison of nasal flap designs

Few studies exist that compare local flap repair designs either mathematically or clinically. Previous mathematical studies use a two-dimensional modeling approach, which is not suited to complex structures like the nose. To quantitatively analyze and compare flap designs for nasal repair using three-dimensional, photographic models. via a three-dimensional imaging system (Vectra M3, Canfield Scientific, Parsippany, NJ, USA), images were captured of actual post-Mohs nasal defects on 12 consecutive patients. Transposition, rotation, and advancement flap designs were designed and assessed based on tissue efficiency (E_t = SA_wound/(SA_wound + SA_trimmed) × 100), suture efficiency (E_s = SA_wound/Length_sutured × 100), total area undermined, combined 1° and 2° flap motion efficiency (E_fm = SA_wound/(SA_undermined - (SA_wound + SA_trimmed)) × 100), incision efficiency (E_i = SA_wound/length_incision × 100), and undermining efficiency (E_u = SA_wound/SA_undermined × 100). Rotation flap designs are the most tissue efficient (p < 0.001). Transposition designs are the least suture efficient (p = 0.012) and require less undermining than the corresponding rotation flaps (although not statistically significant). Advancement flaps have the highest flap motion efficiency (p = 0.027). Incision and undermining efficiency is equivalent between all three designs (p = 0.308 and p = 0.158, respectively). While statistically significant differences exist between the flaps studied, the clinical significance is unknown. Consequently, the choice in repair design should be made based on its ability to attain a functionally and aesthetically successful reconstruction.

Evaluating complications in below-knee skin cancer surgery after introduction of preoperative appointments: A 2-year retrospective cohort study

Below-knee dermatological surgery has a high risk of complications such as wound infection, bleeding, and necrosis. In this study, we evaluated the impact of preoperative appointments on complication risks. We searched the medical records of the Helsinki University Central Hospital (HUS) Dermatosurgery unit for all below-knee surgeries during 2016, when no preoperative nurse appointments were carried out, and compared it with 2018, when preoperative appointments for risk patients were introduced. The study included 187 patients in 2016 and 179 patients in 2018, of whom 68 (about one third) attended preoperative appointments. At the appointments, risk factors were evaluated, and compression therapy was introduced when possible. The results show complication rates of 13.4% in 2016 vs 10.1% in 2018 (P = .33), despite significantly higher risks in the 2018 patient group. The odds ratio for complications in appointment attendees vs non-attendees was reduced after adjustments to 0.58; however, this was insignificant (P = .47). The odds of complications for skin grafts were considerably higher: 11.33 vs other surgery techniques (P = .00). In conclusion, the introduction of preoperative appointments appeared to reduce complications in below-knee surgery. For graft reconstructions, complication risk is high, even with carefully planned pre- and postoperative care. Further studies are needed to evaluate preventable risk factors of below-knee graft reconstructions.

Evidence-based Sterility: The Evolving Role of Field Sterility in Skin and Minor Hand Surgery

Field sterility is commonly used for skin and minor hand surgery performed in the ambulatory setting. Surgical site infection (SSI) rates are similar for these same procedures when performed in the main operating room (OR). In this paper, we aim to look at both current evidence and common sense logic supporting the use of some of the techniques and apparel designed to prevent SSI. This is a literature review of the evidence behind the ability of gloves, masks, gowns, drapes, head covers, footwear, and ventilation systems to prevent SSIs. We used MEDLINE, EMBASE, and PubMed and included literature from the inception of each database up to March 2019. We could not find substantial evidence to support the use of main OR sterility practices such as head covers, gowns, full patient draping, laminar airflow, and footwear to reduce SSIs in skin and minor hand surgery. Field sterility in ambulatory minor procedure rooms outside the main OR is appropriate for most skin and minor hand surgery procedures. SSIs in these procedures are easily treatable with minimal patient morbidity and do not justify the cost and waste associated with the use of main OR sterility.

Collaboration in Outreach: The Kumasi, Ghana, Model

Hand surgery does not have to be expensive. Substituting evidence-based field sterility for main operating room sterility and using wide-awake, local anesthesia, no tourniquet (WALANT) surgery instead of sedation makes hand surgery much more affordable worldwide. This article explains how North Americans collaborated with Ghanaian hand surgeons and therapists to establish more affordable hand care in Kumasi. It describes how multiple nonprofit organizations collaborate to create trans-Atlantic Webinars and a reverse fellowship program to share hand surgery and therapy knowledge between North American and Ghanaian hand care providers.

Association of Mohs Reconstructive Surgery Timing With Postoperative Complications

Importance

Same-day Mohs reconstructive surgery is not always possible; moreover, a delay can offer benefits such as improved surgical planning and increased blood supply to the cauterized wound bed. However, recent work found that delaying reconstruction by more than 2 days increases the postoperative complication rate.

Objective

To review the outcomes of Mohs micrographic surgery (MMS) reconstruction with respect to patient- and surgery-specific variables, especially timing of repair.

Design, Setting, and Participants

Retrospective, single-institution cohort study of patients who underwent Mohs reconstructive surgery by 1 of the 2 senior authors from January 2012 to March 2017 for cutaneous squamous cell carcinoma or basal cell carcinoma. No patients had to be excluded for inadequate follow-up or incomplete medical records.

Main Outcomes and Measures

Postoperative complications including hematoma, infection, dehiscence, and partial or full graft or flap loss.

Results

A total of 633 defects in 591 patients (median [range] age, 65 [21-96] years; 333 [56.3%] female) were identified over the 5-year period. Reconstructions occurred from less than 24 hours to 32 days after MMS, with 229 (36.2%) delayed longer than 48 hours. Patient-specific variables reviewed included comorbidities, age, smoking status, and use of anticoagulant or antiplatelet medications. Surgery-specific variables analyzed included location and size of defect, time interval between MMS and reconstruction, and reconstructive modalities. Single-variable analysis was performed to determine whether each variable was associated with postoperative complications. On multivariable binary logistic regression, smoking status (odds ratio [OR], 2.46; 95% CI, 1.29-4.71; P = .007), defect size (OR exp(B), 1.04; 95% CI, 1.01-1.06; P = .006), full-thickness defects (OR, 1.56; 95% CI, 1.08-2.25; P = .02), interpolated flaps with cartilage grafting (OR, 8.09; 95% CI, 2.65-24.73; P < .001), and composite grafts (OR, 6.35; 95% CI, 2.25-17.92; P < .001) were associated with an increased risk of postoperative complications.

Conclusions and Relevance

We found no association between timing of Mohs reconstructive surgery and complications, indicating that a delayed repair did not increase the risk of infection or flap failure. Variables associated with an increased risk of postoperative complications include smoking status, size of the defect, full-thickness defects, interpolated flaps with cartilage grafting, and the use of composite grafts.

Level of Evidence

3.

Randomized Controlled Trial of Preoperative Topical Decolonization to Reduce Surgical Site Infection for Staphylococcus aureus Nasal Swab-Negative Mohs Micrographic Surgery Patients

BACKGROUND

Surgical site infection (SSI) is mainly due to endogenous bacteria. Topical decolonization is a preoperative intervention currently advised for proven nasal carriers of Staphylococcus aureus (S. aureus).

OBJECTIVE

The authors assessed whether topical decolonization could be of benefit for patients who are not nasal carriers of S. aureus.

METHODS AND MATERIALS

The authors performed a randomized controlled trial of S. aureus nasal swab-negative patients. Five days before Mohs surgery topical decolonization with nasal mupirocin and chlorhexidine, body wash was started. The control group had no intervention.

RESULTS

In the week after Mohs surgery, the infection rate in the intervention group was 2% (n = 661, 14) and that of the control group was 4% (n = 689, 29).

CONCLUSION

Topical decolonization reduces SSI in nasal swab-negative Mohs surgery patients.

Retrospective Evaluation of the Safety of Large Skin Flap, Large Skin Graft, and Interpolation Flap Surgery in the Outpatient Setting

BACKGROUND

As the number of cutaneous surgeries continues to increase, it is important to evaluate the safety of dermatologic surgery in the outpatient setting.

OBJECTIVE

The authors sought to determine postoperative bleeding, infection, dehiscence, and necrosis rates in office-based dermatologic surgery using large flap, large graft, and interpolation flap repairs. The authors evaluated the relationship between these complications and surgical site, closure type, repair size, antibiotic use, and antithrombotic use.

METHODS

Eligible patients were identified through searching the electronic medical records from one Mohs micrographic surgeon at University Hospitals Medical Center. Patient information, surgery characteristics, and complication information were collected. Univariate and multivariate analyses were conducted to reveal associations between each complication and closure type, repair size, repair site, antithrombotic use, and antibiotic use.

RESULTS

Three hundred and thirty-one reconstruction procedures after Mohs micrographic surgery and excision qualified for the study. The rates of postoperative infection, hemorrhage, hematoma, necrosis, and dehiscence were 5%, 0.3%, 2.4%, 3%, and 0.9%, respectively.

CONCLUSION

Complications were infrequent and non-life-threatening. The authors' results indicate that dermatologic surgery using large flaps, interpolation flaps, and large grafts is safe in the office setting.

Association of Postoperative Antibiotics With Surgical Site Infection in Mohs Micrographic Surgery

BACKGROUND

Surgical site infection (SSI) is the most frequent complication of Mohs micrographic surgery. Previous studies have identified risk factors for SSI, but it is not known whether antibiotic prophylaxis mitigates this risk.

OBJECTIVE

To measure the association between antibiotic prophylaxis and SSI in a convenience sample of Mohs cases and to report on the utility of propensity scoring to control for confounding by indication in registry data.

METHODS

Data were drawn from a pilot quality improvement registry of 816 Mohs cases. The relationship between antibiotic prophylaxis and SSI was assessed with logistic regression modeling using propensity score methods to adjust for confounding.

RESULTS

One hundred fifty-one cases were prescribed antibiotic prophylaxis (18.5%). Of 467 cases with follow-up, 16 (3.4%) developed SSI. Infection rates were higher in subjects prescribed prophylaxis, but propensity adjustment reduced this effect. Adjusted odds of infection were 1.47-fold higher in subjects prescribed antibiotics and not statistically significant (95% confidence interval 0.29-7.39; p = .64).

CONCLUSION

Although there was no significant difference in SSI among patients prescribed prophylactic antibiotics, statistical precision was limited by the low incidence of infection. Larger population-based prospective registry studies including propensity adjustment are needed to confirm the benefit of prophylactic antibiotics in high-risk surgical cases.

The Canadian Model for Instituting Wide-Awake Hand Surgery in Our Hospitals

Clinic-based hand surgery performed under local anesthetic has been steadily increasingly performed in Canada for 50 years. The drive for its development stems from the Canadian health care system's finite funding structure and resources. Benefits have extended far beyond cost and garbage reduction. It has resulted in greatly improving patient care by increasing comfort and safety with the elimination of sedation, the tourniquet, night surgery, and by improving access to care. This article details the rationale and development of clinic-based hand surgery from a Canadian perspective and provides tips and strategies for other centers looking to implement a similar clinic.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery

BACKGROUND

Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS).

OBJECTIVE

We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS.

MATERIALS AND METHODS

A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls.

RESULTS

Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure.

CONCLUSION

This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Do Patterns of Reconstruction Choices After Mohs Surgery Vary by Specialty? A Pilot Study of Mohs Surgeons and Facial Plastic Surgeons

BACKGROUND

Differences in approach to repair a specified defect after Mohs micrographic surgery (MMS) between specialties have not been previously examined.

OBJECTIVE

To assess the difference in frequency of which reconstruction repairs are selected after MMS, among Mohs surgeons and facial plastic surgeons (FPS), and evaluate whether the level of satisfaction with the final repair outcome differed between specialties.

MATERIALS AND METHODS

The study was approved by the Saint Louis University Institutional Review Board. A link to the survey was distributed to members of American College of Mohs Surgery (ACMS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), between January and May 2016.

RESULTS

The reconstructive procedure selected most often ("top choice") was not significantly different between Mohs surgeons and FPS for the majority of the images. There was no material difference in how dermatologists and FPS rate the aesthetic outcome of the 3 presented closure types, with the exception of one closure type-nose with graft.

CONCLUSION

Mohs surgeons were found to more likely cluster around a single preference for their reconstruction technique compared with FPS, in which a higher percentage of surgeons also selected other options.

A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery

BACKGROUND

Many patients undergoing Mohs micrographic surgery for basal and squamous cell carcinomas are immunocompromised, yet postoperative complications associated with different types of immunosuppression are largely unstudied.

OBJECTIVE

To determine the incidence and nature of postoperative complications in immunosuppressed patients undergoing Mohs micrographic surgery.

METHODS

A retrospective cross-sectional chart review of patient characteristics, clinical characteristics, and complications.

RESULTS

Univariable analysis showed that compared with immunocompetence, immunosuppression was associated with 9.6 times the odds of postoperative complication (P = .003), with solid organ transplant recipients having 8.824 times higher odds (P = .006) and immunosuppressive therapy use displaying 5.775 times higher odds (P = .021). Surgical site infection (2.5%) and dehiscence (0.51%) were more prevalent among immunosuppressed patients, with an overall complication rate of 5.4% in the immunosuppressed population. Multivariable analysis of the association between immunosuppression and postoperative complication closely trended toward, but did not meet, significance (P = .056).

LIMITATIONS

This was a single-center, retrospective study. Other limitations include lack of non-solid organ transplants, limited medication-related data on nontransplant patients, and exclusion of cases involving patients with double transplants or multiple sources of immunosuppression.

CONCLUSIONS

Immunosuppression overall, particularly owing to solid organ transplant and immunosuppressive therapy use, places patients at higher risk for postoperative complications, including surgical site infection and wound dehiscence following MMS.