1
|
Bakeman AE, Tong L, Rhee JS, Friedland DR, Adams JA, Luo J, Kasprzak JM, Pawar SS. Wound Healing Complications Associated with Staged Reconstruction after Facial Lentigo Maligna Resection. Facial Plast Surg Aesthet Med 2024. [PMID: 39056115 DOI: 10.1089/fpsam.2023.0296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
Background: The rates and risk factors for wound complications following staged reconstruction after facial lentigo maligna (LM) resection have not been well described. Objectives: (1) To identify the rate and types of wound complications, including infection, graft necrosis, distal flap necrosis, hematoma, superficial epidermolysis, and seroma among patients undergoing staged reconstruction after resection of LM as documented in the surgeon's clinical notes within 30 days of the procedure. (2) To determine a threshold defect size that may predict the development of wound complications. Design and Outcomes: Retrospective review at an academic medical center of patients who underwent staged reconstruction after facial LM resection over a 5-year period. Results: Ninety-eight patients were identified with a mean age of 69.2 ± 13.6 years; 37% of patients were female. The most common defect sites were the cheek (n = 41; 42%) and nose (n = 22; 22%). Twenty-five of 98 patients (26%) demonstrated complications, with the most common being wound infection (36%) and graft necrosis (24%). Those receiving perioperative antibiotics had lower rates of complication (odds ratio [OR]: 0.36; 95% confidence interval [CI]: 0.13,0.96; p = 0.041). Defects greater than 2.7 cm in maximal diameter had the highest sensitivity for predicting complications. Conclusions: Patients undergoing staged reconstruction after facial LM resection have a high rate of wound complication (26%) and defect size > 2.7 cm may be an important risk factor.
Collapse
Affiliation(s)
- Anna E Bakeman
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ling Tong
- Department of Health Informatics and Administration, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - John S Rhee
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David R Friedland
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jazzmyne A Adams
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jake Luo
- Department of Health Informatics and Administration, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - Julia M Kasprzak
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sachin S Pawar
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
2
|
Lalonde DH, Gruber MM, Ahmad AA, Langer MF, Sepehripour S. New Frontiers in Wide-Awake Surgery. Plast Reconstr Surg 2024; 153:1212e-1223e. [PMID: 38810165 DOI: 10.1097/prs.0000000000011414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Explain the most important benefits of wide-awake surgery to patients. 2. Tumesce large parts of the body with minimal pain local anesthesia injection technique to eliminate the need for sedation for many operations. 3. Apply tourniquet-free surgery to upper and lower limb operations to avoid the sedation required to tolerate tourniquet pain. 4. Move many procedures out of the main operating room to minor procedure rooms with no increase in infection rates to decrease unnecessary cost and solid waste in surgery. SUMMARY Three disruptive innovations are changing the landscape of surgery: (1) minimally painful injection of large-volume, low-concentration tumescent local anesthesia eliminates the need for sedation for many procedures over the entire body; (2) epinephrine vasoconstriction in tumescent local anesthesia is a good alternative to the tourniquet and proximal nerve blocks in extremity surgery (sedation for tourniquet pain is no longer required for many procedures); and (3) evidence-based sterility and the elimination of sedation enable many larger procedures to move out of the main operating room into minor procedure rooms with no increase in infection rates. This continuing medical education article explores some of the new frontiers in which these changes affect surgery all over the body.
Collapse
Affiliation(s)
| | | | | | - Martin F Langer
- the Clinic for Trauma, Hand, and Reconstructive Surgery, University Clinic Muenster
| | | |
Collapse
|
3
|
Abril-Pérez C, Mansilla-Polo M, Escutia-Muñoz B, Sanmartín O, Garcés JR, Rodríguez-Prieto MA, Ruiz-Salas V, de Eusebio-Murillo E, Miñano-Medrano R, González-Sixto B, Artola-Igarza JL, Alfaro-Rubio A, Redondo P, Delgado-Jiménez Y, Sánchez-Schmidt JM, Allende-Markixana I, Alonso-Pacheco ML, García-Bracamonte B, de la Cueva-Dobao P, Navarro-Tejedor R, Ciudad-Blanco C, Carnero-González L, Vázquez-Veiga H, Cano-Martínez N, Serra-Guillén C, Vilarrasa E, Sánchez-Sambucety P, López-Estebaranz JL, Flórez-Menéndez Á, Martorell-Calatayud A, Gil P, Morales-Gordillo V, Toll A, Ocerin-Guerra I, Mayor-Arenal M, Suárez-Fernández R, Sainz-Gaspar L, Descalzo MA, Garcia-Doval I, Botella-Estrada R. Mohs micrographic surgery in immunosuppressed vs immunocompetent patients: Results of a prospective nationwide cohort study (REGESMOHS, Spanish registry of Mohs surgery). J Eur Acad Dermatol Venereol 2024. [PMID: 38733285 DOI: 10.1111/jdv.20103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/01/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Immunosuppressed (IS) patients, particularly solid organ transplant recipients and those on immunosuppressive therapy, face a higher incidence and recurrence of nonmelanoma skin cancers (NMSC), including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). Mohs micrographic surgery (MMS) is the preferred treatment for high-risk NMSC due to its high cure rate and margin examination capabilities. However, IS patients may experience more complications, such as surgical site infections, and a greater risk of recurrence, making their outcomes a subject of interest. OBJECTIVES This study aimed to compare IS and immunocompetent (IC) patients undergoing MMS for NMSC in terms of baseline characteristics, intra- and post-surgical complications, and postoperative recurrence rates. METHODS The study utilized data from the REGESMOHS registry, a 7-year prospective cohort study in Spain. It included 5226 patients, categorizing them into IC (5069) and IS (157) groups. IS patients included solid organ transplant recipients, those on immunosuppressive treatments, individuals with haematological tumours and HIV-positive patients. Patient data, tumour characteristics, surgical details and outcomes were collected and analysed. RESULTS IS patients demonstrated a higher proportion of SCC, multiple synchronous tumours and tumours invading deeper structures. Complex closures, unfinished MMS and more surgical sections were observed in the IS group. Although intra-operative morbidity was higher among IS patients, this difference became non-significant when adjusted for other variables such as year of surgery, antiplatelet/anticoagulant treatment or type of closure. Importantly, IS patients had a substantially higher recurrence rate (IRR 2.79) compared to IC patients. CONCLUSIONS This study suggests that IS patients may be at a higher risk of development of AE such as bleeding or tumour necrosis and are at a higher risk of tumour recurrence. Close follow-up and consideration of the specific characteristics of NMSC in IS patients are crucial. Further research with extended follow-up is needed to better understand the long-term outcomes for this patient group.
Collapse
Affiliation(s)
- Carlos Abril-Pérez
- Hospital Universitario La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe (ISS La Fe), Valencia, Spain
| | - Miguel Mansilla-Polo
- Hospital Universitario La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe (ISS La Fe), Valencia, Spain
| | - Begoña Escutia-Muñoz
- Hospital Universitario La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe (ISS La Fe), Valencia, Spain
| | | | - Joan R Garcés
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro Médico Teknon, Barcelona, Spain
| | | | - Verónica Ruiz-Salas
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro Médico Teknon, Barcelona, Spain
| | | | | | - Beatriz González-Sixto
- Complexo Hospitalario Universitario de Pontevedra, Grupo de Investigación DIPO, IIS Galicia Sur-SERGAS-UVIGO, Pontevedra, Spain
| | | | | | | | - Yolanda Delgado-Jiménez
- Hospital Universitario Quirón Salud, Madrid, Spain
- Hospital Universitario de la Princesa, Madrid, Spain
| | | | | | | | | | | | | | - Cristina Ciudad-Blanco
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Hospital La Zarzuela, Madrid, Spain
| | | | - Hugo Vázquez-Veiga
- Complexo Hospitalario Universitario de Santiago, Santiago Compostela, Spain
| | | | | | - Eva Vilarrasa
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Centro Médico Teknon, Barcelona, Spain
| | | | | | - Ángeles Flórez-Menéndez
- Complexo Hospitalario Universitario de Pontevedra, Grupo de Investigación DIPO, IIS Galicia Sur-SERGAS-UVIGO, Pontevedra, Spain
| | | | - Pilar Gil
- Clínica Universidad de Navarra, Pamplona, Spain
| | | | | | | | | | | | - Laura Sainz-Gaspar
- Complexo Hospitalario Universitario de Santiago, Santiago Compostela, Spain
| | - Miguel A Descalzo
- Fundación Piel Sana Academia Española de Dermatología, Madrid, Spain
| | | | - Rafael Botella-Estrada
- Hospital Universitario La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria La Fe (ISS La Fe), Valencia, Spain
- Universidad de Valencia, Valencia, Spain
| |
Collapse
|
4
|
Lauck KC, Cho SW, Rickstrew J, Tolkachjov SN. Adverse events after empiric antibiotic administration in dermatologic surgery: A global, propensity-matched, retrospective cohort study. J Am Acad Dermatol 2024; 90:1065-1067. [PMID: 38266681 DOI: 10.1016/j.jaad.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/16/2023] [Accepted: 01/14/2024] [Indexed: 01/26/2024]
Affiliation(s)
| | - Seo Won Cho
- Texas A&M College of Medicine, Dallas, Texas
| | - Jace Rickstrew
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania
| | - Stanislav N Tolkachjov
- Baylor University Medical Center, Dallas, Texas; Texas A&M College of Medicine, Dallas, Texas; Epiphany Dermatology, Dallas, Texas; Department of Dermatology, University of Texas at Southwestern, Dallas, Texas.
| |
Collapse
|
5
|
McKesey J, Mazhar M, Alam M, Srivastava D, Nijhawan RI. Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review. Dermatol Surg 2024; 50:428-433. [PMID: 38318842 DOI: 10.1097/dss.0000000000004101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
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.
Collapse
Affiliation(s)
| | - Momina Mazhar
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Murad Alam
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Divya Srivastava
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Rajiv I Nijhawan
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| |
Collapse
|
6
|
Algarin YA, Jaalouk D, Pulumati A, Nouri K. The role of teledermatology in Mohs micrographic surgery: a review. Arch Dermatol Res 2024; 316:119. [PMID: 38625403 PMCID: PMC11021301 DOI: 10.1007/s00403-024-02851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/07/2024] [Accepted: 03/24/2024] [Indexed: 04/17/2024]
Abstract
This paper explores the role of teledermatology (TD) in Mohs micrographic surgery (MMS) at various stages of patient care. The study aims to assess the benefits, limitations, and patient experiences surrounding TD integration into MMS practices. We conducted a PubMed search using keywords related to TD and MMS, categorizing selected articles into pre-operative, intra-operative, and post-operative stages of MMS. TD reduced waiting times (26.10 days for TD compared to 60.57 days for face-to-face [FTF]) and consultation failure rates (6% for TD vs. 17% for FTF) for MMS preoperative consultations. It also shortened time to treatment by two weeks and led to notable travel savings (162.7 min, 144.5 miles, and $60.00 per person). Telepathology facilitated communication and decision-making during MMS, improving accuracy and efficiency, especially in challenging cases requiring collaboration where physical presence of another surgeon or pathologist is not feasible. Telepathology definitively diagnosed benign lesions and malignant tumors in 81.8% of cases (18/22). Additionally, there was a 95% agreement between conventional light microscopy diagnosis and telepathology in tumors (19/20), and 100% agreement for all 20 Mohs frozen section consultations. For post-operative follow-up, telephone follow-up (TFU) and text messaging proved effective, cost-efficient alternatives with high patient satisfaction (94% in New Zealand and 96% in the U.K.) and early complication identification. This study underscores TD's multifaceted benefits in MMS: enhanced patient experience preoperatively, improved communication during surgery, and cost-effective postoperative follow-up. Limitations include the financial expense and technical issues that can arise with TD (connectivity problems, delays in video/audio transmission, etc.). Further studies are needed to explore emerging TD modalities in post-operative patient management. The integration of TD into MMS signifies a progressive step in dermatological care, offering convenient, cost-effective, and better solutions with the potential to enhance patient experiences and outcomes.
Collapse
Affiliation(s)
- Yanci A Algarin
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, VA, USA.
- Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA.
| | - Dana Jaalouk
- Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Anika Pulumati
- Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
- Department of Dermatology, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Keyvan Nouri
- Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| |
Collapse
|
7
|
Ireland PA, Borruso L, Spencer SKR, Rosen R, Rosen R. Direct oral anticoagulants in skin surgery: a systematic review of their complications and recommendations for perioperative management. Int J Dermatol 2024; 63:413-421. [PMID: 38009338 DOI: 10.1111/ijd.16916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/27/2023] [Accepted: 11/08/2023] [Indexed: 11/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Patrick A Ireland
- Prince of Wales Hospital, Randwick, NSW, Australia
- University of New South Wales, Randwick, NSW, Australia
| | - Luca Borruso
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Sascha K R Spencer
- Prince of Wales Hospital, Randwick, NSW, Australia
- University of New South Wales, Randwick, NSW, Australia
| | | | - Robert Rosen
- Prince of Wales Hospital, Randwick, NSW, Australia
- Southderm, Kogarah, NSW, Australia
| |
Collapse
|
8
|
McDonald SM, Neidenbach PJ. Intralesional 5-Fluorouracil in the Treatment of Squamous Cell Carcinoma in an Elderly Patient. Cureus 2024; 16:e55855. [PMID: 38590475 PMCID: PMC11001315 DOI: 10.7759/cureus.55855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/08/2024] [Indexed: 04/10/2024] Open
Abstract
Squamous cell carcinoma (SCC) is the second leading form of skin cancer. In the elderly population, surgery may carry more risk and significant morbidity in comparison to less invasive forms of treatment. This case report describes the successful use of intralesional 5-fluorouracil (IL5-FU) to treat cutaneous squamous cell carcinoma (cSCC). A 98-year-old white woman presented in early May 2017 with a 3.5-cm rapidly growing crusted nodule on her left proximal-lateral arm. She had a past medical history of chronic obstructive pulmonary disease, atrial fibrillation, and heart failure. The patient also had a frail body habitus and weighed 80 pounds. Physical examination revealed a large, ulcerated, crateriform mass on the left proximal-lateral arm. A shave biopsy was performed, which revealed a well-differentiated SCC, composed of nodular masses of neoplastic squamous cells with atypical nuclei, keratin pearl formation, and scattered mitotic figures with surrounding fibrosis and inflammation. The patient was wheelchair-bound and oxygen-dependent and, thus, not considered a good surgical or radiation candidate. Treatment was decided with 5-fluorouracil. At a four-week follow-up appointment, there was no visible or palpable evidence of the tumor. There was no sign of recurrence at three months, indicating treatment success. The patient later died due to cardiac arrest in September 2017. The elderly population with cSCC can benefit from intervention and treatment with IL5-FU when surgery is not an option due to patient comorbidities. IL5-FU can potentially be used in areas where access to a dermatologist, surgeon, or surgical services is limited.
Collapse
Affiliation(s)
- Stephanie M McDonald
- Department of Dermatology, Edward Via College of Osteopathic Medicine, Spartanburg, USA
| | - Peter J Neidenbach
- Department of Dermatology, Edward Via College of Osteopathic Medicine, Spartanburg, USA
| |
Collapse
|
9
|
Ouyang K, Gamal A, Wilkowski CM, Mahlberg SJ, Carroll BT. Microbial Contamination of Smart Watches in Dermatologic Surgeries: A Cross-Sectional Study. Dermatol Surg 2024; 50:192-193. [PMID: 37890019 PMCID: PMC10873120 DOI: 10.1097/dss.0000000000003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Kelsey Ouyang
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Ahmed Gamal
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | | | - Scott J. Mahlberg
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| | - Bryan T. Carroll
- Department of Dermatology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH
| |
Collapse
|
10
|
Schnabl SM, Garbe C, Breuninger H, Walter V, Aebischer V, Huynh J, Ghoreschi FC, Häfner HM, Scheu A. Tumeszenz-Lokalanästhesie bei geriatrischen Patienten mit Hauttumoren im Kopf-Hals-Bereich - Eine retrospektive Studie an 782 Patienten: Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients. J Dtsch Dermatol Ges 2024; 22:210-222. [PMID: 38361199 DOI: 10.1111/ddg.15287_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/28/2023] [Indexed: 02/17/2024]
Abstract
ZusammenfassungHintergrund und ZielsetzungAufgrund ihrer Morbidität werden dermatochirurgische Eingriffe bei älteren Patienten vorzugsweise in Tumeszenz‐Lokalanästhesie durchgeführt. Allerdings ist die Datenlage hierzu begrenzt. Ziel der Arbeit war es, die Tumeszenz‐Lokalanästhesie für Hautkrebsoperationen bei älteren Patienten mit dem Fokus auf klinische Vorteile (Behandlungsprozesse, Schmerzmanagement) und dem lokalen postoperativen Komplikationsrisiko zu evaluieren.Patienten und MethodikUntersuchung von Patienten ≥75 Jahren mit stationär durchgeführten Hautkrebsoperationen im Kopf‐Hals‐Bereich unter Tumeszenz‐Lokalanästhesie.Ergebnisse2940 Eingriffe bei 782 Patienten (Durchschnittsalter 83,3 Jahre) mit dem Ziel einer vollständigen Tumorresektion während des stationären Aufenthaltes wurden durchgeführt. 3,8 (Bereich: 1–20) Eingriffe erfolgten über einen Zeitraum von durchschnittlich 4,9 Tagen (Bereich: 1–28). 43,2% benötigten keine postoperative Analgesie. 53,5% erhielten NSAID, 3,3% Opioide. Wundinfektionen (13,6%) waren die häufigste lokale postoperative Komplikation. Chirurgische Interventionen aufgrund von Nachblutungen waren in 2,8% der Fälle erforderlich. Keine der Blutungen waren hämoglobinrelevant oder lebensbedrohlich. Nahtdehiszenzen und Nekrosen waren selten (0,6%).SchlussfolgerungenDie Tumeszenz‐Lokalanästhesie ist für Hautkrebsoperationen bei älteren Menschen eine effektive Anästhesiemethode. Durch den Verzicht auf eine Vollnarkose können die Behandlungsabläufe optimiert und anästhesiologische Risiken minimiert werden. Lokale postoperative Komplikationen treten eher selten auf und sind gut behandelbar. Die langanhaltende Analgesie führt zu einem geringeren Analgetikabedarf und selteneren Medikamenteninteraktionen.
Collapse
Affiliation(s)
| | - Claus Garbe
- Universitäts-Hautklinik, Eberhard Karls Universität Tübingen
| | | | - Vincent Walter
- Universitäts-Hautklinik, Eberhard Karls Universität Tübingen
| | | | - Julia Huynh
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | | | | | - Alexander Scheu
- Universitäts-Hautklinik, Eberhard Karls Universität Tübingen
| |
Collapse
|
11
|
Chen A, Ray P, Rogers H, Bialowas C, Butala P, Chen M, Daveluy SD, Davidson C, Faringer P, Guarda H, Kantor J, Kaweski S, Lawrence N, Lickstein D, Lomax J, Parra S, Retson N, Suryadevara A, Smith R, Tollefson TT, Wisco OJ. Evidence-Based Performance Measures for Reconstruction after Skin Cancer Resection: A Multidisciplinary Performance Measure Set. Plast Reconstr Surg 2024; 153:424e-441e. [PMID: 38266139 DOI: 10.1097/prs.0000000000010916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND The American Society of Plastic Surgeons commissioned the multidisciplinary Performance Measure Development Work Group on Reconstruction after Skin Cancer Resection to identify and draft quality measures for the care of patients undergoing skin cancer reconstruction. Included stakeholders were the American Academy of Otolaryngology-Head and Neck Surgery, the American Academy of Facial Plastic and Reconstructive Surgery, the American Academy of Dermatology, the American Society of Dermatologic Surgery, the American College of Mohs Surgery, the American Society for Mohs Surgery, and a patient representative. METHODS Two outcome measures and five process measures were identified. The outcome measures included the following: (1) patient satisfaction with information provided by their surgeon before their facial procedure, and (2) postprocedural urgent care or emergency room use. The process measures focus on antibiotic stewardship, anticoagulation continuation and/or coordination of care, opioid avoidance, and verification of clear margins. RESULTS All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the stakeholder societies. CONCLUSION The work group recommends the use of these measures for quality initiatives, Continuing Medical Education, Continuous Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.
Collapse
Affiliation(s)
| | - Peter Ray
- East Hills Professional Center and Marshall University Joan C. Edwards School of Medicine
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Silva C, Samaan C, Shamloul N, Kamrani P, Sun H, Urbonas R, Kunselman A, Helm K. Predictive value of excision site bacterial burden and development of surgical site infection: A retrospective cohort study. J Am Acad Dermatol 2024; 90:372-374. [PMID: 37704107 DOI: 10.1016/j.jaad.2023.07.1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/05/2023] [Accepted: 07/22/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Colleen Silva
- Department of Dermatology, Springfield Clinic, Peoria, Illinois.
| | - Christen Samaan
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Norhan Shamloul
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Payvand Kamrani
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Haorui Sun
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Rebecca Urbonas
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Allen Kunselman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Klaus Helm
- Department of Dermatology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| |
Collapse
|
13
|
Schnabl SM, Garbe C, Breuninger H, Walter V, Aebischer V, Huynh J, Ghoreschi FC, Häfner HM, Scheu A. Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients. J Dtsch Dermatol Ges 2024; 22:210-221. [PMID: 38243888 DOI: 10.1111/ddg.15287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/28/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND AND OBJECTIVES Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk. PATIENTS AND METHODS Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia. RESULTS 2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%). CONCLUSIONS Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.
Collapse
Affiliation(s)
| | - Claus Garbe
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | - Helmut Breuninger
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | - Vincent Walter
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| | | | - Julia Huynh
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Carola Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Alexander Scheu
- Department of Dermatology, University of Tuebingen, Tuebingen, Germany
| |
Collapse
|
14
|
Austin HK, Gamboa GM, Waters-Hollingsworth C. Excision of Invasive Squamous Cell Carcinoma Complicated by Osteomyelitis and Tobacco Use: A Case Report. Cureus 2024; 16:e54629. [PMID: 38524043 PMCID: PMC10959414 DOI: 10.7759/cureus.54629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
Squamous cell carcinoma (SCC) is a common type of skin cancer that can be treated through surgical excision using Mohs micrographic surgery (MMS) which results in minimal scarring and low complications. Soft tissue defects as a result of MMS that are too large to be primarily closed can be repaired with secondary intention healing through the use of biologic prosthetics that promote dermal regeneration and tissue remodeling with high success rates. Other non-surgical treatment options include chemotherapy (topical or systemic), radiation, or immunotherapy for advanced skin cancers. In this case, our patient is a 76-year-old male with a history of tobacco use who presented with ulcerative SCC and developed a necrotic soft-tissue infection of Pseudomonas aeruginosa complicated by calvarial osteomyelitis six weeks following wide excision of scalp SCC and wound defect repair with application of Integra® Bilayer Wound Matrix (Integra LifeSciences, Princeton, New Jersey, United States) to promote re-vascularization and tissue regrowth. The patient is currently recovering well after the excision of the necrotic scalp lesion and second-stage reconstruction with right scalp fasciocutaneous flap and full-thickness skin graft with proper antibiotic administration. Complications were likely due to delayed wound healing from post-operative cigar use increasing his risk for infection and application of biologic prosthetics that potentially served as a nidus for bacterial adherence and biofilm production of P. aeruginosa, which led to osteomyelitis, an exceedingly rare complication for patients that undergo MMS.
Collapse
Affiliation(s)
- Harriet Kaye Austin
- Plastic and Reconstructive Surgery, University of Central Florida College of Medicine, Orlando, USA
| | - Gloria M Gamboa
- Plastic and Reconstructive Surgery, Orlando Veterans Affairs Medical Center, Orlando, USA
| | | |
Collapse
|
15
|
Richards E, Brown A, Wernham A. Review of infection and bleeding complications in excisional skin surgery. Clin Exp Dermatol 2024; 49:111-120. [PMID: 37798083 DOI: 10.1093/ced/llad339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
Skin excision is the primary treatment for skin cancer. Complication rates from skin cancer excision are generally low but rates of complications may vary according to procedural complexity, site and patient factors. It is important that patients are fully informed through the consent process considering individual circumstances, the Montgomery ruling and material risks. The clinician must use an evidence-based approach to the consent process and assessment of risk. We have searched the literature and reviewed the current evidence regarding complications, and their incidence where data were available, following excisional skin surgery. This article aims to enable clinicians to better inform patients during the consent process about associated bleeding and infection risk.
Collapse
Affiliation(s)
- Ellen Richards
- Royal Devon University Healthcare NHS Trust, Exeter, Devon, UK
| | - Alistair Brown
- Royal Devon University Healthcare NHS Trust, Exeter, Devon, UK
| | | |
Collapse
|
16
|
Dizon MP, Linos E, Swetter SM. Estimating remaining life expectancy in veterans with basal cell carcinoma using an automated electronic health record scoring system: A retrospective cohort study. J Am Acad Dermatol 2024; 90:98-105. [PMID: 37742837 DOI: 10.1016/j.jaad.2023.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/26/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND Active surveillance may be considered for low-risk basal cell carcinomas (BCCs) in patients with limited life expectancy; however, estimates of life expectancy are not readily available. Veterans Health Administration's Care Assessment Need (CAN) score may address this problem. OBJECTIVE We examined the CAN score's performance in predicting 1-, 3-, and 5-year mortality in US veterans with BCC. METHODS This retrospective cohort study used national Veterans Health Administration's electronic medical record data. The CAN score's performance in the prediction of mortality in veterans with BCC was evaluated based on tests of goodness-of-fit, discrimination, and calibration. RESULTS For 54,744 veterans with BCC treatment encounters between 2013 and 2018, the CAN score performed well in the prediction of mortality based on multiple tests. A threshold CAN score of 90 had a positive predictive value of 55% for 3-year mortality, clinically useful in identifying patients with intermediate-term survival. LIMITATIONS The study relied upon the combination of diagnosis codes and procedure codes to identify BCC cases. CONCLUSION The CAN score has the potential to improve the quality of cancer care for veterans by providing clinicians with an estimate of life expectancy and facilitating conversations in cases where active surveillance can be considered.
Collapse
Affiliation(s)
- Matthew P Dizon
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California; Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Health Policy, Stanford University School of Medicine, Palo Alto, California.
| | - Eleni Linos
- Program for Clinical Research and Technology, Stanford University, Stanford, California
| | - Susan M Swetter
- Dermatology Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; Department of Dermatology/Cutaneous Oncology, Stanford University Medical Center and Cancer Institute, Stanford, California
| |
Collapse
|
17
|
Council ML. Commentary on "Tranexamic Acid Prevention of Hemorrhagic Complications After Interpolated Flap Repair: A Single-Center Retrospective Cohort Study". Dermatol Surg 2023; 49:1143-1144. [PMID: 37815501 DOI: 10.1097/dss.0000000000003956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Martha Laurin Council
- Division of Dermatology, Department of Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| |
Collapse
|
18
|
Freeman SC, Heath MS, Neill B, Morris C, Lucero OM, Yu W, Bar A, Leitenberger JJ. Tranexamic Acid Prevention of Hemorrhagic Complications Following Interpolated Flap Repair: A Single-Center, Retrospective, Cohort Study. Dermatol Surg 2023; 49:1139-1142. [PMID: 37712760 DOI: 10.1097/dss.0000000000003931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) is increasingly being used to prevent hemorrhagic complications after dermatologic surgery. Interpolated flap repairs following Mohs micrographic surgery are at risk for increased bleeding events and unplanned health care utilization, particularly among patients on antithrombotic medication. OBJECTIVE To assess bleeding events after interpolated flap repair in patients receiving TXA compared with those who did not. MATERIALS AND METHODS A retrospective review identified interpolated flap repairs in a 5-year period. Hemorrhagic complications were analyzed, defined as major bleeding events, which included all unplanned medical visits, and minor bleeding events, which included any unplanned patient phone calls or messages through electronic medical record. RESULTS One hundred fifteen patients had interpolated flap repair during the 5-year period, of which 21 (18.3%) received TXA postprocedure. Twenty-seven bleeding events were identified in the non-TXA group compared with 1 event in the TXA-treated group. Patients who received TXA were less likely to have had a bleeding event (28.7% vs 4.8%, p < .01). CONCLUSION Patients undergoing interpolation flap repair were less likely to experience a bleeding event after subcutaneous injection of TXA.
Collapse
Affiliation(s)
- S Caleb Freeman
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Michael S Heath
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Brett Neill
- Swann Dermatology Partners, Springfield, Missouri
| | | | - Olivia M Lucero
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Wesley Yu
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Anna Bar
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | | |
Collapse
|
19
|
Hicks A, Mazumder A, Moody R, Kumanan K, Behshad R. Clinical Characteristics of Gram-Negative Surgical Site Infections in Patients Treated With Mohs Micrographic Surgery: A Retrospective Analysis. Dermatol Surg 2023; 49:981-984. [PMID: 37738243 DOI: 10.1097/dss.0000000000003915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) are the most common adverse events after Mohs micrographic surgery (MMS). However, there is a paucity of literature characterizing gram-negative (GN) SSIs after MMS. OBJECTIVE This study aimed to depict the clinical features and risk factors of GN infections after MMS. MATERIALS AND METHODS A retrospective review was performed from all postoperative wound cultures after MMS from 2017 to 2021 at Saint Louis University Medical Center. Patient demographics, surgical details, and wound clinical characteristics at follow-up appointments were reviewed. RESULTS Six hundred and seventy-six wound cultures were eligible with 15.1% yielding GN infection. Gram-negative SSIs had significantly lower rates of severe erythema and purulence compared with gram-positive (GP) SSIs, and only had significantly more edema compared with culture-negative wounds ( p < .05). Although not significant, there was a trend for GN SSIs to have higher rates of pain compared with culture-negative wounds ( p = .075). CONCLUSION Gram-negative SSIs after MMS may present with more subtle clinical features, especially compared with typical GP infections. Having a low threshold for obtaining wound culture for edematous or painful postoperative wounds may aid in detecting potentially overlooked GN infections.
Collapse
Affiliation(s)
| | - Anika Mazumder
- Cook County Health, Department of Dermatology, Chicago, IL
| | - Rylee Moody
- Saint Louis University School of Medicine, St. Louis, MO
| | - Krithika Kumanan
- SSM Health SLUCare, Department of Health and Clinical Outcomes Research, Saint Louis University, St. Louis, MO
| | - Ramona Behshad
- SSM Health SLUCare, Department of Dermatology, St. Louis, MO
| |
Collapse
|
20
|
Chen R, Krueger S, Flahive J, Mahmoud BH. Wound Care Adherence in Mohs Micrographic Surgery: A Prospective Cohort Study. Dermatol Surg 2023; 49:921-925. [PMID: 37506091 DOI: 10.1097/dss.0000000000003889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
BACKGROUND Patients undergoing Mohs micrographic surgery (MMS) are given detailed wound care instructions to prevent postoperative complications. Previous studies have revealed low treatment adherence in general dermatology, but adherence to postoperative wound care and its potential association with poor surgical outcomes remain largely unstudied. OBJECTIVE To determine the frequency and causes of wound care nonadherence in patients who underwent MMS. MATERIALS AND METHODS A questionnaire containing a modified Eight-Item Morisky Medication Adherence Measure Scale was administered to Mohs patients at their 1 to 2 weeks postoperative visit. RESULTS Sixty-three patients were solicited and consented to completing the questionnaire. The average modified Eight-Item Morisky Medication Adherence Measure Scale score was 7.4 of 8, indicating high adherence. Old age and wound care assistance were associated with increased adherence. Factors contributing to nonadherence included feeling well, being too busy, wound care causing discomfort, and being with friends or family. One patient (1.6%) with high adherence developed an epidermal inclusion cyst within the scar. No other complications were observed. CONCLUSION Most MMS patients demonstrated high adherence to wound care instructions, and nonadherence was not associated with postoperative complications.
Collapse
Affiliation(s)
- Ryan Chen
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Steven Krueger
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Julie Flahive
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Bassel H Mahmoud
- Department of Dermatology, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| |
Collapse
|
21
|
Höper R, Rosen M, Kofler K, Häfner HM, Kofler L. Influence of perioperative antiplatelet and anticoagulant medication management on bleeding events in dermatosurgery-A prospective observational study. J Eur Acad Dermatol Venereol 2023; 37:1906-1913. [PMID: 37246474 DOI: 10.1111/jdv.19228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/05/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Perioperative management of antiplatelet and anticoagulant (AP/AC) therapy is a matter of balancing the risks of bleeding and thromboembolic events. Reliable data for dermatosurgery are still lacking, especially for direct oral anticoagulants (DOAC). OBJECTIVES The aim was to prospectively evaluate the influence of AP/AC-medication on bleeding risk in dermatosurgery with focus on exact intervals between DOAC intake and procedure performed on post-operative bleeding. METHODS Patients with or without AP/AC-therapy were included in the study without randomization. Exact times of DOAC-intake, procedure performed and post-operative bleeding were documented. Data collection was prospectively and standardized done by one person. RESULTS We evaluated 1852 procedures in 675 patients. Post-operative bleeding occurred after 15.93% (n = 295) of all procedures, but only a few of them were severe (1.57%, n = 29). Compared to patients without AP/AC-medication, severe post-operative bleeding occurred significantly more often under dual antiplatelet therapy (11.76%, n = 2; p = 0.0166) and bridging of either vitamin K antagonist (9.09%, n = 2; p = 0.0270) or DOAC (15.38%, n = 2; p = 0.0099). There was no significant difference in the frequency of severe bleeding regarding to the preoperative DOAC-free period. CONCLUSIONS Although AP/AC-therapy is associated with a significant higher rate of post-operative bleeding, no life-threatening bleeding was recorded. Long preoperative pausing or bridging of DOAC does not lead to significantly less severe bleeding events.
Collapse
Affiliation(s)
- Rabea Höper
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
| | - Michael Rosen
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
| | - Katrin Kofler
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
- skin+more MVZ GmbH, Biberach, Germany
| | - Hans-Martin Häfner
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
| | - Lukas Kofler
- Department of Dermatology, University Medical Center, Eberhard Karls University, Tuebingen, Germany
- Scientific Working Group for Anticoagulation in Dermatosurgery of the German Working Group of Dermatological Angiology (ACoDermS of the ADA)
- skin+more MVZ GmbH, Biberach, Germany
| |
Collapse
|
22
|
Desisto NG, Ortiz AS, Yang SF, Stephan SJ, Patel PN. State of the Evidence for Facial Skin Cancer Reconstruction. Facial Plast Surg 2023; 39:220-229. [PMID: 36603830 DOI: 10.1055/a-2008-2798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.
Collapse
Affiliation(s)
- Nicole G Desisto
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alexandra S Ortiz
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shiayin F Yang
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott J Stephan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Priyesh N Patel
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
23
|
Postoperative Complications After Interpolated Flap Repair for Mohs Defects of the Nose: A Multicenter Prospective Cohort Study. Dermatol Surg 2023; 49:135-139. [PMID: 36728063 DOI: 10.1097/dss.0000000000003653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Dermatologists perform most interpolated flaps after skin cancer resection. Prospective, multicenter data on complications after interpolated flap repair in this setting are limited. OBJECTIVE To determine the rate of physician-reported complications after interpolated flap repair of the nose. METHODS Multicenter, prospective cohort study of 169 patients undergoing 2-stage interpolated flap repair of post-Mohs nasal defects. Frequency of bleeding, infection, dehiscence, necrosis, hospitalization, and death in the 30 days after flap placement and flap takedown are reported. RESULTS Patients experienced 23 complications after flap placement (13.61%) and 6 complications after flap takedown (3.55%) that were related to the surgical procedure. The most frequent complication after flap placement was bleeding (9, 5.33%, 95% confidence interval [CI]: 2.83%-9.82%). The most frequent complication after flap takedown was infection (5, 2.96%, 95% CI: 1.27%-6.74%). There was one hospitalization related to an adverse reaction to antibiotics. There were no deaths. CONCLUSION Most complications after interpolated flap repair for post-Mohs defects of the nose are minor and are associated with flap placement. Interpolated flap repair for post-Mohs defects can be performed safely in the outpatient setting under local anesthesia.
Collapse
|
24
|
Antibiotic Use and Surgical Site Infections in Immunocompromised Patients After Mohs Micrographic Surgery: A Single-Center Retrospective Study. Dermatol Surg 2022; 48:1283-1288. [DOI: 10.1097/dss.0000000000003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
|
25
|
Sanjuan-Cerveró R, Peña-Molina F, Sanjuan-Aragó A, Iglesia NDL, Franco-Ferrando N. Via clínica para cirugía mediante técnica WALANT fuera del estándar de cirugía mayor ambulatoria. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2022. [DOI: 10.1055/s-0042-1756202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Resumen
Objetivo Desarrollar y valorar al año una vía clínica para procedimientos de cirugía de mano utilizando anestesia local sin torniquete y con el paciente despierto, denominada técnica WALANT (wide awake, local anesthesia, no tourniquet, en inglés).
Materiales y Métodos Se planificó y ejecutó una vía clínica para pacientes de cirugía de mano no compleja, y se realizó una comparativa de costes entre dotación completa del quirófano y cirugía local con la técnica WALANT.Como indicadores de la calidad, se calculó la tasa de suspensiones quirúrgicas y el número de pacientes intervenidos. Se comparó el tiempo medio de estancia hospitalaria entre los pacientes intervenidos de forma ordinaria y en el quirófano WALANT. Se valoró la reducción en la lista de espera quirúrgica en síndrome del túnel del carpo y dedo en gatillo.
Resultados Los gastos directos fueron un 48,9% menores en el procedimiento WALANT. Se valoraron 254 pacientes en 2020 y 339 en 2021. La tasa de suspensión fue del 5,1% (0,4% por motivos médicos). El tiempo de estancia en el hospital fue significativamente menor para los pacientes del grupo WALANT (z = -8,743; p = 0,000). La disminución en la lista quirúrgica fue de 113 días.
Conclusiones La cirugía mediante la técnica WALANT adecuada a esta vía clínica permite la intervención de pacientes con menos recursos, lo que disminuye los gastos directos y alivia las unidades de Cirugía Ambulatoria.
Collapse
Affiliation(s)
- Rafael Sanjuan-Cerveró
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España
| | - Fernando Peña-Molina
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España
| | - Aurora Sanjuan-Aragó
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España
| | - Nicolas de la Iglesia
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España
| | - Nuria Franco-Ferrando
- Servicio de Cirugía Ortopédica y Traumatología, Hospital de Denia, Denia, Alicante, España
| |
Collapse
|
26
|
Abstract
BACKGROUND The temporal branch of the facial nerve is at risk of damage during Mohs micrographic surgery (MMS). This complication leads to motor deficit in the ipsilateral upper face with resultant functional and cosmetic impairment. OBJECTIVE To identify patient, tumor, and surgical risk factors associated with temporal nerve damage. MATERIALS AND METHODS A single-institution, retrospective review of MMS cases involving anatomic sites within the temporal nerve danger zone was performed. Risk factors were compared between cases with and without nerve damage. RESULTS Of 616 cases within the danger zone, 28 (4.5%) had postoperative nerve dysfunction. Variables significantly associated with dysfunction included patient immunosuppression, tumor size, aggressive tumor histology, recurrent tumors, high degree of subclinical spread, and greater average number of Mohs stages. Preoperative tumor size and postoperative defect size of ≥3 cm resulted in a ×37 and ×40 increased odds of nerve damage, respectively. Sex, age, and basal versus squamous cell carcinoma were not significantly associated with temporal nerve damage. No patients with a postoperative defect size measuring <2 cm had nerve damage. CONCLUSION The overall risk of damage to the temporal nerve during MMS is low, but there are certain risk factors that warrant increased counseling about this potential complication.
Collapse
|
27
|
Lalla SC, Bonadurer GF, Murad MH, Brewer JD. Prophylactic antibiotics and Postoperative Surgical Site Infections in cutaneous surgery: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
28
|
Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer. Cancers (Basel) 2022; 14:cancers14153835. [PMID: 35954498 PMCID: PMC9367341 DOI: 10.3390/cancers14153835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/03/2022] [Indexed: 01/20/2023] Open
Abstract
Simple Summary Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery. Abstract Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.
Collapse
|
29
|
Perioperative Practices in Dermatologic Surgery. Dermatol Surg 2022; 48:924-926. [PMID: 35862644 DOI: 10.1097/dss.0000000000003530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mohs micrographic surgery is generally safe and well tolerated. Various perioperative practices are employed with the aim of reducing adverse events; however, implementation is variable, and limited efficacy data are available. OBJECTIVE This study sought to assess perioperative practice patterns among dermatologic surgeons with regards to antibiotic prophylaxis (AP), anticoagulation, activity restrictions, and antiseptic choice. METHODS AND MATERIALS Two surveys were distributed by the American College of Mohs Surgery (ACMS) and the American Society for Mohs Surgery (ASMS) to their membership via email. RESULTS One hundres seventy-seven surgeons participated, with membership from ACMS (61%), ASMS (35%), or both organizations (4%) represented. Systemic AP is prescribed preoperatively by 96% (162/168) and postoperatively by 91% (161/177) of surgeons for variable clinical indications. Therapeutic antiplatelet and anticoagulant medications are rarely held (3%-5%, 4-7/149), whereas preventative aspirin (30%, 45/149), NSAIDs (25%, 36/145), and supplements known to have an anticoagulant effect (54%, 80/149) are more commonly held. Antiseptic choice and recommended activity restrictions vary. CONCLUSION Perioperative practices of dermatologic surgeons are variable and, where applicable, may deviate from guidelines. These findings underscore the need for standardization and updated guidelines for perioperative practices in dermatologic surgery.
Collapse
|
30
|
Rutkowski D, Littlewood Z, Touyz SJJ, Collier N, Madan V, Ghura H, Yiu ZZN, Telfer N. Prevalence of wound complications following Mohs micrographic surgery: a cross-sectional study of 1000 patients undergoing Mohs surgery and wound repair in a UK teaching hospital. Clin Exp Dermatol 2022; 47:1536-1542. [PMID: 35490302 PMCID: PMC9546076 DOI: 10.1111/ced.15226] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
Abstract
Background Mohs micrographic surgery (MMS) for nonmelanoma skin cancer is often quoted as having an excellent safety profile. Aim To determine the complication rate of patients undergoing MMS in a large UK Mohs unit and subdivide complication rates into mild/intermediate and major, and to identify potential risk factors necessitating a clinical intervention. Methods This was a single‐centre, cross‐sectional study of 1000 consecutive cases of MMS performed with in‐house repair. Notes from the postsurgical dressing clinics were reviewed at Visit 1 (Days 7–14) and Visit 2 (approximately Week 6). Based upon the intervention required and effect on cosmetic/functional outcome, complications were classified as minor, intermediate or major. Logistic regression modelling was used to identify risk factors associated with a complication that needed a clinical intervention (i.e. intermediate or major). Results In total, 1000 Mohs surgeries were performed on 803 patients, resulting in 1067 excisions. Complication rates in our cohort were low (minor 3.6%, intermediate 3.1% and major 0.8%) Potential risk factors for developing a complication included skin graft (unadjusted OR = 4.89, 95% CI 1.93–12.39; fully adjusted OR = 7.13, 95% CI 2.26–22.45) and patients undergoing surgery on the forehead (unadjusted OR = 3.32, 95% CI 0.95–11.58; fully adjusted OR = 5.34, 95% CI 1.40–20.42). Patients whose wounds were allowed to heal by secondary intention healing (6.8%) exhibited no complications. Conclusion We advocate that patients should be informed during the consent procedure that less than 1 in every 100 patients (0.75%) undergoing MMS will have a serious adverse event (major complication) affecting their cosmetic or functional outcome.
Collapse
Affiliation(s)
- David Rutkowski
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK.,Centre for Dermatology Research, University of Manchester, Biomedical Research Centre, Manchester, UK
| | - Zoe Littlewood
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Sarah J J Touyz
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Nick Collier
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Vishal Madan
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Harvinder Ghura
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| | - Zenas Z N Yiu
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK.,Centre for Dermatology Research, University of Manchester, Biomedical Research Centre, Manchester, UK
| | - Nick Telfer
- Northern Care Alliance NHS Foundation Trust, Salford, Manchester, UK
| |
Collapse
|
31
|
Mohs micrographic surgery revisited: A multidisciplinary, collaborative approach for the treatment of aggressive and recurrent basal cell carcinoma on the head and neck. J Plast Reconstr Aesthet Surg 2022; 75:3373-3383. [PMID: 35643596 DOI: 10.1016/j.bjps.2022.04.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
Abstract
Mohs micrographic surgery is the preferred surgical option for high-risk basal cell carcinomas. In our institution, the method is exclusively used for the treatment of aggressive and recurrent facial tumours selected via multidisciplinary team meetings and consistently managed using a multidisciplinary approach. The aim of this retrospective patient-record study was to examine the outcomes for basal cell carcinomas managed with Mohs micrographic surgery and to present our experience from multidisciplinary team meetings and interdisciplinary collaborations. All patients treated between September 2009 and March 2019 at Karolinska University hospital were included. In a total of 143 facial basal cell carcinomas in 138 patients, 86 primary and 57 recurrent, the recurrence rate was 4.9% after a median follow-up of 24 months. In regions, where highly specialised Mohs surgeons performing all the steps of the procedure are limited, interdisciplinary collaboration can be an effective strategy for appropriate patient selection and for performing all steps of Mohs surgery with dermatosurgeons eradicating the tumour, pathologists evaluating the histopathology, followed by reconstructive surgery by plastic surgeons. The approach we present here provides a robust and functioning Mohs surgical service during the build-up of the organisation, while providing the opportunity to train new surgeons. Once the clinic has been set up, the multidisciplinary approach should always be considered and applied when dealing with complex cases.
Collapse
|
32
|
Hansen T, Gangal A, Hijab E, Barrett D, Yeung H, Cao Y, Switchenko J, Blalock TW. Postoperative Surgical Site Infection Rate in Patients with Diabetes following Mohs Micrographic Surgery: A Retrospective Analysis. J Eur Acad Dermatol Venereol 2022; 36:927-931. [PMID: 35122334 DOI: 10.1111/jdv.17986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Incidence of surgical site infection (SSI) following Mohs micrographic surgery (MMS) among patients with diabetes is largely unknown. OBJECTIVE Evaluate diabetes as a potential SSI risk factor in MMS by comparing SSI incidence in a cohort of patients with and without diabetes. METHODS 5-year retrospective review to determine SSI rate in patients with diabetes compared to patients without diabetes. SSI incidence in patients with diabetes was further compared by A1c, and the impact of antibiotics on SSI rate was also examined. RESULTS Overall rate of SSI was 1.47% (53/3,597 cases). SSI rate among patients with diabetes was 1.95% (14/719 cases) compared to 1.35% (39/2,878 cases) in patients without diabetes, with a non-significant odds ratio for SSI of 1.45 (95% CI = 0.78-2.68, p = 0.241). Multivariable logistic regression analysis revealed no difference in SSI. Stratification of diabetic patients by A1c into ≥7.0 and <7.0 compared to patients without diabetes yielded no statistically significant difference in SSI among all groups (p = 0.815). Whether an antibiotic was prescribed did not significantly impact SSI rate between groups. CONCLUSION No significant difference in postoperative SSI was found in patients with diabetes compared to patients without diabetes following MMS regardless of degree of glycemic control.
Collapse
Affiliation(s)
- Trevor Hansen
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ameya Gangal
- Emory University School of Medicine, Atlanta, GA, USA
| | - Eman Hijab
- Emory University School of Medicine, Atlanta, GA, USA
| | - Devon Barrett
- Emory University School of Medicine, Atlanta, GA, USA
| | - Howa Yeung
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| | - Yichun Cao
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Jeffrey Switchenko
- Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Travis W Blalock
- Department of Dermatology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
33
|
Ehsani-Chimeh N, Miller M, Brown M. Catastrophic Bleeding Complications in 2 High-Risk Patients After Dermatologic Surgery. Dermatol Surg 2021; 47:1664-1665. [PMID: 34608088 DOI: 10.1097/dss.0000000000003244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Nazanin Ehsani-Chimeh
- Department of Dermatology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | |
Collapse
|
34
|
Matos S, Sturm B, Buhnerkempe M, Larson R, Wilson M. Risk Factors for Infection After Minor Dermatologic Procedures: A Case-Control Study. Dermatol Surg 2021; 47:1562-1565. [PMID: 34417389 DOI: 10.1097/dss.0000000000003163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic. OBJECTIVE To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office. MATERIALS AND METHODS In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls. RESULTS Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation. CONCLUSION The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck.
Collapse
Affiliation(s)
- Sophia Matos
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Brea Sturm
- Department of Internal Medicine, Mercy Hospital St. Louis, St. Louis, Missouri
| | - Michael Buhnerkempe
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Rebecca Larson
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Morgan Wilson
- Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois
| |
Collapse
|
35
|
Postoperative Candida Infection following Complex Periocular Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3891. [PMID: 34745791 PMCID: PMC8563074 DOI: 10.1097/gox.0000000000003891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/01/2021] [Indexed: 11/27/2022]
Abstract
Postoperative candida infection is a rarely reported complication in cutaneous surgery, although it may develop more often in particular clinical settings. We present a 59-year-old woman with a well-controlled human immunodeficiency virus infection. She developed a bright red eruption with satellite pustules 2 weeks after excision of recurrent lentigo maligna melanoma of the left lower eyelid and periocular region. Due to defect size and complexity of the reconstruction (glabellar transposition flap, Hughes flap, composite graft from upper contralateral eyelid, and full-thickness skin graft from ipsilateral retroauricular region), she was placed on prophylactic oral amoxicillin-clavulanic acid and topical bacitracin and polymyxin. Immediate postoperative course was unremarkable, and sutures were removed after 7 days. Three days later, she developed bright red erythema and pustules within the surgical site and complained of burning. Empirically she was switched to topical gentamicin and oral ciprofloxacin, and later to linezolid, due to inadequate response. Wound culture grew Candida albicans sensitive to fluconazole and voriconazole. After oral fluconazole and topical clotrimazole initiation, the patient rapidly improved. The graft remained viable and apart from small partial dehiscence on the cheek, the healing was unremarkable. Apart from the case presentation, we also discuss different factors associated with postoperative candida infection, including immunocompromised status, surgical procedure location, and postoperative antibiotic use. Early recognition and treatment of postoperative candida infections are crucial to prevent delayed healing and associated morbidity.
Collapse
|
36
|
Castner NB, Slutsky JB. Quantifying Utilization of Skin Substitutes by Mohs Micrographic Surgeons: A Cross-Sectional Analysis of Medicare Data. Dermatol Surg 2021; 47:1505-1506. [PMID: 34417385 DOI: 10.1097/dss.0000000000003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Nicholas B Castner
- Department of Dermatology, Stony Brook University Hospital, Stony Brook, New York
| | | |
Collapse
|
37
|
Erickson SP, Foshee JP, Baumann BC, Council ML, MacArthur KM. Mohs Surgical Site Infection Rates and Pathogens for the Mask-Covered Face During the COVID-19 Pandemic Versus the Pre-COVID Era. Dermatol Surg 2021; 47:1507-1510. [PMID: 34699442 PMCID: PMC8547580 DOI: 10.1097/dss.0000000000003240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Stephen P. Erickson
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - James P. Foshee
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Brian C. Baumann
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martha L. Council
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kelly M. MacArthur
- Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
38
|
Robinson MA, Patel AB, Wilmas KM, Thomas V, Heberton M. Cutaneous Surgery Outcomes in Patients on Epidermal Growth Factor Receptor Inhibitors. Dermatol Surg 2021; 47:1519-1521. [PMID: 34417386 DOI: 10.1097/dss.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
| | - Anisha B Patel
- Department of Dermatology, John P. and Katherine G. McGovern Medical School, Houston, Texas
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas
| | - Kelly M Wilmas
- Department of Dermatology, John P. and Katherine G. McGovern Medical School, Houston, Texas
| | - Valencia Thomas
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas
| | - Meghan Heberton
- Department of Dermatology, MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
39
|
Aizman L, Barbieri JS, Feit EM, Lukowiak TM, Perz AM, Shin TM, Miller CJ, Golda N, Leitenberger JJ, Carr DR, Nijhawan RI, Hasan A, Eisen DB, Etzkorn JR. Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment. Dermatol Surg 2021; 47:1214-1219. [PMID: 34081047 DOI: 10.1097/dss.0000000000003113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS Multi-center, prospective discrete choice experiment (DCE). RESULTS Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.
Collapse
Affiliation(s)
- Leora Aizman
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - John S Barbieri
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elea M Feit
- LeBow College of Business, Drexel University, Philadelphia, Pennsylvania
| | - Tess M Lukowiak
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Allison M Perz
- Cooper Medical School of Rowan University, Camden, New Jersey
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nicholas Golda
- Department of Dermatology, University of Missouri School of Medicine, Columbia, Missouri
| | - Justin J Leitenberger
- Department of Dermatology, Oregon Health and Science University School of Medicine, Portland, Oregon
| | - David R Carr
- Division of Dermatology, the Ohio State University Medical Center, Columbus, Ohio
| | - Rajiv I Nijhawan
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Aliza Hasan
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Daniel B Eisen
- Department of Dermatology, University of California-Davis, Sacramento, California
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
40
|
Ruiz-Salas V, Sanmartin-Jiménez O, Garcés JR, Vilarrasa E, Miñano-Medrano R, Escutia-Muñoz B, Flórez-Menéndez Á, Artola-Igarza JL, Alfaro-Rubio A, Redondo P, Delgado-Jiménez Y, Sánchez-Schmidt J, Allende-Markixana I, García Bracamonte B, de la Cueva-Dobao P, Ciudad C, Carnero-González L, Vázquez-Veiga H, Sánchez-Sambucety P, Estebaranz JL, Botella-Estrada R, González-Sixto B, Martorell A, Morales-Gordillo V, Toll-Abelló A, Mayor-Arenal M, Suárez-Fernández R, Sainz-Gaspar L, Descalzo MA, Garcia-Doval I. Complications Associated with Mohs Micrographic Surgery: Data from the Nationwide Prospective Cohort REGESMOHS. Dermatology 2021; 238:320-328. [PMID: 34380138 DOI: 10.1159/000517010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Large prospective studies on the safety of Mohs micrographic (MMS) surgery are scarce, and most focus on a single type of surgical adverse event. Mid-term scar alterations and functional loss have not been described. OBJECTIVES To describe the risk of MMS complications and the risk factors for them. METHODS A nationwide prospective cohort collected all adverse events on consecutive patients in 22 specialised centres. We used multilevel mixed-effects logistic regression to find out factors associated with adverse events. RESULTS 5,017 patients were included, with 14,421 patient-years of follow-up. 7.0% had some perioperative morbidity and 6.5% had mid-term and scar-related complications. The overall risk of complications was mainly associated with use of antiaggregant/anticoagulant and larger tumours, affecting deeper structures, not reaching a tumour-free border, and requiring complex repair. Age and outpatient setting were not linked to the incidence of adverse events. Risk factors for haemorrhage (0.9%) were therapy with antiaggregant/anticoagulants, tumour size, duration of surgery, and unfinished surgery. Wound necrosis (1.9%) and dehiscence (1.0%) were associated with larger defects and complex closures. Immunosuppression was only associated with an increased risk of necrosis. Surgeries reaching deeper structures, larger tumours and previous surgical treatments were associated with wound infection (0.9%). Aesthetic scar alterations (5.4%) were more common in younger patients, with larger tumours, in H-area, and in flap and complex closures. Risk factors for functional scar alterations (1.7%) were the need for general anaesthesia, larger tumours that had received previous surgery, and flaps or complex closures. CONCLUSIONS MMS shows a low risk of complications. Most of the risk factors for complications were related to tumour size and depth, and the resulting need for complex surgery. Antiaggregant/anticoagulant intake was associated with a small increase in the risk of haemorrhage, that probably does not justify withdrawal. Age and outpatient setting were not linked to the risk of adverse events.
Collapse
Affiliation(s)
- Verónica Ruiz-Salas
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro Médico Teknon, Barcelona, Spain
| | | | - Joan R Garcés
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro Médico Teknon, Barcelona, Spain
| | - Eva Vilarrasa
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.,Centro Médico Teknon, Barcelona, Spain
| | | | | | | | | | | | | | - Yolanda Delgado-Jiménez
- Hospital Universitario Quirón Salud, Madrid, Spain.,Hospital Universitario de la Princesa, Madrid, Spain
| | | | | | | | | | - Cristina Ciudad
- Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Hospital La Zarzuela, Madrid, Spain
| | | | - Hugo Vázquez-Veiga
- Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | | | | | | | | | | | | | | | | | | | - Laura Sainz-Gaspar
- Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Ignacio Garcia-Doval
- Fundación Piel Sana Academia Española de Dermatología, Madrid, Spain.,Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | | |
Collapse
|
41
|
Ip KHK, Chan BCY. How We Do It: Color-Coded Patient Labels for Enhanced Surgical Instrument Identification During Mohs Micrographic Surgery. Dermatol Surg 2021; 47:1122-1123. [PMID: 33867459 DOI: 10.1097/dss.0000000000003028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Ken Hiu-Kan Ip
- Dermatology Department, Auckland District Health Board, Auckland, New Zealand
| | | |
Collapse
|
42
|
Electrosurgery Use During Post-Mohs Micrographic Surgery Repair and Complication Rates-How Important is a Dry Field? Dermatol Surg 2021; 47:1200-1204. [PMID: 34347693 DOI: 10.1097/dss.0000000000003119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electrosurgery is used to achieve hemostasis during surgery. There are no studies exploring the effects of the use or avoidance of electrodessication during Mohs micrographic surgery (MMS) repair. Given the growing concerns for tissue aerosolization, occupational smoke exposure, and spread of infectious diseases, it is important to determine the importance of electrical hemostasis. MATERIALS AND METHODS In this retrospective study, electronic medical records of a single, tertiary, academic dermatology practice were reviewed. All MMS cases that underwent surgical repair from January 1 to December 31, 2019, by 2 dermatologic surgeons (one who used electrodessication during repair and one who did not) were included. Patient demographic data, information regarding the procedures, and complications occurring 90 days after MMS were recorded. RESULTS One hundred ninety-eight cases of MMS repair used electrodessication, whereas 193 cases did not. There was no significant difference in the demographic makeup, MMS procedure, or 90-day complication rates between the 2 groups. No major adverse events were MMS-related. CONCLUSION The use or avoidance of electrodessication during MMS repair was not associated with increased 90-day postoperative complications, suggesting that a greater tolerance of moderate oozing at a surgical site during MMS repair is reasonable to minimize electrosurgical tissue damage and occupational smoke exposure.
Collapse
|
43
|
Surgical Site Infection After Dermatologic Procedures: Critical Reassessment of Risk Factors and Reappraisal of Rates and Causes. Am J Clin Dermatol 2021; 22:503-510. [PMID: 33797060 DOI: 10.1007/s40257-021-00599-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While rates are low, surgical site infections are the most common complication of dermatologic surgery. Surgical site infections have important consequences including impairment of wound healing, suboptimal cosmetic outcome, hospitalization, increased healthcare costs, and rarely, systemic infection. It is imperative to understand the risk factors and existing preventative measures to minimize the development of infection. This article reviews the available literature regarding surgical site infections following dermatologic procedures, to evaluate the standard of diagnosis and role of wound culture, risk factors, mimicking conditions, and significance of antibiotic prophylaxis. We offer a critical reassessment of the current literature on risk factors and reappraisal of infection rates to promote evidence-based patient care. We conclude that the strongest evidence suggests that diabetes mellitus is likely associated with increased surgical site infections. Immunosuppression is often clinically considered a risk factor; however, the evidence is mixed. In general the addition of antibiotics does not confer benefit except in high-risk sites. Conclusively, Mohs micrographic surgery has been proven safe in office and inpatient settings. We agree that sterile glove use for simple procedures is likely not a significant factor in the development of surgical site infections; however, we hypothesize that the overall sterile technique and setting may play a role in longer and/or more complex procedures.
Collapse
|
44
|
Chen A, Albertini JG, Bordeaux JS, Chen MW, Cook JL, Davidson C, Donnelly KC, Galaria II, Hannan CM, Kantor J, Kapp DL, Lawrence N, Lober CW, Loeding LD, Miller A, Ness DT, Neves RI, Revenaugh PC, Setabutr P, Tholpady SS, Tollefson TT, Van Beek MJ, Weiss PR, Alam M. Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection. Dermatol Surg 2021; 47:891-907. [PMID: 34228675 DOI: 10.1097/dss.0000000000003115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Andrew Chen
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - John G Albertini
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Jeremy S Bordeaux
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Michael W Chen
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Jonathan L Cook
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Caryn Davidson
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Katelyn C Donnelly
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Irfan I Galaria
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Catherine M Hannan
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Jonathan Kantor
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Daniel L Kapp
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Naomi Lawrence
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Clifford W Lober
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Lauren D Loeding
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Alexander Miller
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Daniel T Ness
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Rogerio I Neves
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Peter C Revenaugh
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Peter Setabutr
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Sunil S Tholpady
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Travis T Tollefson
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Marta J Van Beek
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Paul R Weiss
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| | - Murad Alam
- Farmington, Conn.; Winston-Salem, Durham, and Gastonia, N.C.; Cleveland, Ohio; Walnut Creek, Irvine, and Sacramento, Calif.; Arlington Heights and Chicago, Ill.; Chantilly, Va.; Washington, D.C.; St. Augustine, West Palm Beach, Tampa, and Orlando, Fla.; Philadelphia and Hershey, Pa.; Marlton, N.J.; Indianapolis, Ind.; Iowa City, Iowa; and New York, N.Y
- From the University of Connecticut; The Skin Surgery Center; University Hospitals Cleveland Medical Center/Case Western Reserve University; Kaiser Permanente; Duke University Medical Center; American Society of Plastic Surgeons; Galaria Plastic Surgery and Dermatology; Veterans Affairs Medical Center; Florida Center for Dermatology; Department of Dermatology, University of Pennsylvania Perelman School of Medicine; private practice; Cooper Medical Center, Rowan University; University of South Florida; University of Central Florida; University of California, Irvine; Piedmont Plastic Surgery and Dermatology; Pennsylvania State University; Rush University Medical Center; University of Illinois at Chicago; R. L. Roudebush Veterans Affairs Medical Center; University of California, Davis, Medical Center; University of Iowa Hospitals & Clinics; private practice; and Northwestern University
| |
Collapse
|
45
|
Bittner GC, Kubo EM, Fantini BDC, Cerci FB. Auricular reconstruction after Mohs micrographic surgery: analysis of 101 cases. An Bras Dermatol 2021; 96:408-415. [PMID: 34090728 PMCID: PMC8245722 DOI: 10.1016/j.abd.2020.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 01/07/2023] Open
Abstract
Background The ear is a region that has a high prevalence of cutaneous carcinomas and several guidelines indicate Mohs micrographic surgery as the first-choice treatment in such cases. Although the technique allows maximum preservation of healthy tissue, many auricular surgical wounds constitute a challenge due to the peculiar local anatomy, with evident curves and reliefs. Auricular reconstruction should prioritize function before aesthetics, but without leaving the latter aside, since postoperative distortions can have a significant psychological impact. Objective To describe the authors’ experience in auricular reconstruction after Mohs surgery and to evaluate the most frequently used repair methods. Methods Retrospective study of consecutive cases submitted to Mohs surgery and auricular reconstruction, over a period of 3 years. Results One hundred and one cases were included and the most common repair method was primary closure (n = 35), followed by full-thickness skin graft (n = 30) and flaps (n = 24). In thirty cases, reconstruction methods were associated. Seven patients had complications (partial graft necrosis, postoperative bleeding or infection). Study limitations Retrospective design and the absence of long-term follow-up of some cases. Conclusions The dermatologic surgeon should be familiarized with different options for auricular reconstruction. Primary closure and skin grafts were the most frequently used repair methods.
Collapse
Affiliation(s)
- Guilherme Canho Bittner
- Dermatology Service, Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil; Private Practice, Campo Grande, MS, Brazil.
| | | | - Bruno de Carvalho Fantini
- Dermatology Service, Universidade de São Paulo, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Felipe Bochnia Cerci
- Dermatology Service, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil; Postgraduate Program in Internal Medicine and Health Sciences, Universidade Federal do Paraná, Curitiba, PR, Brazil; Private Practice, Curitiba, PR, Brazil
| |
Collapse
|
46
|
Combalia M, Garcia S, Malvehy J, Puig S, Mülberger AG, Browning J, Garcet S, Krueger JG, Lish SR, Lax R, Ren J, Stevenson M, Doudican N, Carucci JA, Jain M, White K, Rakos J, Gareau DS. Deep learning automated pathology in ex vivo microscopy. BIOMEDICAL OPTICS EXPRESS 2021; 12:3103-3116. [PMID: 34221648 PMCID: PMC8221965 DOI: 10.1364/boe.422168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 05/09/2023]
Abstract
Standard histopathology is currently the gold standard for assessment of margin status in Mohs surgical removal of skin cancer. Ex vivo confocal microscopy (XVM) is potentially faster, less costly and inherently 3D/digital compared to standard histopathology. Despite these advantages, XVM use is not widespread due, in part, to the need for pathologists to retrain to interpret XVM images. We developed artificial intelligence (AI)-driven XVM pathology by implementing algorithms that render intuitive XVM pathology images identical to standard histopathology and produce automated tumor positivity maps. XVM images have fluorescence labeling of cellular and nuclear biology on the background of endogenous (unstained) reflectance contrast as a grounding counter-contrast. XVM images of 26 surgical excision specimens discarded after Mohs micrographic surgery were used to develop an XVM data pipeline with 4 stages: flattening, colorizing, enhancement and automated diagnosis. The first two stages were novel, deterministic image processing algorithms, and the second two were AI algorithms. Diagnostic sensitivity and specificity were calculated for basal cell carcinoma detection as proof of principal for the XVM image processing pipeline. The resulting diagnostic readouts mimicked the appearance of histopathology and found tumor positivity that required first collapsing the confocal stack to a 2D image optimized for cellular fluorescence contrast, then a dark field-to-bright field colorizing transformation, then either an AI image transformation for visual inspection or an AI diagnostic binary image segmentation of tumor obtaining a diagnostic sensitivity and specificity of 88% and 91% respectively. These results show that video-assisted micrographic XVM pathology could feasibly aid margin status determination in micrographic surgery of skin cancer.
Collapse
Affiliation(s)
- Marc Combalia
- Department of Dermatology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Sergio Garcia
- Department of Dermatology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Josep Malvehy
- Department of Dermatology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Susana Puig
- Department of Dermatology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | | | - James Browning
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Sandra Garcet
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - James G. Krueger
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Samantha R. Lish
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Rivka Lax
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Jeannie Ren
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
| | - Mary Stevenson
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Nicole Doudican
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - John A. Carucci
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Manu Jain
- Ronald O. Pearlman Department of Dermatology, New York University, 550 First Avenue, New York, NY 10016, USA
| | - Kevin White
- Department of Dermatology, Oregon Health & Science University, 3303 South Bond Avenue, Portland, OR 97239, USA
| | - Jaroslav Rakos
- SurgiVance Inc., 310 East 67th Street, New York, NY 10065, USA
| | - Daniel S. Gareau
- The Rockefeller University, 1230 York Avenue, New York, NY 10065, USA
- SurgiVance Inc., 310 East 67th Street, New York, NY 10065, USA
| |
Collapse
|
47
|
Efficacy and Safety of Simultaneous Application of HIFEM and Synchronized Radiofrequency for Abdominal Fat Reduction and Muscle Toning: A Multicenter Magnetic Resonance Imaging Evaluation Study. Dermatol Surg 2021; 47:969-973. [PMID: 34001694 DOI: 10.1097/dss.0000000000003086] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Radiofrequency and high-Intensity Focused Electromagnetic (HIFEM) field procedure are well-known, stand-alone, body-shaping modalities, yet their simultaneous application has not been investigated. OBJECTIVE The aim is to evaluate the efficacy of a novel device simultaneously delivering HIFEM and radiofrequency for subcutaneous fat reduction and muscle toning. MATERIALS AND METHODS Forty-one subjects with an average age of 39.7 ± 11.5 years were recruited. The subjects received 3 abdominal treatments (one per week). Magnetic resonance imaging images of the treated area were evaluated at baseline and at 1-, 3-, and 6-month visits for changes in subcutaneous fat, muscle thickness, and abdominal separation (AS). Anthropometric data and digital photographs were collected. Subject satisfaction and therapy comfort were evaluated. RESULTS The muscle mass increase peaked at 3 months, showing 26.1% thickening. The fat thickness reduction was most prominent at 3 months, showing a 30.8% reduction. The AS decreased by 18.8% at 3 months after treatment. The waist circumference reduced by 5.87 ± 3.64 cm at a 3-month follow-up. Six-month data showed maintenance of these outcomes. The treatment was considered as comfortable with high patient satisfaction. CONCLUSION The analysis of magnetic resonance imaging images and waist measurements showed that the therapy combining HIFEM and radiofrequency is highly effective in reducing subcutaneous fat and muscle thickening.
Collapse
|
48
|
Evidence-based clinical practice guideline: Reconstruction after skin cancer resection. J Am Acad Dermatol 2021; 85:423-441. [PMID: 33931288 DOI: 10.1016/j.jaad.2021.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 10/21/2022]
Abstract
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.
Collapse
|
49
|
Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection. Plast Reconstr Surg 2021; 147:812e-829e. [PMID: 33890904 DOI: 10.1097/prs.0000000000007789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
50
|
Andrew TW, Garioch JJ, Lovat PE, Moncrieff MD. Predictive indicators for revisional surgery in nasal reconstruction after Mohs surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Abstract
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.
Collapse
|