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Fronek L, Davis MJ, Greenway HT, Kelley B. Shared decision making for perioperative antibiotic use during Mohs micrographic surgery on the lower extremities. JAAD Int 2024; 16:155-162. [PMID: 39006918 PMCID: PMC11245999 DOI: 10.1016/j.jdin.2024.03.011] [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: 03/16/2024] [Indexed: 07/16/2024] Open
Abstract
Background While there is a higher risk of surgical site infection (SSI) on the lower extremities following Mohs micrographic surgery (MMS), antibiotic prophylaxis (AP) is debated. Objective To determine the role of shared decision making (SDM) in guiding AP usage during MMS on the lower extremities. Materials and methods A prospective observational study was conducted whereby patients received a standardized SDM discussion or routine counseling. Patient satisfaction quantified by the shared decision-making questionnaire (SDMQ9) survey, rate of SSI, and rate of AP prescription were recorded. Results In total, 51 patients were included. While there were less antibiotics prescribed in the treatment group (20% versus 50%, P = .025), this did not affect incidence of SSI (8% in treatment group versus 7.7% in control group, P = .668). Patient satisfaction was statistically greater in SDM group (4.73 versus 2.18 in control (P < .001). Conclusion Patient satisfaction scores were higher among the patients who received SDM. While the usage of AP was lower in the SDM group, this did not affect incidence of SSI. This study allows the opportunity to apply SDM in the setting of MMS, which to our knowledge has not yet been attempted in the field of dermatologic surgery.
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Affiliation(s)
- Lisa Fronek
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
| | - Michael J Davis
- Department of Dermatology, Memorial Sloan Kettering, Mohs Micrographic Surgery, New York, New York
| | - Hubert T Greenway
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
| | - Benjamin Kelley
- Department of Dermatology, Scripps Clinic Torrey Pines Bighorn Mohs Surgery and Dermatology, San Diego, California
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2
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DeSisto NG, Arnaud EH, Chowdhury N, Davis SJ, Kimura KS, Stephan SJ, Patel PN, Yang SF. Forehead Flap Practices: A Cross-Sectional Survey of Facial Plastic and Reconstructive Surgeons. Facial Plast Surg Aesthet Med 2023. [PMID: 38150510 DOI: 10.1089/fpsam.2023.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background: The paramedian forehead flap (PMFF) is a well-established technique utilized for reconstruction of complex nasal defects. Objective: To identify the different techniques and management of patients undergoing PMFF reconstruction and compare these with current literature. Methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were sent a practice survey highlighting various nuances in PMFF reconstruction. The survey included questions about flap design, operative techniques, and perioperative care. Results: In total, 172 responses were received (14% response rate). Mean years of practice after fellowship was 15.8 years with most respondents performing either 1-5 (33.1%) or 6-10 (27.3%) PMFFs per year. Common practices included the use of general anesthesia, elevation of PMFF in the subgaleal plane (59.6%), and pedicle division at 3 weeks (80%) (p < 0.001). Complication rates ranged between 1% and 5%. The nose was the most common site for revision (p < 0.001) and the average number of secondary procedures after forehead flap division was 1.1 (standard deviation 0.81). The most variability in responses was seen for methods of internal lining reconstruction. Conclusion: Reconstructive surgeons frequently divide the PMFF pedicle at 3 weeks or later and have variable approaches to reconstruction of the internal lining with low complication rates overall.
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Affiliation(s)
- Nicole G DeSisto
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ethan H Arnaud
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Naweed Chowdhury
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Seth J Davis
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kyle S Kimura
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott J Stephan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Priyesh N Patel
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Shiayin F Yang
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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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.
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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
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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.
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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
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Lu KW, Khachemoune A. Skin substitutes for the management of mohs micrographic surgery wounds: a systematic review. Arch Dermatol Res 2023; 315:17-31. [PMID: 35169876 DOI: 10.1007/s00403-022-02327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 12/15/2021] [Accepted: 01/28/2022] [Indexed: 01/07/2023]
Abstract
The data on skin substitute usage for managing Mohs micrographic surgery (MMS) wounds remain limited. This systematic review aimed to provide an overview of skin substitutes employed for MMS reconstruction, summarize clinical characteristics of patients undergoing skin substitute-based repair after MMS, and identify advantages and limitations of skin substitute implementation. A systematic review of Ovid MEDLINE, EMBASE, Cochrane Library, and Web of Science databases, from inception to April 7, 2021, identified all cases of MMS defects repaired using skin substitutes. A total of 687 patients were included. The mean patient age was 70 years (range: 6-98 years). Commonly used skin substitutes were porcine collagen (n = 397), bovine collagen (n = 78), Integra (n = 53), Hyalofill (n = 43), amnion/chorion-derived grafts (n = 40), and allogeneic epidermal-dermal composite grafts (n = 35). Common factors influencing skin substitute selection were cost, healing efficacy, cosmetic outcome, patient comfort, and ease of use. Some articles did not specify patient and wound characteristics. Skin substitute usage in MMS reconstruction is not well-guided. Blinded randomized control trials comparing the efficacy of skin substitutes and traditional repair methods are imperative for establishing evidence-based guidelines on skin substitute usage following MMS.
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Affiliation(s)
- Kimberly W Lu
- Renaissance School of Medicine, Stony Brook University, 100 Nicolls Road, Stony Brook, NY, 11794, USA
| | - Amor Khachemoune
- Veterans Affairs Medical Center, Brooklyn, NY, USA. .,Department of Dermatology, SUNY Downstate, Brooklyn, NY, USA. .,Veterans Affairs Hospital and SUNY Downstate Dermatology Service, 800 Poly Place, Brooklyn, NY, 11209, USA.
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6
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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]
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7
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Gangal A, Hansen T, Blalock T, Stoff B. Ethics of Antibiotic Stewardship in Dermatology. J Am Acad Dermatol 2022; 87:719-720. [PMID: 35218851 DOI: 10.1016/j.jaad.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/16/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ameya Gangal
- Department of Dermatology, Emory University School of Medicine.
| | - Trevor Hansen
- Department of Dermatology, Emory University School of Medicine
| | - Travis Blalock
- Department of Dermatology, Emory University School of Medicine
| | - Benjamin Stoff
- Department of Dermatology, Emory University School of Medicine; Emory Center for Ethics
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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.
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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
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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.
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Zhang H, Tang K, Wang Y, Fang R, Sun Q. Rosacea Treatment: Review and Update. Dermatol Ther (Heidelb) 2020; 11:13-24. [PMID: 33170491 PMCID: PMC7858727 DOI: 10.1007/s13555-020-00461-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Indexed: 01/08/2023] Open
Abstract
Rosacea is a chronic and inflammatory skin disease characterized by flushing, nontransient erythema, papules/pustules, telangiectasia, and phymatous changes. Secondary manifestations, such as itching, burning, or stinging, are often observed in patients with rosacea. In 2017, a phenotype-based approach for diagnosis and classification was recommended. With the update of the diagnosis and classification of rosacea, treatment options for patients with rosacea have attracted the attention of dermatologists. Here, we summarize the latest advances in rosacea treatment, including skin care and cosmetic treatments, topical therapies, oral therapies, laser- and light-based therapies, injection therapies, treatments for specific types of rosacea, treatments for systemic comorbidities, and combination therapies. The impact of the phenotype-based approach on rosacea treatment and future directions are also discussed.
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Affiliation(s)
- Hanlin Zhang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Keyun Tang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yuchen Wang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Rouyu Fang
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Qiuning Sun
- Department of Dermatology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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