Development of Cerebral Air Emboli During Mohs Micrographic Surgery

An algorithmic approach to scalp reconstructive surgery: maximization of cosmetic and functional outcomes

BACKGROUND

Scalp reconstruction requires knowledge of scalp anatomy and reconstructive options. Advances in the field have led to numerous procedures being at the disposal of the reconstructive surgeon, expanding treatment options for patients.

OBJECTIVE

To provide an algorithmic approach and general guidelines to consider when deciding on which scalp surgery will optimize cosmetic and functional outcomes.

METHODS & MATERIALS

Previous literature was searched for the last 20 years to provide an updated guide.

RESULTS

Taking into consideration the location, size and local scalp anatomy of a presenting defect will lead to optimal surgical outcomes. Other confounding factors such as bone exposure and extremely large defects will affect decision making. An algorithmic approach has been provided in this review.

CONCLUSION

While many reconstructive surgical options are available, the best ones will depend on individual presentation of scalp defects. Location and size are first line considerations while local scalp anatomy will allow for tailoring of reconstructive options. This will help to maximize cosmetic and aesthetic considerations.

Mohs Surgery for Advanced Tumors of the Scalp

BACKGROUND

The scalp presents unique surgical challenges, and specialized techniques are sometimes required to achieve optimal results. Tumors arising on the scalp may also be at increased risk of complications such as in-transit metastasis and perineural invasion.

OBJECTIVE

To review challenges to Mohs micrographic surgery on the scalp and techniques for successful tumor extirpation and reconstruction.

METHODS AND MATERIALS

This article reviews our experience with tumors of the scalp including techniques that we have found helpful both for tumor removal and for reconstruction.

CONCLUSION

Familiarity with the anatomy of the scalp as well as common challenges encountered during Mohs surgery may help improve outcomes and impart increase confidence to the practicing surgeon.

Association of Central Nervous System Depression With Topical Brimonidine When Used for Hemostasis: A Serious Adverse Event

Importance

Minor bleeding is the most common complication of dermatologic surgery. Topical brimonidine, 0.33%, gel has been reported for the use of hemostasis in dermatologic surgery. The safety profile and risk of systemic toxic effects when brimonidine is used topically for hemostasis is unknown.

Objective

To determine the risk of systemic toxic effects of topical brimonidine, 0.33%, gel when used for hemostasis.

Design, Setting, and Participants

In this case series from a private practice (Hollywood Dermatology), 2 patients presented for dermatologic procedures, complicated by persistent bleeding.

Interventions

Patients were treated with 10 g of brimonidine, 0.33%, gel applied under occlusion for hemostasis.

Main Outcomes and Measures

Mental status, cardiopulmonary function.

Results

Both patients experienced deterioration of mental status, respiratory depression, and somnolence. Results from cardiac testing, laboratory workup, and imaging were negative for cardiac or neurologic etiology. Both patients improved in less than 24 hours.

Conclusions and Relevance

Topical brimonidine, 0.33%, gel can result in systemic central nervous system toxic effects when used as a hemostatic agent. At present, it is not possible to define a quantity with which brimonidine can be used safely, nor can a safe wound size be defined. We, therefore, urge against the use of topical brimonidine as a hemostatic agent until its safety is further investigated.