Preoperative Expectations and Values of Patients Undergoing Mohs Micrographic Surgery

Quantification of Erythema Associated With Continuous Versus Interrupted Nylon Sutures in Facial Surgery Repair: A Randomized Prospective Study

BACKGROUND

Patients are often concerned about the cosmetic appearance of scars following Mohs micrographic surgery (MMS), including residual erythema. However, few studies have compared the cosmetic outcomes between different suturing techniques.

OBJECTIVE

To compare the erythema intensity (EI) associated with interrupted sutures (IS) and continuous sutures (CS), and the degree of its reduction over time.

MATERIALS AND METHODS

Mohs micrographic surgery patients were randomized to have half of their defect repaired with IS and the other half with CS. Postoperatively, subjects were assessed at 1 week, 2 months, and 6 months and close-up photographs of their scars were taken. Computer-assisted image analysis was utilized to quantify the EI in each half-scar.

RESULTS

The average EI of IS was greater than that of CS by 9.3% at 1 week (p < .001) and 7.2% at 2 months (p < .021) but comparable at 6 months. These differences were clinically detectable, but EI differences resolved by 6 months in most cases. At 6 months, EI regressed by 33.5% in IS and 26.3% in CS.

CONCLUSION

Continuous sutures are associated with less erythema during early scar maturation but are comparable to IS at 6 months. These results may guide the choice of suturing technique to improve early cosmetic outcomes and overall patient satisfaction.

Patient-Centered Care in Dermatologic Surgery: Practical Strategies to Improve the Patient Experience and Visit Satisfaction

Patient-centered care in dermatologic surgery emphasizes addressing the preferences, values, and concerns of the surgical patient in an effort to improve the overall experience. Impediments affecting the delivery of Mohs micrographic surgical treatment of skin cancers are present throughout the perioperative period. Defining actionable strategies to improve outcomes can be challenging due to sparse literature and minimal high-quality scientific studies. This review focuses on the current evidence supporting practical recommendations in each surgical setting to improve the patient experience and increase visit satisfaction.

The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.

Patients' Body Image Improves After Mohs Micrographic Surgery for Nonmelanoma Head and Neck Skin Cancer

BACKGROUND

Most skin cancers occur on the head and neck, areas of the body that are significant to an individual's body image (BI) perception. Poor BI is a robust risk factor for depression and decreased quality of life. Thus, patients with nonmelanoma head and neck skin cancer (NMHNSC) may be more vulnerable to BI disturbance and the negative sequelae of poor BI.

OBJECTIVE

Describe the nature of BI concerns in patients diagnosed with NMHNSC and assess how BI changes with treatment.

METHODS AND MATERIALS

Patients undergoing Mohs micrographic surgery (MMS) for NMHNSC completed assessments of BI and well-being before (N = 239) and 6 months after (N = 80) treatment with MMS. Demographic and tumor data were gathered through retrospective chart review.

RESULTS

Body image improved significantly 6 months after MMS, and the magnitude of this change was large (η = 0.18). Repair length (length of final scar irrespective of repair type) >4 cm predicted poorer BI at 6-month follow-up.

CONCLUSION

Patients' BI improves after treatment with MMS for NMHNSC.

Correlation Between Appropriate Use Criteria and the Frequency of Subclinical Spread or Reconstruction With a Flap or Graft for Melanomas Treated With Mohs Surgery With Melanoma Antigen Recognized by T Cells 1 Immunostaining

BACKGROUND

Published appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) for melanoma are based on consensus opinion.

OBJECTIVE

To evaluate whether published AUC identify melanomas for which MMS may benefit patients by detecting subclinical spread or confirming clear microscopic margins before flap or graft reconstruction.

MATERIALS AND METHODS

Retrospective cohort study of 591 melanomas in 556 patients evaluating the correlation between current AUC (anatomic location, recurrent status, and tumor stage) and subclinical spread or reconstruction with a flap or graft.

RESULTS

Anatomic location on the head, neck, genitalia, hands, feet, or pretibial leg was associated with a significantly higher frequency of subclinical spread (odds ratio (OR) 1.89, p = .0280) and flap or graft reconstruction (OR 10.3, p = .0001). Compared with primary lesions, recurrent melanomas had a higher frequency of subclinical spread (OR 1.78, p = .0104) and reconstruction with a flap or graft (OR 1.67, p = .0217). The frequencies of subclinical spread and flap or graft reconstruction did not differ between in situ and invasive melanomas.

CONCLUSION

Anatomic location and recurrent status are useful criteria to identify melanomas that may benefit from MMS. Tumor stage is not a useful criterion, as MMS has similar benefits for subsets of both invasive and in situ melanomas.

Continuous versus interrupted sutures for facial surgery repair: a randomized prospective study

BACKGROUND

The cosmetic appearance of a facial scar is a concern for patients undergoing Mohs micrographic surgery (MMS). Although suturing technique may influence scar cosmesis, few studies have been published comparing suturing methods for MMS repair.

OBJECTIVE

To compare the cosmetic appearance of facial MMS scars sutured with either continuous or interrupted percutaneous nylon sutures.

MATERIALS AND METHODS

Patients with facial MMS defects were randomized to have half their scar sutured with interrupted 5-0 nylon stitches, whereas the other half of the scar was closed with running 5-0 nylon stitches. The appearance of each half of the scar was assessed at 1 week, 8 weeks, and 6 months by the principal investigator. Blinded photographic evaluation at 1 week and 6 months was completed by a plastic surgeon and general dermatologist.

RESULTS

A total of 105 patients were entered into the trial, and 101 completed all time point assessments. There was no statistically significant difference in scar outcome using each of the 3 scar assessment scales, at any time point, for any assessor (blinded and nonblinded).

CONCLUSION

Interrupted and continuous 5-0 nylon sutures result in an equivalent final cosmetic appearance of facial MMS scars. Given its advantages, running sutures may be the preferred closure technique for facial repair.

Physician specialty cost differences of treating nonmelanoma skin cancer

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.