Association between number of stages in Mohs micrographic surgery and surgeon-, patient-, and tumor-specific features: a cross-sectional study of practice patterns of 20 early- and mid-career Mohs surgeons.

OBJECTIVE: To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early- to mid-career Mohs surgeons and to assess other factors affecting number of stages. METHODS: Statistical analysis of MMS logs of 20 representative early- to mid-career surgeons. RESULTS: There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS: Early- and mid-career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. The authors have indicated no significant interest with commercial supporters.

A rare presentation of squamous cell carcinoma in a patient with PIBIDS-type trichothiodystrophy.

The clinical presentation of trichothiodystrophy type F includes photosensitivity, ichthyosis, brittle hair, intellectual impairment, decreased fertility, and short stature, often referred to as the PIBIDS syndrome. While many of these patients demonstrate features also found in xeroderma pigmentosum patients, including similar nucleotide excision repair gene defects and photosensitivity, PIBIDS patients rarely demonstrate cutaneous malignancies. This case report demonstrates the rare presentation of squamous cell carcinoma developing in a PIBIDS patient.

Reconstruction of a large surgical defect on the lower eyelid and infraorbital cheek.

An 83-year-old white woman was referred for Mohs micrographic surgery of a lentigo maligna on the left malar cheek. The tumor was completely removed in four stages, leaving an irregularly shaped defect that measured 3.8 x 4.7 cm and that involved the left lower lateral eyelid and infraorbital cheek (Figure 1). How would you reconstruct this defect?

Multiple subclinical syringomatous proliferations encountered during Mohs surgery for basal cell carcinoma.

BACKGROUND: Examination of Mohs surgery frozen sections may lead to discovery of incidental benign neoplasms such as syringomas. OBJECTIVE: An unusual occurrence of numerous subclinical syringomatous proliferations discovered during Mohs surgery for a basal cell carcinoma that posed a diagnostic and management dilemma is reported. METHODS: Clinical records and histologic sections are examined. RESULT: Multiple syringomatous proliferations were noted around a basal cell carcinoma during Mohs surgery. A few foci were atypical appearing and focally extending into the deep dermis causing a diagnostic dilemma. All atypical syringomatous proliferations were excised. Evaluation of final Mohs margins by permanent sections and biopsies of normal-appearing facial skin showed multiple benign syringomas. CONCLUSION: Although solitary subclinical syringomas have been described in association with basal cell carcinomas, the occurrence of multiple syringomas and syringomatous proliferations has not been previously reported. Dermatologists should be aware of the existence of this phenomenon and consider permanent section evaluation to better determine nature of unusual incidental tumors identified in frozen sections during Mohs surgery.

Comparison of botulinum toxins A and B in the aesthetic treatment of facial rhytides.

Botulinum toxin injections have become a popular treatment for minimizing or eliminating facial wrinkles. After injection, the toxin acts to paralyze or weaken facial mimetic muscles. Two antigenically distinct serotypes, botulinum toxin type A (BTX-A) and botulinum toxin type B (BTX-B), are currently available. BTX-A is a lyophilized powder preparation requiring reconstitution; BTX-B is a ready-to-use liquid formulation. Both agents produce the same resultant clinical effect (i.e., muscle weakening). However, in addition to differences with respect to formulation, they are pharmacologically distinct in terms of molecular size, cellular mechanism of action, and species sensitivity. BTX-A has been used for aesthetic purposes for more than 10 years. Clinical studies and observations have shown that it is an effective agent for treating hyperkinetic facial lines. BTX-B was approved for use in cervical dystonia in 2000, but it has been used off-label to treat facial wrinkles as reported in several open-label studies. These preliminary dose-ranging studies have demonstrated that BTX-B is also effective. Both agents are extremely safe nonsurgical modalities for hyperkinetic facial lines. This article reviews the pharmacology and molecular features of BTX-A and BTX-B and highlights some of the key clinical studies that have been published to date with these two agents.

Multiple infundibulocystic basal cell carcinomas: case report of unique unilateral presentation.

BACKGROUND: Basal cell carcinoma shows a wide spectrum of clinical and histologic appearances. A distinct tumor variant with follicular infundibulocystic differentiation is recognized, and there are only a few reports on its clinical presentation and management. OBJECTIVE: To report a case of multiple infundibulocystic basal cell carcinomas with a unique unilateral presentation. METHODS: A clinical history was obtained. Photographs were taken, and punch biopsies were performed. RESULTS: An 83-year-old Caucasian female presented with multiple unilateral, asymptomatic, skin-colored, dome-shaped papules around the right mouth for 11 years without apparent change. Punch biopsies revealed findings typical of infundibulocystic basal cell carcinoma. CONCLUSIONS: A patient with clinically indolent multiple unilateral infundibulocystic basal cell carcinomas is described. Given the location of these multiple lesions, standard treatment modalities for basal cell carcinomas would have significant cosmetic and functional implications. A management approach with clinical follow-up and surgical intervention only for changing lesions is discussed.