Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

A cohort study of personal and family history of skin cancer in relation to all-cause and cancer-specific mortality.

PURPOSE: Even though the fatality rate from skin cancers is low, evidence from a few cohort studies has raised the possibility that people with a personal history of skin cancer may have a higher all-cause mortality rate compared with those without a personal history of skin cancer. The purpose of the present study was to investigate the potential links between a personal history or family history of skin cancer and all-cause and cancer-specific mortality METHODS: A prospective cohort (n = 8,622) was assembled within the NHANES I follow-up study. Cox Proportional Hazard Regression analysis was used to estimate the hazard ratios (HR) and 95% confidence intervals (CI) for the association for personal and family history of skin cancer and all-cause and cancer-specific mortality. RESULTS: After adjustment for several potential confounding variables, a personal history of skin cancer was associated with decreased risk for all-cause mortality (HR 0.72, 95% CI 0.61-0.85), whereas the results for cancer-specific mortality were consistent with a null association (HR 0.97, 95% CI 0.74-1.27). A family history of skin cancer was not significantly associated with all-cause mortality (HR 0.97, 95% CI 0.76-1.24) or cancer-specific mortality (HR 0.69, 95% CI 0.38-1.24). CONCLUSION: The results of the present study do not support the hypothesis that a personal history or family history of skin cancer is associated with an increased risk of all-cause or cancer-specific mortality. The high prevalence of skin cancer adds to the public health significance of this question, providing a strong rationale for further research to resolve this question.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

A cohort study of personal and family history of skin cancer in relation to future risk of non-cutaneous malignancies.

PURPOSE: Skin cancer has repeatedly been observed to be a marker of increased risk for developing an internal malignancy. The purpose of our study was to further investigate this association while also characterizing the potential role of family history of skin cancer in relation to risk for non-cutaneous malignancies. METHODS: Our study used data from 8,408 participants from the NHANES I epidemiological follow-up study. Cox-proportional hazards models were used to estimate the risk for developing an internal cancer associated with a personal history and family history of skin cancer during follow-up. RESULTS: A personal history of skin cancer was associated with significantly increased risk of developing an internal cancer in adjusted models [hazard ratio (HR) 1.33, 95% confidence interval (CI) 1.09-1.61] but a family history of skin cancer was not associated with increased risk (HR 0.80, 95% CI 0.58-1.11). CONCLUSIONS: Consistent with prior reports, a personal history of skin cancer was associated with increase of developing internal malignancies, but this did not hold true for a family history of skin cancer. Further research is needed to understand why a personal history of skin cancer acts as a marker for increased risk for internal cancer.

The Nasal Tip Rotation Flap for Reconstruction of the Lateral Nasal Tip, Anterior Ala, and Soft Triangle: The Authors' Experience With 55 Patients.

BACKGROUND: Defects of the lateral nasal tip, anterior ala, and soft triangle subunits lack reconstructive options that are consistently satisfactory. For such defects, the novel anterior-based nasal tip rotation flap provides functional and aesthetic results in a single operative session. OBJECTIVE: To describe the authors' experience with the nasal tip rotation flap, including patient selection and design modifications to enhance aesthetic success. METHODS: An IRB-approved retrospective database review of nasal tip rotation flap repairs was performed at the Medical University of South Carolina and Stanford University Medical Center. The design and surgical technique of this flap are described and illustrated, emphasizing factors such as nasal shape and defect location in modifying flap design. RESULTS: The nasal tip rotation is a single-stage, local flap that provides optimal tissue match with recapitulation of the native topography of the nasal tip and incision lines that are well hidden at the junction of cosmetic subunits. The mechanics of the flap distribute closure tension widely across the alar rim without focal notching or airway compromise. CONCLUSION: The nasal tip rotation flap is a reliable, cosmetically elegant repair that fills a gap in the reconstructive options for anterior ala and soft triangle defects on the nose.

Applications of Burow's Grafts in the Reconstruction of Mohs Micrographic Surgery Defects.

BACKGROUND: Surgical defects in anatomically challenging locations, such as near free margins or crossing cosmetic subunits, may present reconstructive challenges to the dermatologic surgeon. For selected defects, Burow's grafts may produce functional and aesthetic results in a single operative session. OBJECTIVE: To describe the applications of the Burow's graft technique for the repair of defects after Mohs micrographic surgery. METHODS: An institutional review board-approved retrospective database review of surgical defects repaired with Burow's grafting after Mohs micrographic surgery at the Medical University of South Carolina was performed. The general technique of Burow's grafting is described, emphasizing proper graft sizing and direction of tension vectors. Varying anatomic locations and defect types are presented, with site-specific considerations and operative photographs. RESULTS: Burow's grafting provides ideal color and textural match, preserves subunit boundaries, results in a compact single-site wound, and may avoid complications of alternate repair choices. The tension vectors produced in closing the graft's harvest site may be designed to prevent distortion of free margins. Burow's grafting may be combined with hinge flaps to repair deep or avascular defects. CONCLUSION: Burow's grafts are reproducible, aesthetic, and useful reconstructive choices for a variety of surgical wounds.

The utility of full-thickness skin grafts (FTSGs) for auricular reconstruction.

BACKGROUND: Full-thickness skin grafts (FTSGs) are a common repair option on the external ear, but there are few large case series examining graft sublocations, dimensions, and outcomes. OBJECTIVE: We sought to report our experience with FTSGs for repair of postsurgical defects of the external ear. METHODS: We conducted a retrospective review of all FTSGs on the ear performed by 2 surgeons (J. C., 2000-2014; B. C. L., 2007-2014) after clearance by Mohs micrographic surgery at a single institution. RESULTS: A total of 1519 FTSGs on the ear were performed between June 2000 and March 2014. The most common sublocations were the superior helix (38.8%), the crura of the antihelix or scapha (18.9%), and the back of ear/back of helix (15.4%). The overall complication rate was 1.6%, and the most common complication was graft failure (1.2%). LIMITATIONS: Data were collected retrospectively from a single institution. Follow-up beyond 3 months was limited. A standardized assessment tool for aesthetic outcomes was not performed. CONCLUSION: By taking advantage of predictable "pincushioning" and combining with local flaps or cartilage grafts, FTSGs can provide more volumetric replacement than previously described. They reliably preserve the height and complex topography of the ear with a low complication rate.

Single-stage interpolation flaps in facial reconstruction.

BACKGROUND: Relatively deep and complex surgical defects, particularly when adjacent to or involving free margins, present significant reconstructive challenges. When the use of local flaps is precluded by native anatomic restrictions, interpolation flaps may be modified to address these difficult wounds in a single operative session. OBJECTIVE: To provide a framework to approach difficult soft tissue defects arising near or involving free margins and to demonstrate appropriate design and execution of single-stage interpolation flaps for reconstruction of these wounds. METHODS: Examination of our utilization of these flaps based on an anatomic region and surgical approach. RESULTS: A region-based demonstration of flap conceptualization, design, and execution is provided. CONCLUSION: Tunneled, transposed, and deepithelialized variations of single-stage interpolation flaps provide versatile options for reconstruction of a variety of defects encroaching on or involving free margins. The inherently robust vascularity of these flaps supports importation of necessary tissue bulk while allowing aggressive contouring to restore an intricate native topography. Critical flap design allows access to distant tissue reservoirs and placement of favorable incision lines while preserving the inherent advantages of a single operative procedure.

Skin cancer in organ transplant recipients: more than the immune system.

Organ transplant recipients (OTRs) are at increased risk of developing nonmelanoma skin cancers. This has long been thought to be caused by immunosuppression and viral infection. However, skin cancer risk among individuals with AIDS or iatrogenic immunodeficiency does not approach the levels seen in OTRs, suggesting other factors play a critical role in oncogenesis. In clinical trials of OTRs, switching from calcineurin inhibitors to mammalian target of rapamycin inhibitors consistently led to a significant reduction in the risk of developing new skin cancers. New evidence suggests calcineurin inhibitors interfere with p53 signaling and nucleotide excision repair. These two pathways are associated with nonmelanoma skin cancer, and squamous cell carcinoma in particular. This finding may help explain the predominance of squamous cell carcinoma over basal cell carcinoma in this population. Mammalian target of rapamycin inhibitors do not appear to impact these pathways. Immunosuppression, viral infection, and impaired DNA repair and p53 signaling all interact in OTRs to create a phenotype of extreme risk for nonmelanoma skin cancer.

Antihelical cartilage grafts for reconstruction of mohs micrographic surgery defects.

OBJECTIVE: To illustrate the safety, efficacy, and versatility of the antihelix as the preferred donor site for auricular cartilage autografts in the reconstruction of nasal and auricular Mohs micrographic surgery defects. MATERIALS AND METHODS: Retrospective chart review of all cartilage autografts performed at the Medical University of South Carolina for the 5-year period July 1, 2006, to June 30, 2011; 307 auricular cartilage autografts were performed in 297 patients. Each case was reviewed for demographic data, graft donor site, repair type, complications, and revisions. RESULTS: Three hundred five of the grafts (99.3%) were harvested from the antihelix and the remaining two (0.7%) from the conchal bowl. The donor site complication rate was 3%. No patients experienced cosmetic or functional deformity of the donor ear. No patients experienced cartilage graft resorption or infection. CONCLUSION: Antihelical cartilage grafts can serve as safe, effective, and versatile alternatives to septal, conchal bowl, and costal margin grafts. The authors feel strongly that the antihelix donor site should be favored when harvesting auricular cartilage for its easy accessibility, large dimension that may be harvested without aesthetic penalty, character of graft, and minimal operative morbidity.

The spiral flap for nasal alar reconstruction: our experience with 63 patients.

OBJECTIVE: To describe our patient selection, design, execution, and results with the spiral flap for distal nasal surgical defects after Mohs micrographic surgery. MATERIALS AND METHODS: We performed a retrospective analysis of all spiral flaps performed over a 5-year period. Sixty-three patients were identified, and charts and photographs were examined. Surgical defects were classified according to alar location. All follow-up encounters were reviewed to assess for complications and need for revisionary procedures. Intraoperative photographs were taken of representative cases to describe the surgical technique. RESULTS: Sixty-three patients on whom the spiral flap was performed were identified over a 5-year period. The flap was used to successfully reconstruct alar defects ranging in size from 5 to 15 mm in diameter. No persistent complications were noted. CONCLUSION: The spiral flap is a reproducible, one-stage flap for small to medium-sized defects of the nasal ala and alar groove that consistently produces topographic restoration with minimal risk of aesthetic or functional complication.

Preoperative expectations and values of patients undergoing Mohs micrographic surgery.

BACKGROUND: Dermatologists have championed Mohs micrographic surgery (MMS) for its unsurpassed treatment success for skin cancers, safety profile, cost-effectiveness, and tissue-sparing quality. It is unclear whether patients undergoing MMS also value these characteristics. OBJECTIVE: To evaluate patients' preoperative expectations of MMS and identify the factors that may influence such expectations METHODS: The study prospectively recruited participants who were newly diagnosed with skin cancer and referred for MMS. A questionnaire listing the characteristics of MMS was given to the participants asking them to score the importance of each characteristic on a 10-point scale. The participants were also asked to provide information regarding their gender, age, subjective health status, education level, family annual income, and their referral source RESULTS: On average, participants placed the highest value, in descending order, on a treatment that yielded the highest cure rate, reconstruction initiation only after complete tumor removal, and the surgeon being a skin cancer specialist. Overall, participants placed high values on characteristics of MMS that dermatologists have long esteemed. CONCLUSION: Our data corroborate that MMS is a valuable procedure that meets the expectations not just of physicians, but also of patients. The authors have indicated no significant interest with commercial supporters.

Cranial neuropathy as a presenting sign of recurrent aggressive skin cancer.

OBJECTIVE: The purpose of this study was to identify and characterize recurrent skin cancers of the head and neck presenting with cranial neuropathies and to review the presentation and the management for this rare subset of cutaneous neoplasms. MATERIALS AND METHODS: A retrospective review was performed for all patients with previous related cutaneous neoplasms presenting with cranial neuropathies referred to a single academic tertiary-care head and neck tumor program from 1999 to 2007. Six cases of head and neck carcinoma with demonstrable cranial neuropathy were identified and analyzed by clinical history, radiographic and surgical findings, and treatment and survival data. A review of the literature, pertinent anatomy, imaging studies, and surgical/nonsurgical management are summarized for these aggressive neurotropic malignancies. RESULTS: Cranial neuropathy was the presenting symptom of recurrent disease in all six patients. Four presented with multiple cranial neuropathies. All exhibited neuropathy of the trigeminal nerve (cranial nerve V). The tumors involved were squamous cell carcinoma (4) and melanoma (2). All patients were multiply symptomatic, presenting with a mean of three neurologic symptoms, including facial numbness (5), facial paralysis or weakness (3), facial pain (3), diplopia (3), paresthesia (3), hearing loss (1), or formication (2). Symptoms were present for an average of 7 months prior to diagnosis of perineural recurrence. Cranial nerve involvement was confirmed in all patients by magnetic resonance imaging, and five patients manifested histologic evidence of perineural tumor infiltration. Treatment consisted of various combinations of surgery, radiation, and chemotherapy for five patients, and one patient declined any intervention. Death rate subsequent to disease was 50%, and follow-up has continued within our institution on all patients for an average of 25.5 months (range, 3-72 months). CONCLUSION: Cranial neuropathy is a rare presentation of recurrent cutaneous neoplasms of the head and neck. Given this infrequent occurrence and shared features of presentation, these highly morbid tumors are often mistakenly diagnosed as Bell's palsy or trigeminal neuralgia. Our findings corroborate previous reports of diagnostic delay, increased tumor burden, and worsened morbidity and mortality associated with such cutaneous malignancies. The critical utility of radiologic imaging for staging and tumor delineation are also supported by our institutional data.

Evaluation of a novel flash lamp system (FLS) incorporating optimal spectral filtration for the treatment of photoaging.

BACKGROUND AND OBJECTIVES: Improvement in photoaging using laser and Intense Pulsed Light (IPL) modalities is well documented in the literature. We report a prospective study evaluating the safety and efficacy of a novel flash lamp IPL system incorporating a spectral filtration system designed to maximize improvement of facial dyschromias, telangiectases, and skin texture. The device was a prototype xenon flashlamp pulsed light. The novel features of this IPL device are the extended pulse duration and smooth temporal pulse profile. STUDY DESIGN/MATERIALS AND METHODS: We enrolled 23 patients (22 female, 1 male) of Fitzpatrick skin type I-IV with evidence of photoaging (lentigenes, ephelides, telangiectases, rhytides). Each patient underwent test sites on their back to establish safe treatment parameters. Using treatment fluences of 20-37 J/cm(2), each patient was given 2-4 full-face treatments separated by 3-4 weeks. RESULTS: Test sites revealed that shorter wavelength filters and shorter pulse durations increased the risk of epidermal injury. Objective assessment by evaluation of pre and post treatment photographs of the face showed an average improvement of 53% in hyperpigmentation, 39% in telangiectases, and 8% in wrinkles. There were no significant adverse effects. CONCLUSIONS: The novel flash lamp IPL system in this study was safe and effective in reducing vascular and pigment dyschromias in patients with skin types I through IV.