Mohs Mapping Fidelity: Optimizing Orientation, Accuracy, and Tissue Identification in Mohs Surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is a highly effective process that requires consistent accuracy in resection, mapping, and histologic interpretation. Although the general sequence in MMS is similar, there are numerous variations among Mohs surgeons as to how this process is performed. OBJECTIVE: This article aims to review the process of MMS, with the intent to identify and mitigate the potential errors at each step. Existing variations will be discussed and protocols offered to minimize error and optimize accuracy. METHODS: A Pubmed search was performed for publications on methods of tissue mapping, orienting, and processing in MMS. RESULTS: Our literature review highlights various techniques for tissue orientation, transfer, flattening, inking, mapping, and processing of later stages and multiple specimens. We discuss our system, which reduces error during tissue transfer, tissue identification in vivo and ex vivo, and tissue flattening. Furthermore, we discuss adaptations to increase the accuracy during reexcisions of subsequent Mohs layers. CONCLUSION: Variations in MMS reflects the diverse training and creativity among Mohs surgeons. Unless potential errors are addressed, however, false negatives will occur and undermine the superior cure rate of MMS.

Azathioprine-induced EBV-positive mucocutaneous ulcer.

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer was recently described as a clinicopathologic entity occurring secondary to iatrogenic or age-related immune suppression. The histopathology of EBV-positive mucocutaneous ulcer reveals a polymorphous infiltrate including atypical large B-cells and Reed-Sternberg-like cells which are CD20-positive, CD30-positive and EBV-positive. The disorder follows an indolent and self-limited course. We report a case of EBV-positive mucocutaneous ulcer secondary to prolonged use of azathioprine for the treatment of pemphigoid and highlight the need for recognition of this disorder by dermatopathologists and dermatologists.

Immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) associated with pemphigoid nodularis: a case report and review of the literature.

The immune dysregulation, polyendocrinopathy, enteropathy, X-linked syndrome (IPEX) is a rare disorder caused by mutations of the FOXP3 gene. The FOXP3 gene encodes a DNA-binding protein of the forkhead/winged-helix family and is the central controller of the development of CD4+CD25+ regulatory T cells. CD4+CD25+ regulatory T cells help prevent autoimmune disease; a deficiency of these cells causes increased immunologic reactivity and autoimmunity. We describe a 14-year-old boy with IPEX syndrome confirmed by mutation analysis of the FOXP3 gene. The patient had chronic dermatitis and later developed bullous pemphigoid. He subsequently formed diffuse prurigo nodularis-like lesions resistant to multiple topical and systemic immunosuppressive medications. These lesions were confirmed by biopsy, direct immunofluorescence, and enzyme-linked immunosorbent assay of the 180 kd bullous pemphigoid antigen to be pemphigoid nodularis. He recently responded to rituximab, allowing discontinuation of his oral prednisone.

A novel technique using a rotation flap for repairing adjacent surgical defects.

BACKGROUND: The incidence of head and neck carcinomas continues to rise. Surgical excision is a frequently used method for removing these carcinomas. It is not uncommon to have multiple skin carcinomas present at the same time or in close proximity to each other. Therefore, surgeons can be presented with the challenge of repairing adjacent surgical defects while avoiding unacceptable wound closure tension and distortion of neighboring structures. OBJECTIVE: The presentation of a novel method for repairing adjacent surgical defects with a rotation flap. MATERIALS: Standard excision tray. CONCLUSION: We present a novel method for repairing adjacent surgical defects with a rotation flap. Surgeons are presented with adjacent surgical defects and challenged to find the repair option that will give the most optimal cosmetic result. The options for closing small adjacent surgical defects include making the defects a single large defect for primary closure, full-thickness skin grafting, primary closure of each defect separately, flap coverage, secondary intention healing, or any combination of these. The use of a single rotation flap to cover two adjacent surgical defects provides the surgeon with a convenient and cosmetically acceptable option that avoids unacceptable wound tension and does not distort neighboring structures.