Site identification challenges in dermatologic surgery: a physician survey.

BACKGROUND: Previous single-institution studies have shown that patients and physicians struggle to identify biopsy sites requiring surgery on the day of treatment. To date no studies have been done to assess if this is a widespread challenge faced by many dermatologic surgeons. OBJECTIVE: We sought to determine if site identification is an issue among Mohs surgeons, and to determine which practice environments have the best supplementary data available to surgeons for site localization. METHODS: We conducted an online survey of 722 members of the American College of Mohs Surgery inquiring about site identification and documentation typically received from referring physicians. RESULTS: Of 325 surveys completed (45% response rate), 71% reported that more than 5% of their patients have difficulty identifying their surgery site. The majority (89%) responded that a photograph is most useful for identifying biopsy sites. Surgeons in academic centers and multispecialty group practices were more likely to receive a photograph versus those in private practice. LIMITATIONS: Individual survey responses may be subject to recall bias. CONCLUSION: Difficulty identifying biopsy sites needing surgery is a common challenge faced by Mohs surgeons. The majority of Mohs surgeons surveyed find photographs the most useful documentation for decreasing the risk of wrong-site dermatologic surgery.

The impact of biopsy technique on upstaging, residual disease, and outcome in cutaneous melanoma.

BACKGROUND: After skin biopsy of malignant melanoma, the findings in the subsequent wide local excision (WLE) sometimes result in upgrading of the T-category. Herein, we examine the influence of biopsy technique on residual disease in melanoma WLE specimens and on upstaging. METHODS: We performed a retrospective review of data from malignant melanoma patients who underwent sentinel lymph node biopsy between 1997 and 2010. RESULTS: A total of 609 patients were biopsied by shave (51%), punch (19%), and excision (30%). Residual disease was seen in 240 patients (39%) at WLE, of whom 60% had undergone shave biopsy. Fifty-nine patients had a T-category upgrade after WLE (10% of all patients); 64% were sampled by shave. Seven percent of patients with a T-category upgrade had negative margins initially. Positive biopsy margin and greater thickness predicted T-category upgrade. CONCLUSIONS: Partial biopsy for melanoma resulted in more residual disease at WLE and a higher rate of T-category upgrade. Moreover, the presence of negative margins at biopsy did not ensure lack of residual disease.

Computer-assisted alignment and tracking of acne lesions indicate that most inflammatory lesions arise from comedones and de novo.

BACKGROUND: Inflammatory acne lesions are believed to derive from comedones; however, their evolution has not been rigorously studied. OBJECTIVE: To examine the evolution of facial acne lesions using serial digital photographs and spatial alignment software. METHODS: Six predefined lesion types, including inflammatory lesions, were counted and tracked from photographs taken every 2 weeks for 12 weeks from 25 individuals with untreated facial acne. RESULTS: Closed comedones occurred most frequently (37%), followed by erythematous macules (26%), inflammatory papules (15%), open comedones (12%), pustules (2%), and nodules (1%). Inflammatory lesions were preceded by comedones (54%), normal-appearing skin (28%), erythematous macules (12%), and scars (6%). LIMITATIONS: Lesions could have appeared and resolved within the 2-week intervals and some comedones may have been too small to identify on digital photographs. CONCLUSION: Our results confirm the comedonal origin of the majority of inflammatory acne lesions. However, a sizeable number (28%) appear to arise from normal skin.

Supraumbilical pyloromyotomy: a unique indication for antimicrobial prophylaxis.

BACKGROUND: The umbilical fold incision for infantile hypertrophic pyloric stenosis provides a convenient exposure and cosmetically appealing scar. This study investigates the possible difference in infection rates between traditional and supraumbilical approaches for pyloromyotomy. METHODS: All patients who underwent pyloromyotomy for infantile hypertrophic pyloric stenosis at a tertiary pediatric hospital were reviewed. Baseline wound infection rate was determined through review of patients with right upper quadrant incisions (group 1). A nonrandomized comparison was performed between patients with a supraumbilical approach (group 2) and those undergoing supraumbilical incisions after prophylactic antibiotic administration (group 3). RESULTS: Complete records were reviewed on 384 patients over a 6-year period. Demographics and preoperative factors were similar among groups. The rate of infection in group 1 (n = 258) was 2.3%. With introduction of the supraumbilical approach, there was a statistically significant increase in wound infection rate to 7.0% (chi 2 ; group 1 vs group 2, P < .05). The use of prophylactic antibiotics with a supraumbilical approach reduced this rate of infection back to 2.3% (chi 2 ; group 1 vs group 3, P < 1.0 and group 2 [n = 85] vs group 3 [n = 42], P < .3). CONCLUSIONS: The risk of wound infection by classic pyloromyotomy of 2.3% is significantly increased with an open supraumbilical approach. The use of prophylactic antibiotics reduces this risk of wound infection.