The incidence of major complications from Mohs micrographic surgery performed in office-based and hospital-based settings.

BACKGROUND: There has been significant interest in the safety of office-based surgery. OBJECTIVE: Our purpose was to compare the safety of Mohs micrographic surgery and related surgical repairs performed in office- and hospital-based settings. METHODS: The study included 3937 consecutive patients undergoing Mohs surgery. Surgery was performed at either an outpatient office or a hospital-based setting. RESULTS: Mohs surgery was performed on 1540 patients in the hospital and 2397 patients underwent surgery in the office. The mean patient age was 66 years, and 61% were men. Ninety-three percent of lesions were basal cell or squamous cell carcinomas, and 86% were located on the head and neck. The average tumor measured 1.1 x 1.0 cm, required 1.7 stages of Mohs surgery, and resulted in a defect measuring 2.4 x 1.8 cm. Linear closures, flaps, grafts, and second-intention healing were utilized in 69%, 14%, 6%, and 11% of defects, respectively. There were no differences in patient or tumor characteristics or the types of closures used at the two operating facilities. The only serious surgical complication was gastrointestinal hemorrhage due to naproxen prescribed postoperatively for auricular chondritis in one patient. CONCLUSION: Mohs micrographic surgery and repair of associated defects can be safely performed in either an office- or hospital-based setting.

Efficacy of narrow-margin excision of well-demarcated primary facial basal cell carcinomas.

BACKGROUND: A 4-mm surgical margin of clinically normal skin is the current standard for elliptical excision of basal cell carcinomas (BCCs). However, a 4-mm surgical margin is often not feasible on the face because of cosmetic and functional concerns. As such, facial excisions of BCCs are typically performed with the appropriate margin determined by the surgeon based on clinical features of the tumor. OBJECTIVE: We designed a study to test the efficacy of narrow-margin elliptical excisions for the treatment of small, well-demarcated facial BCCs. METHODS: A total of 134 primary, small (<1 cm), well-demarcated, facial nodular BCCs were excised as an ellipse with 1-, 2-, or 3-mm margins around the visible border of the tumor. The margin used was decided by the dermatologic surgeon based on cosmetic, anatomic, and functional factors, with the goal of clearing the tumor in a single excision. Using the Mohs technique for elliptical specimens, frozen sections were prepared and examined microscopically to provide complete histologic margin control. RESULTS: In all, 134 facial BCCs were included in the study. On average, the tumors measured 0.6 x 0.5 cm. Of these, 27 (20.1%) had positive margins, requiring additional excision. Excisions with 1-, 2-, and 3-mm margins were associated with positive margins in 16%, 24%, and 13% of tumors, respectively. There was no statistically significant difference in the occurrence of positive margins based on tumor size, anatomic location, or the measured margin used. CONCLUSION: Narrow margins (1-3 mm) are inadequate for the excision of small, well-demarcated, primary nodular BCCs of the face. To avoid repetitive operations and the risk of recurrence in anatomically sensitive areas, these tumors should be treated with standard wide margins (eg, 4 mm), or have Mohs micrographic surgery for histologic margin control.

Surgical repair of temple defects after Mohs micrographic surgery.

BACKGROUND: It is typically recommended that linear surgical closures follow a relaxed skin tension line (RSTL). In the temple, these lines generally run parallel to the orbital rim. However, closures parallel to RSTLs are not feasible for many medium and large surgical defects because of anatomic constraints. OBJECTIVES: We sought to describe our method of repairing temple defects and assess the cosmetic outcome of temple defects repaired perpendicular to the RSTLs. METHODS: We performed a two-phase study of temple closures. In the first phase, a retrospective analysis was performed to assess the defect size and type of closure used for 99 consecutive temple defects. In the second phase, 27 of 86 patients who previously underwent linear surgical repairs in the temple that were designed perpendicular to the RSTLs were evaluated 12 to 24 months postoperatively to assess the cosmetic outcome. Results In the first phase of the study, there was an inverse correlation between the width of the postoperative defect and the ability to close the defect parallel to the RSTLs. The percentage of defects that could be repaired parallel to the RSTLs for defects up to 1 cm in width, 1.1 to 2 cm in width, and greater than 2 cm in width was 46%, 28%, and 8%, respectively. In the second phase of the study, 27 patients with temple defects repaired perpendicular to the RSTLs were evaluated an average of 1.7 years after operation. Most scars (83%) were clinically invisible or barely visible. There were no cases with residual standing cones (dog-ears) or hypertrophic scars. CONCLUSION: The vast majority of temple defects can be repaired in a linear fashion. Smaller defects (width < 1 cm) can be repaired parallel to the RSTL. Those that are larger (width 1-3 cm) or more medially located can be repaired perpendicular to the RSTL, using loose cheek skin for the closure. Very large defects (width > 3-5 cm) or those with limited cheek mobility may require flaps or skin grafts for closure.

Clinical appearance of full-thickness skin grafts of the nose.

BACKGROUND: Full-thickness skin grafting (FTSG) is an option for reconstruction of nasal defects. OBJECTIVE: To correlate the clinical outcome of FTSG on the nose with donor site, location of the defect, and defect size. METHODS: Patients with FTSG on the nose following Mohs' micrographic surgery were enrolled. Clinical and photographic assessments were performed. RESULTS: There were 54 FTSGs; the mean age was 20.6 months, and the average size was 2.1 cm2. The clinical assessment score was significantly different across donor sites, with dog-ear skin providing the best results, followed, respectively, by conchal bowl, preauricular, postauricular, and inner arm skin (p = .006). The global clinical outcome determined from the clinical assessment score was good for inner arm skin and excellent for other sites. The photographic assessment score was not different among donor sites (p = .601). There was no correlation of location and size of the defect to the clinical outcome assessed clinically and photographically (p>.05). CONCLUSION: All potential donor sites should be considered to select the donor site that best matches the defect.

Squamous cell carcinoma of the auricle and Mohs micrographic surgery.

BACKGROUND: Squamous cell carcinoma (SCC) of the ear compared with SCC occurring at other skin sites has an increased incidence of recurrence following treatment. OBJECTIVE: To determine the following variables: patient age and gender, life status, tumor location, and recurrence rate following Mohs micrographic surgery (MMS). METHODS: The charts of 117 patients with 144 invasive SCCs of the auricle were reviewed. The patients were contacted by telephone to confirm tumor recurrence and patients' life status. The range of follow-up was 7 to 67 months (average 34.6 months) after MMS. RESULTS: The patients' ages ranged from 34 to 90 years (mean age 71 years). The male to female ratio was 22:1. The helix was the most common site of occurrence (50.7%). Local recurrence after MMS was found in four patients (five tumors). MMS was performed on these five recurrent tumors, with no further recurrences. Telephone confirmation was obtained on 91 patients (26 patients could not be contacted) with 122 tumors, which included the 4 patients with 5 recurrent tumors. There were no additional recurrences. Of these 122 tumors, 35 were followed for less than 2 years (average 16.6 months), and 87 were followed for 2 years or more (average 41.8 months). From the chart review and telephone contact, the 2-year local recurrence rate was 5.7% (5 of 87 tumors) after MMS. The average size of these 87 tumors was 3.5 cm2. Twelve of 91 patients had died with evidence of active disease from causes unrelated to SCC. CONCLUSION: Invasive SCC of the ear was once a formidable disease with a severe prognosis. The course of this disease has been appreciably improved by early diagnosis and treatment with MMS.

Granular cell tumor of the heel treated with Mohs technique.

BACKGROUND: Granular cell tumors, also known as granular cell myoblastomas, are uncommon neoplasms of unknown etiology. Most granular cell tumors are benign and present as solitary, painless dermal nodules of the head and neck. Few of these tumors are reported on the lower extremities and only eight cases of granular cell tumor of the foot have been reported. Of these eight, only two clinically benign granular cell tumors occurred on the heel. OBJECTIVE: The objective was to describe the first reported case of malignant granular cell tumor of the heel. METHODS: All reported cases of granular cell tumor of the foot are reviewed and clinical details of a malignant granular cell tumor of the heel are provided. RESULTS: The malignant granular cell tumor of the heel was extirpated with two stages of Mohs microscopic surgery. No recurrence was noted at 22 months. CONCLUSION: Malignant granular cell tumor of the heel is among the rarest of malignancies. In this case, the tumor appears to have been successfully treated with Mohs micrographic surgery.

Eyebrow reconstruction: options for reconstruction of cutaneous defects of the eyebrow.

BACKGROUND: Reconstruction of cutaneous eyebrow defects is a challenge, as eyebrow positioning provides an important role in communication, cosmesis, and signaling age, gender, and emotional status. Special consideration must be paid in order to maintain eyebrow symmetry and to avoid distortion of the hairline. OBJECTIVE: To demonstrate reconstructive options for the eyebrow that preserve maximal function and cosmesis. METHODS: The anatomy and function of the eyebrow are reviewed. Descriptions of five techniques of eyebrow reconstruction are then presented, including specific limitations and benefits of each closure option. Pertinent details regarding flap mechanics, design, and patient selection are also included. RESULTS: There are several options available for reconstruction of the eyebrow. Each closure method has advantages and disadvantages. The selection must be individualized, depending on the extent and location of the eyebrow defect relationship to other structures, gender, and age of patients. Each of the five closure options aid to maintain the function and aesthetic appearance of the eyebrow. CONCLUSION: Understanding the unique anatomy and function of the eyebrow, including its movement in facial expression, is useful in achieving good reconstructive outcomes while maintaining normal eyebrow function.

Keratoacanthoma as a postoperative complication of skin cancer excision.

BACKGROUND: Keratoacanthomas usually occur spontaneously as a single rapidly growing tumor on sun-exposed skin. Multiple keratoacanthomas are rarely seen. Keratoacanthomas may also develop after trauma, laser resurfacing, radiation therapy, and at the donor site after skin grafting. OBJECTIVE: We report 6 cases of keratoacanthomas that developed in and around healing and healed surgical sites after treatment of skin cancer. These tumors developed 1 to 3 months after surgery and were sometimes multiple. METHODS: We performed follow-up examinations of patients' wounds after the treatment of skin cancer. Histological examination of nodules developing in the margins of healing wound sites and in the scars of healed wound sites after Mohs micrographic surgery revealed keratoacanthomas. RESULTS: The tumors presented as a rapidly growing nodule or nodules, with the typical morphology and pathology of keratoacanthoma. One patient developed multiple keratoacanthomas at surgical and nonsurgical sites. These nodules were treated by a combination of excision, curettage and electrodesiccation, and oral isotretinoin, 4 mg/d. CONCLUSION: Keratoacanthoma must be considered in the differential diagnosis of a rapidly growing nodule within or around the surgical site after skin cancer surgery.

Squamous cell carcinoma of the nail unit with evidence of bony involvement: a multidisciplinary approach to resection and reconstruction.

BACKGROUND: Squamous cell carcinoma (SCC) of the nail bed is a rare disorder that is often misdiagnosed for years before definitive diagnosis with biopsy. Proper evaluation of this carcinoma includes radiographic evaluation for bony involvement of the phalanges of the affected digit. If bony involvement is evident by x-ray, amputation of the distal phalanx or the affected digit is warranted. Mohs micrographic surgery of the affected nail unit is advantageous in preserving vital tissue for reconstruction after phalangeal amputation by a hand surgeon, thus maximizing preservation of the densely innervated tissue from the volar finger pulp. This approach may maximize functional capacity of the reconstructed digit. OBJECTIVE: To describe a multidisciplinary approach to resection, amputation, and reconstruction of digits with SCC of the nail bed. METHODS: This is a description of three cases and a review of the pertinent medical literature. RESULTS: Three SCCs of the nail bed were excised with Mohs micrographic surgery, preserving the volar pulp and skin of the distal finger. The patients were then referred for distal phalanx amputation and reconstruction by a hand surgeon. All patients remained disease free with acceptable function of the reconstructed digits at 15, 17, and 38 months of follow-up. CONCLUSION: Although uncommon, SCC of the nail bed must be considered in all nails with chronic disease. Preoperative evaluation should include hand radiographs in search of bony involvement. Tissue-sparing excision combined with distal amputation of the affected phalanx and reconstruction of the digit using spared tissue may maximize hand and digit function.

Mohs tissue mapping and processing: a survey study.

BACKGROUND: Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. OBJECTIVE: To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. METHODS: Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. RESULTS: Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or "slits" are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 microm (53.9%) and less frequently at 4 microm (21.9%). CONCLUSION: There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.