Shared decision making for perioperative antibiotic use during Mohs micrographic surgery on the lower extremities.

Background: While there is a higher risk of surgical site infection (SSI) on the lower extremities following Mohs micrographic surgery (MMS), antibiotic prophylaxis (AP) is debated. Objective: To determine the role of shared decision making (SDM) in guiding AP usage during MMS on the lower extremities. Materials and methods: A prospective observational study was conducted whereby patients received a standardized SDM discussion or routine counseling. Patient satisfaction quantified by the shared decision-making questionnaire (SDMQ9) survey, rate of SSI, and rate of AP prescription were recorded. Results: In total, 51 patients were included. While there were less antibiotics prescribed in the treatment group (20% versus 50%, P = .025), this did not affect incidence of SSI (8% in treatment group versus 7.7% in control group, P = .668). Patient satisfaction was statistically greater in SDM group (4.73 versus 2.18 in control (P < .001). Conclusion: Patient satisfaction scores were higher among the patients who received SDM. While the usage of AP was lower in the SDM group, this did not affect incidence of SSI. This study allows the opportunity to apply SDM in the setting of MMS, which to our knowledge has not yet been attempted in the field of dermatologic surgery.

Pinch Grafting: A Systematic Review of Modern Perspectives and Applications in Dermatologic Surgery and Wound Healing.

BACKGROUND: Pinch grafting has experienced a resurgence in interest in recent years, stemming from its simplicity, safety, and potential in restoring tissue integrity. While historically employed for chronic nonhealing wounds, pinch grafts have shown promise following surgical procedures, particularly those involving the lower extremities. OBJECTIVE: To systematically review the literature and present an updated overview of the current applications of pinch grafting. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In collaboration with a medical reference librarian, the PubMed, Embase, Scopus, and Web of Science databases were searched for studies reporting on the use of pinch grafting from 2000 onward. The references of each included article were also screened. RESULTS: Ten articles met final inclusion criteria. In total, 300 patients underwent pinch grafting for treatment of skin ulceration, while an additional 35 cases were performed as an alternative to primary closure following skin cancer resection. Overall, pinch grafting was safe and well tolerated, with minimal adverse outcomes reported. CONCLUSION: Pinch grafting is a safe, straightforward, and effective technique to promote the healing of chronic wounds. While the procedure shows early promise in emerging applications within dermatologic surgery, only about 10% of the reported cases involved this indication, reflecting a need for further research in this area.

Hidradenocarcinoma: A Case Series From the Scripps Clinic With a Systematic Review of the Literature.

BACKGROUND: Hidradenocarcinoma (HAC) is a rare adnexal carcinoma. To the best of the authors' knowledge, there are no published systematic reviews on HAC. OBJECTIVE: To incorporate a case series from the authors' institution and systematically integrate reported information to provide a reference tool for optimization of diagnosis and management. METHODS: A comprehensive MEDLINE search was conducted from database inception to 2021 using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This yielded 225 studies with 165 cases of HAC. References of included articles were also searched. In addition, 9 patients with HAC were identified from the authors' institution over the past 10 years. RESULTS: The mean age of HAC presentation is 60 years with a slight male predilection (60%). The head and neck is the most commonly affected region. Over 36% of cases either presented with metastatic disease or went on to metastasize. The most common treatment type was wide local excision, followed by Mohs micrographic surgery. CONCLUSION: Early detection with accurate histologic interpretation is prudent in all cases of HAC. Wide local excision is the current first-line treatment. However, Mohs micrographic surgery offers complete marginal analysis with evidence of reduced risk of metastasis and better outcomes compared with wide local excision. Currently, there are no National Comprehensive Cancer Network guidelines for the treatment of HAC, and consensus guidelines are limited to tumor and nodal metastasis staging provided by the American Joint Committee on Cancer, eighth edition. Thus, this case series and systematic review integrates important aspects of diagnosis, workup, and management of HAC.

Liposomal and Nonliposomal Bupivacaine for Mohs Surgery: A Systematic Review.

BACKGROUND: Lidocaine is the most commonly used local anesthetic for Mohs micrographic surgery (MMS), but given its limited half-life, postoperative pain remains a significant concern for patients. Bupivacaine is used in various surgical subspecialty procedures and has demonstrated improved pain control compared with lidocaine. However, its role in MMS is insufficiently explored. OBJECTIVE: To systematically review the current literature for reports on use of bupivacaine, traditional nonliposomal and newer liposomal formulations, for MMS. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. The MEDLINE, PubMed, and EMBASE databases were queried for articles presenting original data on the use of bupivacaine for MMS. RESULTS: Of 483 potentially relevant articles, 3 studies met final inclusion criteria, capturing a total of 253 patients involved in primary investigations comparing bupivacaine to traditional local anesthesia for MMS. Bupivacaine was well-tolerated and associated with comparable or modestly reduced intraoperative and postoperative pain and opioid use. CONCLUSION: Bupivacaine may have a role in prolonging intraoperative anesthesia, reducing acute postoperative pain, and reducing postoperative opioid use after MMS. However, large, prospective studies are needed to solidify the generalizability and clinical utility of these findings.

Endocrine Mucin-Producing Sweat Gland Carcinoma and Primary Cutaneous Mucinous Carcinoma: A Case Series.

Endocrine mucin-producing sweat gland carcinoma (EMPSGC) and primary cutaneous mucinous carcinoma (PCMC) are rare low-grade neoplasms thought to arise from apocrine glands that share many histological features and are proposed to be on a single histopathologic continuum, with EMPSGC as the in situ form that may progress to the invasive PCMC. Management involves a metastatic workup and either wide local excision (WLE) with greater than 5 mm margins or Mohs micrographic surgery (MMS) in anatomically sensitive areas. We present 2 cases of EMPSGC and 3 cases of PCMC and review their clinical and histopathologic features, differential diagnoses, and treatment.

Neurotropic melanoma arising from a neurocristic hamartoma.

Neurotropic melanoma is a rare type of malignant melanoma with nerve invasion or neural differentiation. Neurocristic cutaneous hamartoma is a rare, benign tumor of the skin and superficial soft tissue that arises from aberrant migration of neural crest cells. We report a rare case of a 74-year-old man with a clinically diagnosed giant congenital nevus of the right mid-back, histopathologically confirmed to be a neurocristic cutaneous hamartoma, who developed neurotropic spindle cell melanoma within the lesion. The patient was treated with serial re-excisions until clear margins were achieved.

Extraocular Sebaceous Carcinoma Treated With Mohs Micrographic Surgery-A 24-Year Retrospective Review of Tumor Characteristics and Treatment Outcomes.

BACKGROUND: Extraocular sebaceous carcinoma (SC) is rare, with distinct features from its ocular counterpart. These neoplasms have been associated with Muir-Torre syndrome (MTS). Associated internal malignancies include gastrointestinal and genitourinary. OBJECTIVE: Assess for local recurrence, metastasis, disease-specific death, and additional malignancies in patients with extraocular SC treated with Mohs micrographic surgery (MMS) at a single referral center. METHODS: Review of patients with extraocular SC treated with MMS between 1995 and 2019. Follow-up was obtained by chart review. RESULTS: Thirty-eight patients with 41 tumors were identified (25, 66% male). During a mean follow-up of 5.9 ± 5 years, one case of metastasis was identified in an incompletely treated case. No recurrence was identified in the remaining 40 tumors. Five of 41 (12%) tumors had aggressive histologic features. Seven of 38 (18%) patients had a diagnosis of MTS or associated risk factors. There was no association between MTS or its risk factors and high-risk tumors. CONCLUSION: There were no incidences of local recurrence, metastasis, or disease-specific death in cases treated completely with MMS. Metastasis and disease-specific death occurred in an incompletely treated case, highlighting the risk associated with aggressive tumors.

Successful Treatment of Chronic Venous Ulcers With a 1,320-nm Endovenous Laser Combined With Other Minimally Invasive Venous Procedures.

BACKGROUND: Venous ulcers are very common with few curative treatment options. OBJECTIVE: To report the closure rate and clinical characteristics of active venous ulcers in a vein clinic using endovenous laser ablation (EVLA) with a 1,320-nm laser. METHODS AND MATERIALS: A prospective database was kept consisting of patients with an active venous ulcer at the time of consultation in a single-practitioner academic vein clinic from March 2007 to May 2014. A database was maintained and charts were reviewed with attention to the length of time the patient reported having the ulcer, procedures performed, and time to ulcer healing. RESULTS: Thirty-one patients were identified at consultation with venous ulceration. One patient's ulcer was healed with conservative medical management before receiving treatment. The remaining 30 patients were treated with a combination of EVLA of the great and/or short saphenous veins, foam sclerotherapy of insufficient varicose and reticular veins, and phlebectomy as appropriate. Two patients were lost to follow up after partial treatment. Ulcer healing occurred in more than 93% (27/29) of patients with a median healing time of 55 days from the time of first treatment. The median follow-up time after treatment was 448 days. CONCLUSION: Endovenous laser ablation with a 1,320-nm laser in combination with foam sclerotherapy and phlebectomy as appropriate is effective treatment of chronic venous ulcers and should be considered as a treatment option for patients with C6 venous insufficiency. To the authors' knowledge, this is the largest, prospective series of chronic venous ulcers treated with EVLA. Further randomized controlled studies are needed to confirm these findings.

Rare case of acral calcified angioleiomyoma with macroscopic calcium extrusion.

Acral calcified angioleiomyoma is an uncommon tumor that presents as a non-descript papule or subcutaneous nodule, classically on the foot. Biopsy or excision is typically the diagnostic method of choice as well as the treatment for these sometimes painful tumors. We report an uncommon clinical presentation of acral calcified angioleiomyoma with considerable extrusion of calcium perforating through the skin.

Infection rates of wound repairs during Mohs micrographic surgery using sterile versus nonsterile gloves: a prospective randomized pilot study.

BACKGROUND: Mohs micrographic surgery (MMS) is a multistep outpatient procedure that has become the treatment of choice for the removal of many cutaneous malignancies. The surgeon initially removes the tumor with nonsterile gloves in MMS. Sterile or nonsterile gloves are then used during the final repairs. OBJECTIVE: This prospective patient-blinded single-institution pilot study was performed to evaluate whether there is a difference in infection rate when using clean, nonsterile gloves versus sterile gloves during tumor removal and the wound repair phases of MMS. MATERIALS AND METHODS: This study randomized 60 patients undergoing MMS. Data on age, sex, anatomic location, number of Mohs stages, closure type, size of final defect, operative time, number of pairs of gloves used, and type of glove used were recorded and evaluated. RESULTS: Three infections were identified. Two infections occurred in the sterile glove arm and one in the clean glove arm. Overall, there was no greater infection rate when using clean, nonsterile gloves than sterile gloves (p=.99). CONCLUSIONS: Our study supports the use of clean, nonsterile gloves as a safe alternative to sterile gloves during all steps of MMS, at a significant cost savings. A larger confirmatory study comparing the equivalence in infection rates between clean and sterile gloves is warranted.

Modified Mohs micrographic surgery for periocular melanoma and melanoma in situ: long-term experience at Scripps Clinic.

BACKGROUND: Excision of invasive melanoma and melanoma in situ (MIS) using variations of the Mohs micrographic surgery (MMS) technique is becoming increasingly common in difficult areas, such as the periocular area, where standard surgical margins may not be feasible, and clinical margins are poorly defined. However, little long-term data evaluating the treatment of periocular melanoma are available in the literature. OBJECTIVE: To present our long-term experience in the treatment of periocular melanoma using a staged, modified Mohs excision technique with rush permanent, paraffin-embedded tissue sections. MATERIALS AND METHODS: A total of 35 patients with periocular melanoma and MIS were treated using modified MMS during a 15-year period. Twenty-nine patients were available with adequate follow-up of greater than 5 years duration. The mean follow-up duration was 94 months. RESULTS: There were a total of five recurrences (17.2%) detected an average of 85 months after excision. Four of the five recurrent tumors had been previously excised. The recurrence rate for primary tumors was 5% (1/20). The recurrence rate for previously excised tumors was 44.4% (4/9). CONCLUSION: Margin-control surgery is favored in the treatment of periocular melanoma to maximize the cure rate and minimize postoperative morbidity by sparing normal tissue. Ample follow-up intervals are required to adequately assess recurrence rates. The best opportunity for cure is associated with the first tumor excision.

Calcium hydroxylapatite tissue filler discovered 6 years after implantation into the nasolabial fold: case report and review.

BACKGROUND: Injectable calcium hydroxylapatite is becoming increasingly popular as a facial soft tissue filler, due in part to its purported longevity of esthetic correction compared with other materials, but little is known about its long-term histologic appearance and persistence in facial skin. We recently encountered calcium hydroxylapatite microspheres incidentally during Mohs surgery of the nasolabial fold 6 years after implantation. OBJECTIVE: To describe the long-term histologic appearance of calcium hydroxylapatite microspheres in human facial skin and review the relevant literature with a consideration of clinical implications. METHOD: Routine hematoxylin and eosin staining was performed on frozen and fixed excised tissue containing calcium hydroxylapatite microspheres. Additional fixed sections were stained using Movat's pentachrome method. RESULTS: Numerous 4- to 20-mum round vacuoles were present throughout the reticular dermis associated with focal fibrosis, interstitial mucin, and little surrounding inflammation. CONCLUSION: Calcium hydroxylapatite microspheres and associated fibrosis may persist in facial dermis at least 6 years after implantation, long after its clinical effects are thought to subside. Dermatologists and dermatopathologists must be mindful of dermal implants because it is likely that incidental encounters will be an increasingly common occurrence.

Treatment of dermatofibroma sarcoma protuberans using modified Mohs micrographic surgery: no recurrences and smaller defects.

OBJECTIVES: The purpose of this study was to evaluate the use of modified Mohs micrographic surgery (MMS) for dermatofibroma sarcoma protuberans (DFSP) in a single institution by a single surgeon. METHODS: The authors conducted a retrospective analysis of 25 patients with DFSP who were treated with modified MMS over the past 19 years at Scripps Clinic. RESULTS: Of the 25 patients treated with modified MMS for DFSP, there were no identifiable recurrences. The mean follow-up time was 101 months. The defect sizes of DFSP lesions treated by modified MMS are smaller than if the lesions had been treated with the standard wide local excision (WLE) margins of 3 cm. LIMITATIONS: This is a retrospective analysis using the data of one surgeon. Five of the 25 patients were not examined in our office. Not all patients had 5-year follow-up. There were no cases of the fibrosarcomatous variant. CONCLUSION: Our data support the growing literature that modified MMS achieves excellent local control for DFSP with a possible benefit of smaller defects when compared with treatment with WLE. The authors have indicated no significant interest with commercial supporters.