Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature.

BACKGROUND: Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE: To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS: A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS: Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION: Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.

Canthal Rotation Flap: Analysis of Flap Mechanics.

BACKGROUND: Surgical defects of the medial canthus lack reconstructive options that are reproducible, precise, and uncomplicated. The canthal rotation flap is a simple rotation flap that respects the geometry of this anatomic location. OBJECTIVE: To describe the authors' experience with reconstructive planning, flap mechanics, and geometric analysis of the medial canthus to achieve the best cosmetic outcome when using the canthal rotation flap. METHODS: A retrospective review of 16 cases performed at Dayton Skin Care Specialists and Skin Care Specialty Physicians between 2016 and 2018 was completed with a blinded visual analog score (VAS). RESULTS: Sixteen patients with Mohs defects in the medial canthus were reconstructed using the canthal rotation flap. Defect diameters ranged from 0.8 to 2.7 cm. Patient ages ranged from 17 to 88 years. The mean flap dimensions were 4.8 cm by 2.15 cm. No major complications were noted. The VAS scar rating at 2 to 5 months follow-up was available for 10 of 16 patients; the mean VAS was 2.1. CONCLUSION: The canthal rotation flap is a reliable, single stage repair for small defects of the medial canthus that is optimized for the unique geometry of the medial canthus. This repair technique adds to the paucity of reconstructive options for the medial canthus.

Inter- and Intra-physician variation in quantifying actinic keratosis skin photodamage.

We investigated the variations in physician evaluation of skin photodamage based on a published photodamage scale. Of interest is the utility of a 10-level scale ranging from none and mild photodamage to actinic keratosis (AK). The dorsal forearms of 55 adult subjects with various amounts of photodamage were considered. Each forearm was independently evaluated by 15 board-certified dermatologists according to the Global Assessment Severity Scale ranging from 0 (less severe) to 9 (the most progressed stage of skin damage). Dermatologists rated the levels of photodamage based upon the photographs in blinded fashion. Results show substantial disagreement amongst the dermatologists on the severity of photodamage. Our results indicate that ratings could be more consistent if using a scale of less levels (5-levels or 3-levels). Ultimately, clinicians can use this knowledge to provide better interpretation of inter-rater evaluations and provide more reliable assessment and frequent monitoring of high-risk populations.

A Novel Technique to Improve Accuracy of Mohs Mapping for Large Stages with a Small Tumor Burden.

Precision of the Mohs micrographic surgery (MMS) process during orientation, microscopic analysis, tissue mapping, and tumor clearance of specimen margins is essential for MMS to attain high cure rates; however, this elaborate process is subject to error. Large tumor stages with a small tumor burden present an avenue for error during MMS mapping. We present a novel technique to improve the accuracy of MMS mapping using an MMS slide marked for residual tumor superimposed onto a mobile device photograph of the surgical defect. This is taken to better identify location of residual tumor both on the digitalized MMS photomap and surgical defect. This novel technique decreases recurrence rates by decreasing the inevitable subjectivity involved with the superimposition of residual tumor foci from a microscopic view onto the digitalized MMS photomap then onto the surgical defect particularly in larger stages with a small tumor burden.

Quantifying skin photodamage with spatial frequency domain imaging: statistical results.

We investigated the change in optical properties and vascular parameters to characterize skin tissue from mild photodamage to actinic keratosis (AK) with comparison to a published photodamage scale. Multi-wavelength spatial frequency domain imaging (SFDI) measurements were performed on the dorsal forearms of 55 adult subjects with various amounts of photodamage. Dermatologists rated the levels of photodamage based upon the photographs in blinded fashion to allow comparison with SFDI data. For characterization of statistical data, we used artificial neural networks. Our results indicate that optical and vascular parameters can be used to quantify photodamage and can discriminate between the stages as low, medium, and high grades, with the best performance of ∼70%, ∼76% and 80% for characterization of low- medium- and high-grade lesions, respectively. Ultimately, clinicians can use this noninvasive approach for risk assessment and frequent monitoring of high-risk populations.

Two Suturing Techniques for the Prevention and Treatment of Nasal Valve Collapse After Mohs Micrographic Surgery.

BACKGROUND: Tumor extirpation of nonmelanoma skin cancer (NMSC) adjacent to the alar groove, using Mohs micrographic surgery (MMS), may risk causing internal nasal valve (INV) collapse, resulting in reduced airflow during inspiration. There are many surgical options described in the literature to repair INV collapse as a postoperative corrective procedure, but few exist as an intra-operative preventative procedure. OBJECTIVE: The authors present 2 distinct methods to prevent and treat INV collapse during the repair of a perialar surgical defect caused by MMS. METHODS: A 3-point stitch method or a modified suspension suture technique was used to prevent INV collapse during the repair of MMS defects overlying the alar groove, for nonmelanoma skin cancers. The 3-point stitch was used with a complex repair. The modified suspension suture was used with flap reconstruction. RESULTS: The 3-point stitch and the modified suspension suture are simple, single-stage surgical solutions for perialar defects with collapse of the INV caused by loss of subcutaneous tissue during MMS. Once executed, patients experienced immediate subjective airflow improvement which was also supported by clinical examination. Patients were followed at 1 week and at 3 months postoperatively. Thirty-four of 35 patients reported good functional and cosmetic results and were satisfied with the final outcome. CONCLUSION: The 3-point stitch and the modified suspension suture techniques are easy and simple methods that can be incorporated into reconstruction after MMS for defects of variable depth covering any multisubunit perialar region to prevent or correct INV collapse.