Part 2: Management of Intraoperative and Perioperative Bleeding.

With an increase in number of patients on antithrombotic therapies, management of bleeding during dermatologic surgery is increasingly important. As described in Part 1, perioperative discontinuation of antithrombotic therapies may increase the risk of embolic events thus the risks and benefits must be weighed carefully when deciding whether to continue or suspend therapy. However, continuing oral anticoagulants may result in increased intraoperative and postoperative bleeding. Here we describe various methods to effectively achieve hemostasis which include: 1) mechanical methods to compress the vasculature 2) pharmacologic agents that induce vasoconstriction 3) physiologic agents that augment clot formation and 4) physical agents that promote platelet aggregation.

Part 1: Management of Antithrombotic Medications in Dermatologic Surgery.

Perioperative management of antithrombotic agents requires practical and medical considerations. Discontinuing antithrombotic therapies increases the risk of thrombotic adverse events including cerebrovascular accidents, myocardial infarction, pulmonary embolism, deep vein thrombosis, and retinal artery occlusion. Conversely, continuation of antithrombotic therapy during surgical procedures has associated bleeding risks. Currently, no guidelines exist regarding management of antithrombotic agents in the perioperative period for cutaneous surgeries and practice differs by surgeon. Here, we review the data on antithrombotic medications in patients undergoing cutaneous surgery including medication-specific surgical and postoperative bleeding risk if the medications are continued, and thromboembolic risk if the medications are interrupted. Specifically, we focus on vitamin K antagonist (VKA) (warfarin), direct-acting oral anticoagulants (DOAC) (rivaroxaban, apixaban, edoxaban, dabigatran), antiplatelet medications (aspirin, clopidogrel, prasugrel, ticagrelor, dipyridamole), unfractionated heparin, low molecular weight heparin (enoxaparin and dalteparin), fondaparinux, bruton tyrosine kinase inhibitors (BTKi) (ibrutinib, acalabrutinib), and dietary supplements (i.e., garlic, ginger, gingko).

How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study.

BACKGROUND: Few studies show how dermatologic surgeons manage problems with site identification. OBJECTIVE: To estimate frequency and characterize management of skin cancer treated by surgery when the anatomic location of the tumor is in question. METHODS: Nationwide, prospective, multisite cohort study. RESULTS: Among 17,076 cases at 22 centers, 98 (0.60%) were lesions in question for which site identification was initially uncertain, with these more often in patients who were male, older, and biopsied more than 30 days ago. Surgeons employed on average 5.0 (95% CI: 4.61-5.39) additional techniques to confirm the site location, with common approaches including: re-checking available documentation (90 lesions, 92%); performing an expanded physical examination (89 lesions, 91%); and asking the patient to point using a mirror (61 lesions, 62%). In 15%, photographs were requested from the biopsying provider, and also in 15%, frozen section biopsies were obtained. In 10%, the referring physician was contacted. Eventually, surgeons succeeded in definitively identifying 82% (80 of 98) of initially uncertain sites, with the remaining 18% (18 of 98) postponed. Most postponed surgeries were at non-facial sites. LIMITATIONS: Sites were academic centers. CONCLUSIONS: When the anatomic location of the tumor is uncertain, dermatologic surgeons use multiple methods to identify the site, and sometimes cases are postponed.

The role of imaging in the management of patients with nonmelanoma skin cancer: Diagnostic modalities and applications.

While uncomplicated cases of nonmelanoma skin cancer can be treated with surgery, destruction, or topical therapy alone, advanced or neglected cases require more complex management decisions. Dermatologists and dermatologic surgeons should be familiar with the imaging techniques relevant to cutaneous oncology and their value in different clinical scenarios. Herein we review imaging modalities used in management of nonmelanoma skin cancer.

The role of imaging in the management of patients with nonmelanoma skin cancer: When is imaging necessary?

When treating aggressive skin cancers, pre- and postoperative imaging provides important information for treatment planning and multidisciplinary cooperation of care. It is important for dermatologists to recognize the clinical scenarios where imaging is indicated in the management of skin cancer. We here address the most common indications for imaging in cutaneous oncology and how to best utilize the modalities available.

Repair of the medial canthus following Mohs micrographic surgery.

BACKGROUND: The medial canthus poses unique reconstructive challenges because of its anatomy and contour. The reconstructive goal should be preservation of the natural concavity that defines it because even small alterations can result in perceptible asymmetry. OBJECTIVE: To present the anatomy of this unique cosmetic subunit and review reconstructive options that preserve contour and function. MATERIALS AND METHODS: A variety of reconstructive approaches for different subunits of the medial canthus are described and discussed. Technical considerations and complications are discussed. RESULTS: The choice of repair will depend on the relative location of the defect on the medial canthus and the proximity to adjacent cosmetic subunits. CONCLUSION: Understanding of the unique contour and anatomy of the medial canthus is essential to choosing the best repair option that preserves contour and symmetry.

Assessment of postoperative pain after Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) has the highest cure rate for the treatment of cutaneous malignancies and is usually performed in an outpatient setting with local anesthesia. Although most patients experience minimal discomfort during the procedure, postoperative pain after MMS has not been well-characterized. The objective of this study was to evaluate the amount of postoperative pain after MMS and to determine whether the degree of pain is correlated with factors such as tumor location, size, number of excisions, or age or sex of the patient. MATERIAL AND METHODS: One hundred fifty-eight patients with skin cancer treated with MMS were included in this study. Information recorded for each study participant included age, sex, diagnosis, tumor location, number of sites, number of Mohs excision stages, and type of repair performed. A daily log was given to patients to record the amount of pain experienced using the Wong-Baker pain scale and any analgesics that were taken for the 8 consecutive days beginning on the day of surgery. RESULTS: The majority of patients reported some degree of pain on day 0 (mean pain score 1.97 ± 1.46) and day 1 (mean pain score 1.15 ± 1.20); the fraction of patients reporting pain and the severity of that pain diminished steadily thereafter. By day 7, only 25 patients (16%) were experiencing any pain (average pain score 0.21). Only 26 patients (16%) required prescription analgesics on the day of surgery (day 0) and fewer on subsequent days. Seventy-seven of the patients used acetaminophen on day 0 (55%), which rapidly declined each subsequent day. Greater reported pain was significant for scalp procedures and multiple same-day procedures. No significant differences in pain scores were noted with regard to age or sex. CONCLUSION: Postoperative pain after MMS was associated with only mild to moderate pain on the day of surgery and the first postoperative day. Most pain was effectively managed using oral acetaminophen, with a minority of patients requiring prescription analgesics. Surgery on the scalp was significantly more painful than on other sites. Patients can be reassured that MMS and reconstruction is well-tolerated and associated with only mild to moderate discomfort postoperatively.

The biomechanical properties of the skin.

BACKGROUND: The skin possesses unique biochemical properties that allow it to protect and conform to the body that it covers. Elements constituting the dermis-collagen and elastin-primarily afford these properties. OBJECTIVES: To define these properties and explore their relevance with regard to aging skin and dermatologic surgery. MATERIALS AND METHODS: In the first part of this review, the determinants of mechanical properties of the skin will be outlined, through an extensive review of the literature. General physical properties that explain the behavior of skin will be defined, and diseases that manifest the extremes of those properties will be discussed. In the second half of this discussion, the surgical implications of skin biomechanics will be reviewed. RESULTS: Emphasis will be placed on understanding how dermatologic surgeons may optimally use skin properties to produce the best cosmetic and functional outcomes possible. CONCLUSION: Understanding of the biomechanical properties of skin is paramount to obtain the best cosmetic outcomes in dermatologic surgery.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study.

Importance: It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs. Objective: To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals. Design, Setting, and Participants: This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019. Exposures: Mohs surgery for nonmelanoma skin cancer. Main Outcomes and Measures: Reason for treatment selection. Results: Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]). Conclusions and Relevance: This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Large facial basal cell carcinoma treated with multimodal combination therapy.

Large basal cell carcinomas (BCCs) with mixed intratumoral histology can present treatment challenges. Although a single treatment modality may be appropriate for some portions of the tumor, it may prove to be inadequate or overly aggressive for others. We describe a patient with a large facial BCC who was referred to our clinic for Mohs micrographic surgery. Biopsies revealed both noduloinfiltrative and superficial patterns. To excise the tumor completely would have been disfiguring, and topical therapy alone would have been inadequate. A multimodal approach using Mohs micrographic surgery to excise the central nodular portion and topical imiquimod to treat the surrounding superficial portion resulted in an excellent clinical outcome. This approach, which minimizes morbidity by capitalizing on the benefits of various techniques, can be applied to any BCC demonstrating distinct nodular and superficial portions.

Ablative laser resurfacing: high-energy pulsed carbon dioxide and erbium:yttrium-aluminum-garnet.

The development of the short-pulsed high-energy carbon dioxide laser in the mid 1990's led to the emergence of laser skin resurfacing. Used in the continuous mode, the CO(2) laser can cut and coagulate simultaneously. Used in the pulsed mode, the CO(2) laser is a powerful tool for epidermal ablation in many different contexts both therapeutic and cosmetic. Both the CO(2) and Erbium YAG lasers emit light in the infrared spectrum. Energy is preferentially absorbed by intracellular water creating rapid heating and vaporization of tissue. Because of the wavelength of the Er:YAG laser (2940 nm) more closely approximates the absorption peak of water (3000 nm) the target chromophore than the CO(2) laser (10,600 nm) nearly all of the energy is absorbed in the epidermis and papillary dermis yielding superficial ablation and less underlying thermal damage. The advantages, disadvantages, and applications of each type of laser resurfacing will be discussed. Despite proven efficacy, the public acceptance of laser resurfacing has declined with the emergence of new laser systems that cause dermal remodeling without ablating the overlying epidermis dramatically reducing recovery time. In the absence of blinded comparison studies, it remains unclear whether the clinical results of the newer 'nonablative' laser systems compare with their ablative predecessors.

LASER-tissue interactions.

As new laser devices continue to emerge, it becomes increasingly important for the clinical dermatologist to understand the basic principles behind their operation. A fundamental understanding of how lasers interact with tissue will enable the physician to choose the most appropriate laser for a given clinical situation. Although the physical laws guiding laser design are vastly complex, the fundamental principles of laser-tissue interaction can be summarized as they are applicable to the clinician.

Epidermotropically metastatic pancreatic adenocarcinoma.

We describe an epidermotropically metastatic pancreatic mucinous ductal adenocarcinoma on the scalp. Neoplastic glandular structures that varied in size and shape containing abundant mucin within the lumens and in the neoplastic cells were present within a seborrheic keratosis and adjacent normal epidermis. Similar neoplastic glandular structures were present in the dermis, some within adnexal epithelium and lymphatic vessels. The patient's history of pancreatic mucinous ductal adenocarcinoma and immunohistochemical staining pattern of carbohydrate antigen 19-9 (CA 19-9) confirmed the diagnosis.

Mohs surgery for malignant eccrine neoplasms.

BACKGROUND: Eccrine carcinomas (ECs) are rare tumors with potentially aggressive clinical behavior and a high recurrence rate following conventional surgical excision. With the exception of microcystic adnexal carcinoma (MAC), there have been few reports on the use of Mohs micrographic surgery (MMS) as a primary treatment for EC. OBJECTIVE: To review the use of MMS for EC and compare treatment outcomes with those of conventional surgical excision. METHODS: We report our use of MMS in 7 cases of EC and review the literature regarding the use of MMS for EC excluding microcystic adnexal carcinoma (MAC), which has been described elsewhere. RESULTS: A total of 19 case reports describing MMS for non-MAS malignant eccrine neoplasms were reviewed. There were no reported recurrences over an average follow-up period of 29 months, whereas the local recurrence rate following conventional surgical excision of these neoplasms from 10-70%. CONCLUSIONS: While the clinical experience is limited, the use of MMS appears to decrease recurrence rates when compared to conventional surgical excision. Further experience and longer follow-up intervals will be necessary to demonstrate superior efficacy and recommended surgical margins.