Reply to Letter: Effectiveness of Mohs and Close.

The following is a response to the Letter to the Editor by Konda, Francis, and Patel regarding the article "Mohs and Close" Technique (MCT) for selected cases to increase the efficiency of Mohs micrographic surgery.1,2 The letter raises questions about our utilization of MCT that require clarification.

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry.

BACKGROUND: In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty. OBJECTIVE: The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS). METHODS: A Delphi process was used to reach consensus on the complications to be recorded. RESULTS: Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection. LIMITATIONS: This article addresses only one aspect of registry development: identifying and defining surgical complications. CONCLUSION: The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

Laboratory errors leading to nonmelanoma skin cancer recurrence after Mohs micrographic surgery.

BACKGROUND: Compared with standard surgical excision, Mohs micrographic surgery (MMS) provides superior cure rates for nonmelanoma skin cancer (NMSC). Although cure rates of NMSC approach 99% with MMS, local recurrences occasionally occur. OBJECTIVE: The authors sought to identify histological features during frozen section examination that were associated with local recurrence of NMSC after MMS. MATERIALS AND METHODS: A retrospective chart review was performed of patients undergoing a second MMS procedure to treat locally recurrent NMSC over a 20-month period. Histological slides were reviewed to assess for possible causes of local recurrence. RESULTS: Of 3,169 NMSCs treated, 22 were locally recurrent. Possible causes of recurrence identified after MMS included dense inflammation in the final margin at sites affected by tumor in prior slides (27%), visible remaining tumor (23%), missing epidermal or dermal tissue (23%), and actinic keratosis (4%). One recurrence was possibly explained by incorrect mapping. No abnormality could be detected in 18% of cases. Possible limitations include the small sample size, retrospective design, and the possibility that some patients may have been lost to follow-up. CONCLUSION: Local recurrences after MMS are extremely rare. When recurrences do occur, they can be attributed to errors in histological interpretation or tumor mapping.

Aggressive extraocular sebaceous carcinoma recurring after mohs micrographic surgery.

Sebaceous carcinomas (SC) are rare adnexal tumors with possible aggressive behavior usually arising in the head and neck region of adults in the seventh decade of life. Treatment has traditionally been with surgical excision with 5-6 mm wide margins but Mohs micrographic surgery (MMS) has also been reported as an effective treatment modality. We present a case of a Caucasian female renal transplant patient with a rapidly enlarging nodule on the left preauricular cheek that was excised with MMS with negative margins. The tumor recurred rapidly and metastasized ultimately leading to the death of the patient. There was some disagreement amongst pathologists as to the possible nature of the diagnosis with the original biopsy being labeled as a poorly differentiated carcinoma. We aim to highlight the potential aggressive nature of SC and review the features of the neoplasm including histological features that help in making the diagnosis.

A malignant granular cell tumor excised with mohs micrographic surgery.

Malignant granular cell tumors are extremely rare, aggressive neoplasms displaying rapid growth and frequent associated metastatic disease. Excision and evaluation for metastatic disease are mandatory. We present a 54-year-old patient with a malignant granular cell tumor, treated with Mohs micrographic surgery. Cutaneous granular cell tumors are uncommon neoplasms, likely of perineural origin. Most follow a benign and uneventful course, with wide local excision being the treatment of choice (Enzinger, 1988). The malignant granular cell tumor is an extremely rare, aggressive variant, which provides a diagnostic challenge and management dilemma, especially with early presentation when it may be mistaken for other entities. There is also controversy regarding surgical management and follow-up of both benign and malignant granular cell tumors.

The efficacy of second-intention healing in the management of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery.

BACKGROUND: The type of repair chosen to manage defects on the dorsal aspects of the hands and fingers can affect overall hand function. Preservation of manual function in these areas is critical. OBJECTIVE: To evaluate the efficacy of second-intention healing of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery and to define optimal wound parameters for choosing second-intention healing. METHODS: Fifty-nine patients who had undergone second-intention healing of a Mohs defect on the dorsum of a hand or finger were contacted and their records obtained; 48 patients completed the study. Healing by second intention was assessed according to self-evaluation and retrospective review of medical records based on six outcome variables, including functional ability, durability, sensation, and cosmetic result. RESULTS: Defects ranged in size from 0.8 to 6.0 cm. Patient records revealed no documented problems with function, durability, sensation, cosmesis, or wound infection. All patients reported excellent or good functional results and normal sensation within the scar, and most reported excellent or good scar durability and cosmesis. CONCLUSION: Second-intention healing is an effective option for repairing defects on the dorsum of the hand and fingers. Large defect size is not a contraindication for second-intention healing.

Layered closure versus buried sutures and adhesive strips for cheek defect repair after cutaneous malignancy excision.

BACKGROUND: Primary closure of surgical defects after excision of cutaneous malignancies has been traditionally accomplished with layered closure. OBJECTIVE: We sought to compare the cosmetic outcome of cheek defects repaired with layered closure versus buried sutures and adhesive strips. METHODS: In all, 38 patients underwent excision of a cutaneous malignancy on the cheek by primary excision or Mohs micrographic surgery. Patients were prospectively randomized to receive layered closure to one half of the repair and buried sutures with adhesive strip closure for the other half of the repair. Follow-up assessment was performed by a blinded evaluator using a visual analog scale. RESULTS: There were no differences in scar contour, erythema, or overall cosmesis between closure types. LIMITATIONS: All study participants were Caucasian, with a mean age of 68 years, limiting generalizability of results. CONCLUSION: Layered closure does not have a cosmetic advantage over buried sutures and adhesive strips for the primary repair of cheek defects.

Giant merkel cell carcinoma masquerading as a benign cyst on the buttock of an african american man.

We report a case of a 60-year-old African American man who presented with a 4-year history of a previously asymptomatic, recently enlarging nodule on his left buttock, which was initially presumed to be an epidermoid cyst. Physical examination revealed a large, fixed, subcutaneous tumor, and a biopsy revealed merkel cell carcinoma. Immunohistochemical staining was positive for pankeratin, CAM 5.2, synaptophysin, and CD56 and negative for CK7, CK20, TTF-1, chromogranin, CD3, CD20, CD57, MART1, and HMB 45. The patient underwent wide local excision of the lesion with removal of the fascia overlying the gluteus and full body positron emission tomography (PET) and was found to have Stage IIb disease. He subsequently received adjuvant radiotherapy limited to the tumor bed at a dose of 60 gray.

Is levofloxacin necessary to prevent postoperative infections of auricular second-intention wounds?

BACKGROUND: Surgeons may prescribe oral quinolones after auricular procedures to prevent postoperative infections, especially those caused by Pseudomonas aeruginosa. OBJECTIVE: This study compares the efficacy of levofloxacin and local wound care to local wound care alone in preventing postoperative infection of auricular second-intention wounds. MATERIALS AND METHODS: This study was a prospective, randomized trial of 84 consecutive patients (82 in the final analysis) who underwent Mohs micrographic surgery for an auricular neoplasm and had a wound left to heal by second intention. After surgery, patients were randomly assigned to receive either local wound care or local wound care with concurrent 500 mg of levofloxacin by mouth daily. RESULTS: Overall, 85.4% of patients had no complications. Complications included 12.2% of patients with inflammatory chondritis and 2.4% of patients with infection. No infections with P. aeruginosa were observed. No statistical significance was observed between the two treatment groups. CONCLUSION: Levofloxacin is not necessary to prevent postoperative infections of auricular second-intention wounds after Mohs surgery.

Skin cancer in skin of color.

UNLABELLED: Skin cancer is less common in persons with skin of color than in light-skinned Caucasians but is often associated with greater morbidity and mortality. Thus, it is crucial that physicians become familiar with skin cancer in persons of color so as to maximize the likelihood of early detection of these tumors. In dark-skinned ethnic groups, squamous cell carcinoma is most common; squamous cell carcinoma and melanoma usually occur on nonsun-exposed sites; and ultraviolet radiation is not an important etiologic factor for skin cancer with the exception of basal cell carcinoma. Races of intermediate pigmentation, such as Hispanics and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and Caucasians. Skin cancers pose a significant risk in skin of color and clinicians should focus on preventive measures in these groups such as regular skin exams, self-examination, public education, and screening programs. LEARNING OBJECTIVE: At the completion of this learning activity, participants should be familiar with the epidemiology and unique clinical features of skin cancer in skin of color and be aware of strategies to prevent skin cancer in skin of color.