Risk Factors That Are Associated With Outliers in Mohs Micrographic Surgery in the National Medicare Population, 2018.

BACKGROUND: Physician variation exists in the mean number of stages performed per Mohs micrographic surgery (MMS) case. Physicians who are outliers in medical practice may be leading to a higher health care cost burden. OBJECTIVE: To identify factors that influence being a high outlier in the mean stages per MMS case. MATERIALS AND METHODS: The study comprised a retrospective analysis of 2018 data from physicians who billed Medicare Part B for Current Procedural Terminology (CPT) 17311 and 17312 (MMS of the head, neck, hands, feet, or genitalia) and/or CPT 17313 and 17314 (MMS of the trunk, arms, or legs). RESULTS: For CPT 17311 and 17312, the odds ratio for being an outlier for a physician in a solo practice relative to a multiphysician facility is 2.4 (1.6-3.8), for a physician who is not an American College of Mohs Surgery (ACMS) member relative to a ACMS member is 2.0 (1.2-3.2), and for a practice located in the West, Northeast, and South is 7.7 (2.8-21.6), 6.2 (2.1-18.6), and 1.8 (0.6-5.4), respectively, relative to in the Midwest. CONCLUSION: Physicians who are practicing solo, practicing in the West or Northeast, and are not ACMS members are more likely to be a high outlier in the mean stages per MMS case.

Single-Stage Adipofascial Turnover Flap as an Alternate Option for Large Nasal Defects Usually Requiring Two-Stage Forehead Flap.

BACKGROUND: Large nasal defects involving the tip, ala, and/or columella with denuded cartilage have traditionally required a two-stage forehead flap. As many Mohs patients are presenting older with increased medical comorbidities, a single-stage adipofascial turnover flap with a full-thickness skin graft was developed by the senior author as an alternative method. The authors hypothesize that the adipofascial turnover flap would have similar success rates and cost less than the forehead flap. METHODS: A retrospective review of all patients in the senior author's practice who underwent either a forehead flap or adipofascial turnover flap between January of 2016 and February of 2019 was conducted. The two groups were compared regarding success, complications, and cost. RESULTS: There were seven forehead flap patients and 11 patients with adipofascial turnover flaps. Overall complications were three of seven (43 percent) for the forehead flap group and one of 11 (9 percent) for the adipofascial turnover flap group. There was one mortality, one revision for asymmetry, and one with airflow obstruction in the forehead group. The adipofascial turnover flap group had one partial skin graft loss that healed with local wound care only. There were no flap failures in either group, and the cost savings averaged over $22,000 in the adipofascial turnover flap group. CONCLUSIONS: The single-stage adipofascial turnover flap with full-thickness skin grafting is a safe, reliable, and less expensive alternate to the forehead flap. The forehead flap will remain a workhorse in nasal reconstruction, but multiple operations increase cost and may contribute to higher complication rates. The adipofascial turnover flap appears to be an efficacious and reasonable option compared with the forehead flap.

Antibiotic Practices in Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery is a safe procedure with low rates of infection. OBJECTIVE: To establish current antibiotic prescribing practices amongst Mohs surgeons. METHODS AND MATERIALS: 16-question survey sent to American College of Mohs Surgery members. RESULTS: 305 respondents with collectively 7,634+ years of experience. The majority performed outpatient surgery (95.0%) and avoided oral or topical antibiotics for routine cases (67.7% and 62.8%, respectively). Prophylactic antibiotics were routinely prescribed for artificial cardiac valves (69.4%), anogenital surgery (53.0%), wedge excision (42.2%), artificial joints (41.0%), extensive inflammatory skin disease (40.1%), immunosuppression (38.9%), skin grafts (36.4%), leg surgery (34.2%), and nasal flaps (30.1%). A minority consistently swabbed the nares to check for staphylococcus aureus carriage (26.7%) and decolonized carriers prior to surgery (28.0%). CONCLUSION: Disparity exists in antibiotic prescribing practices amongst Mohs surgeons. There may be under-prescription of antibiotics for high risk factors like nasal flaps, wedge excisions, skin grafts, anogenital/lower extremity site, and extensive inflammatory disease. Conversely, there may be over-prescription for prosthetic joints or cardiac valves. Increased guideline awareness may reduce post-operative infections and costs/side effects from antibiotic over-prescription. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.4695.

Can Nonsterile Gloves for Dermatologic Procedures Be Cost-Effective without Compromising Infection Rates?

Over the last decade, studies have compared the use of sterile gloves (SGs) versus nonsterile gloves (NSGs) on surgical site infection (SSI) rates in Mohs micrographic surgery (MMS). In this study, we sought to determine SSI rates before and after employment of NSGs for dermatologic procedures. Infection data were collected from January 2009 to December 2015 on 7365 tumors treated with MMS and 1620 tumors treated by surgical excision. For MMS procedures using chlorhexidine as the antiseptic, the SSI rate with SGs was 3.39% compared to 3.06% with NSGs. For surgical excisions, the SSI rate was 3.02% with SGs and 4.17% with NSG. Using NSGs for MMS tumor resection and reconstruction can provide cost savings without adversely affecting SSI rates, and could also be considered in dermatologic procedures, including electrodessication and curettage and surgical excisions.

A 4-year retrospective assessment of postoperative complications in immunosuppressed patients following Mohs micrographic surgery.

BACKGROUND: Many patients undergoing Mohs micrographic surgery for basal and squamous cell carcinomas are immunocompromised, yet postoperative complications associated with different types of immunosuppression are largely unstudied. OBJECTIVE: To determine the incidence and nature of postoperative complications in immunosuppressed patients undergoing Mohs micrographic surgery. METHODS: A retrospective cross-sectional chart review of patient characteristics, clinical characteristics, and complications. RESULTS: Univariable analysis showed that compared with immunocompetence, immunosuppression was associated with 9.6 times the odds of postoperative complication (P = .003), with solid organ transplant recipients having 8.824 times higher odds (P = .006) and immunosuppressive therapy use displaying 5.775 times higher odds (P = .021). Surgical site infection (2.5%) and dehiscence (0.51%) were more prevalent among immunosuppressed patients, with an overall complication rate of 5.4% in the immunosuppressed population. Multivariable analysis of the association between immunosuppression and postoperative complication closely trended toward, but did not meet, significance (P = .056). LIMITATIONS: This was a single-center, retrospective study. Other limitations include lack of non-solid organ transplants, limited medication-related data on nontransplant patients, and exclusion of cases involving patients with double transplants or multiple sources of immunosuppression. CONCLUSIONS: Immunosuppression overall, particularly owing to solid organ transplant and immunosuppressive therapy use, places patients at higher risk for postoperative complications, including surgical site infection and wound dehiscence following MMS.

Assessment of Frontalis Myocutaneous Transposition Flap for Forehead Reconstruction After Mohs Surgery.

Importance: Forehead reconstruction after Mohs surgery has become a challenge for dermatology surgeons, and achieving an excellent cosmetic and functional result is imperative in this location. Objective: To highlight the utility of a frontalis myocutaneous transposition flap (FMTF) for forehead reconstruction after Mohs surgery. Design, Setting, and Participants: Surgical technique case series including 12 patients with large forehead defects recruited between January 2010 and June 2017 at the Dermatology Department of the University Clinic of Navarra, Spain. All patients underwent Mohs micrographic surgery for skin cancer (5 basal cell carcinomas, 4 melanomas, 2 squamous cell carcinomas, and 1 adnexal tumor) located on the forehead (8 paramedian, 2 midline, and 2 lateral subunits) resulting in defects ranging from 9 to 28 cm2 in size. Intervention: Mohs micrographic surgery followed by FMTF. Taking into account the defect's size and location, a lateral lobulated flap is designed with an inferior pedicle and incision lines are made vertically to the hairline containing part of the frontalis muscle or its fascia. The flap swings into the primary defect and direct closure of the donor site is achieved. Additional corrections for removing skin folds or a guitar-string suture can be made. Main Outcomes and Measures: Absence of acute complications and achievement of high aesthetic and functional goals in postoperative follow-up. Results: Satisfactory cosmetic and functional results were achieved for all 12 patients (7 men and 5 women; mean age, 62.7 years [range, 47-86 years]) and there were no postoperative complications. All the myocutaneous flaps survived without any acute complications, such as episodes of local bleeding, infection, flap margin necrosis, or congestion. Postoperative follow-up ranged from 6 months to 3 years. No patient needed scar revision. Six patients presented with paresthesia in areas of the forehead and scalp. Sensory recovery tended to improve over time, and paresthesia gradually decreased, disappearing in 5 of 6 cases after 12 months. In 3 patients there was a minimal hair transposition that required laser treatment. Conclusions and Relevance: The FMTF provides a simple method for 1-stage reconstruction of large forehead defects as an alternative to classic advancement flaps.

A Retrospective Assessment of Postoperative Bleeding Complications in Anticoagulated Patients Following Mohs Micrographic Surgery.

BACKGROUND: A significant number of patients undergoing Mohs micrographic surgery (MMS) for skin cancer are treated with oral anticoagulants. The incidence of postoperative complications associated with new classes of oral anticoagulants remains largely unknown. OBJECTIVE: To determine the incidence of postoperative complications in patients undergoing MMS on both traditional oral anticoagulants and new novel oral anticoagulants. MATERIALS AND METHODS: A single-center retrospective chart review was performed for all patients treated with oral anticoagulants who underwent MMS between July 1, 2012 and June 30, 2015 at University of California, San Diego. RESULTS: The data from this study demonstrated that patients treated with a novel oral anticoagulant at the time of MMS had a statistically significant greater risk for developing postoperative hemorrhagic complications compared to patients treated with traditional oral anticoagulants. CONCLUSION: Dermatologic surgeons should manage both traditional oral anticoagulants and novel oral anticoagulants in a similar manner. Future studies are warranted.

Applying a Visual Assessment Tool to Facial Linear Scars.

Previous scar scales have focused on verbal descriptions. A nonverbal visual assessment tool would provide a simple way for patients and physicians to quantify scar appearance. The authors sought to use a validated visual assessment tool for linear surgical scars to assess linear scars on the face and to determine whether patients and surgeons rate scars similarly. A total of 143 patients with linear facial scars resulting from repair of Mohs micrographic surgery defects used the visual assessment tool to rate their surgical scar. Six physicians used the tool to rate a subset of the patients' scar photographs. The scar ratings for patients and physicians were compared. Among the scars rated by both the patients and physicians (n = 79), patients had a significantly lower mean (i.e., more favorable) rating compared with the physicians. This was a single-center study including only Caucasian patients. The visual assessment tool to rate linear surgical scars provided a simple method for both patients and physicians to assess the overall appearance of postsurgical scars. Difference in the scar ranking between patients and physicians indicate the importance of incorporating both patient and physician point of view when assessing scars.

A practical decision-tree model to predict complexity of reconstructive surgery after periocular basal cell carcinoma excision.

BACKGROUND: Periocular basal cell carcinomas (pBCC) have unpredictable growth. The authors seek to derive a decision rule for predicting surgical complexity in pBCC. MATERIALS AND METHODS: This study was conducted at two centres in New Zealand from September 2010 to November 2015. Baseline demographic information and an initial assessment of operative complexity (a four-point grading scale) were collected. Assessment of operative complexity was repeated at the time of reconstruction. Univariate analysis was applied to identify the associative factors and supervised machine learning was used to determine the best predictive models to construct a clinical decision rule. RESULTS: A total of 156 patients and 156 periocular BCC were analysed. Univariate analysis revealed that older age, recurrent skin cancer, large tumour size, being a public patient and high complexity at pre-operative assessment were associated with high actual operative complexity. Tumour histology was not associated with more complex surgery. Machine learning analyses revealed that Naive Bayesian classifier was able to distinguish surgical complexity with an average area under the receiver operating characteristic curve (AUC) of 0.854 (95% CI: 0.762-0.946) whereas a simpler, alternating decision tree (ADT) that used only three clinical variables achieved an AUC of 0.853 (95% CI: 0.739-0.931). The ADT model was 10.1 times more likely to correctly identify a high complexity case. The three predictive variables were pre-operative assessment of complexity (high vs. low), surgical delays [early (<75 days) or delayed (≥75 days)], and tumour size [small (<14 mm), or large (≥14 mm)]. For the subgroup with large tumours but low initial assessed complexity, late surgery was associated with a 6.7-fold increase in risk of high-risk surgery. CONCLUSIONS: A simple, three-variable risk stratification system was able to predict the operative complexity of pBCC.

Assessment of intraoperative pain during Mohs micrographic surgery (MMS): An opportunity for improved patient care.

BACKGROUND: Intraoperative pain during Mohs micrographic surgery (MMS) has not been characterized. However, many patients report postoperative pain on the day of MMS. OBJECTIVE: We sought to determine if patients experience pain during their MMS visit. METHODS: In phase I of this study, patients were asked to report intraoperative pain level using the verbal numerical rating scale (0-10) at discharge. In phase II, pain levels were assessed before each Mohs layer and at discharge, to determine whether pain was experienced throughout the day. RESULTS: Pain was reported at some point during the MMS day for 32.8% of patients (n = 98). The mean pain number reported was 3.7 (range 1-8) out of 10. Pain was more commonly reported by patients who spent a longer time in the office, had 3 or more Mohs layers, and had a flap or graft repair. Patients most frequently reported pain with surgical sites of the periorbital area and nose. LIMITATIONS: Time between Mohs layers was not measured. There was nonstandardized use of intraoperative local anesthesia volume and oral pain medications. CONCLUSION: Some patients experience pain during MMS. However, the majority of patients report a low level of pain. Additional preventative measures could be considered in patients at higher risk.

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.

Heightened infection-control practices are associated with significantly lower infection rates in office-based Mohs surgery.

BACKGROUND: Reported infection rates for Mohs micrographic surgery (MMS) range from less than 1% to 3.5%. OBJECTIVE: To determine whether lower infection rates are possible for MMS with a consistently applied infection-control regimen. METHODS: A series of 832 consecutive patients with 950 tumors undergoing MMS formed the cohort for a retrospective study of infections before and after a program of heightened infection-control practices at a single-surgeon academic Mohs practice. The sterility upgrade included jewelry restrictions, alcohol hand scrub before stages and reconstruction, sterile gloves and (during reconstruction) sterile gowns for staff, and sterile towels and dressings for patients during Mohs stages. RESULTS: Infection rate was 2.5% (9 infections/365 tumors) before the sterility upgrade and 0.9% (5 infections/585 tumors) after, a statistically significant difference (p=.04). CONCLUSION: MMS already has low rates of infection, but this study shows that rigorous infection-control practices can significantly affect infection rates. The authors have indicated no significant interest with commercial supporters.

Patient safety in dermatology: a review of the literature.

OBJECTIVE: We performed a literature review of patient safety topics pertinent to dermatology and related to outpatient settings for situations in which data from dermatology are lacking. METHODS: Searches in MEDLINE via PubMed interface, OVID and Google Scholar were carried out from October, 2008 through May, 2009 for English-language articles published between 1948 and 2009. Each search combined 2 or 3 of the following terms: patient safety, medical error, human error, preventable adverse event, dermatology, outpatient, ambulatory care, medication error, diagnostic error, laboratory error, pathology error, office-based surgery, wrong-site procedure, infections, falls, laser safety, scope of practice. Personal communications, websites, books, dermatology newsletters and major textbooks were also scrutinized. Potentially relevant articles and communications were critically evaluated by the authors. References from these articles were searched for "other relevant articles." SUMMARY: Patient safety studies in dermatology and outpatient settings are lagging behind those in inpatient settings. Systems changes are needed to reduce medical errors rather than penalize individual healthcare workers. Although technology may improve patient safety in numerous aspects, it introduces new sources of errors. CONCLUSION: Our review reveals few studies on dermatologic patient safety, supporting the pressing need for such studies and reports in the future.

Successful treatment of non-healing wounds with Xelma(R).

Chronic wounds come in all shapes and sizes and may be associated with co-morbidities that have a direct impact upon healing and the quality of life of patients, their families, carers, and even co-workers. Cosmetic appearance is important to both genders but especially so to female patients and unsightly wounds that are difficult to hide cause extreme problems that may have psychological implications. In addition to the effect that they have on patients, these wounds are associated with considerable resource requirements, which impact heavily on the already burdened NHS. This article presents three case studies of patients with chronic wounds that have shown a positive response, in terms of healing and impact upon the patient's quality of life, to an advanced wound care product - Xelma(R).