Comparison of MITF and Melan-A Immunohistochemistry During Mohs Surgery for Lentigo Maligna-Type Melanoma In Situ and Lentigo Maligna Melanoma.

BACKGROUND: Mohs micrographic surgery (MMS) with frozen section immunohistochemistry is a treatment option for malignant melanoma in situ (MMIS) and lentigo maligna melanoma (LMM). Melan-A is a cytoplasmic melanocyte immunostain useful on frozen sections but may lack specificity. Microphthalmia transcription factor (MITF) is a more specific nuclear melanocyte immunostain less frequently used in MMS. OBJECTIVE: To quantify melanocyte density in chronic sun-damaged skin (CSDS), negative margin, and tumor from patients undergoing MMS for MMIS and LMM using MITF and melan-A. METHODS: Sixteen patients with MMIS or LMM had frozen sections from CSDS, negative margin, and 12 tumor samples, stained with MITF and melan-A. Melanocyte counts were performed. RESULTS: Chronic sun-damaged skin mean melanocyte count (MMC) for MITF and melan-A was 9.8 and 13.7, respectively, (p < .001). Negative margin MMC for MITF and melan-A was 8.84 and 14.06, respectively, (p < .001). Tumor MMC for MITF and melan-A was 63.5 and 62.4, respectively. CONCLUSION: Although both MITF and melan-A facilitate the identification of tumor during MMS for MMIS and LMM, the apparent melanocyte density on tumor-free CSDS appears higher with melan-A than MITF. Microphthalmia transcription factor provides a crisp outline of melanocyte nuclei and is a useful alternative stain to melan-A for MMS of melanoma.

Complications With New Oral Anticoagulants Dabigatran and Rivaroxaban in Cutaneous Surgery.

BACKGROUND: Anticoagulant medications to date are not associated with increased risk of severe life-threatening complications during cutaneous surgery. Dabigatran and rivaroxaban are new orally administered anticoagulants that do not require laboratory monitoring and have no available specific antidotes, making perioperative management more complex. To the authors' knowledge, published data on the use of dabigatran or rivaroxaban in patients undergoing cutaneous surgery are limited. OBJECTIVE: The authors sought to study perioperative complications associated with dabigatran and rivaroxaban during cutaneous surgery. MATERIALS AND METHODS: Retrospective chart analysis was performed for all patients who underwent Mohs micrographic surgery or basic excision while taking dabigatran or rivaroxaban between January 1, 2010, and September 1, 2013, at Mayo Clinic, Rochester, MN. RESULTS: Twenty-seven patients taking dabigatran underwent 41 cutaneous surgeries, with only 1 mild bleeding complication observed that was remedied with a pressure dressing. Four patients on rivaroxaban underwent 5 cutaneous surgeries without complication. CONCLUSION: Because no patients on dabigatran or rivaroxaban experienced severe hemorrhagic complications during cutaneous surgery, a strategy of continuing these medically necessary medications during cutaneous surgery seems reasonable.

Comparison of full-thickness skin grafts versus second-intention healing for Mohs defects of the helix.

BACKGROUND: Two repair options for Mohs defects of the helix include full-thickness skin grafting and second-intention healing. Limited long-term data exist comparing these 2 repair options. OBJECTIVE: To compare outcomes of full-thickness skin grafts (FTSG) versus second-intention wound healing for Mohs defects on the helix. METHODS: In this study, 29 second-intention and 18 FTSG repairs were evaluated using a visual analog scale (VAS). Patient questionnaires and retrospective chart analysis were used to assess secondary outcomes. RESULTS: The average second-intention VAS score was 82.1 (standard deviation [SD] = 7.6), and the average FTSG VAS score was 75.2 (SD = 16.7) (difference of 6.9, 95% confidence interval: -1.3 to 15.1, p = .061). A subsequent noninferiority test indicated that cosmetic outcome of second-intention healing was at least as good as that of FTSG in the authors' study (p < .001). Retrospective chart analysis revealed no significant difference in complications. Patient-reported outcomes were not significantly different. CONCLUSION: Mohs surgical defects of the helix left to heal by second-intention have comparable long-term cosmetic outcomes to those repaired by FTSG. There was no significant difference in complications, and patients were highly satisfied with both repair options.

Mohs micrographic surgery for the treatment of hidradenocarcinoma: the Mayo Clinic experience from 1993 to 2013.

BACKGROUND: Hidradenocarcinoma (HAC) is a rare malignant adnexal neoplasm with reported metastatic potential and undefined optimal treatment. OBJECTIVE: To review clinical characteristics and outcomes of patients with HAC treated with Mohs micrographic surgery (MMS). MATERIALS AND METHODS: The authors performed a retrospective chart review of patients with HAC treated by MMS at Mayo Clinic from 1993 to 2013, recording patient demographics, tumor characteristics, MMS stages to clearance, follow-up, recurrence, metastasis, and mortality. RESULTS: Ten patients underwent MMS for HAC more than 20 years. The average age was 62.8 years, with 6 females and 4 males. Occipital scalp was the most common location (40%), followed by extremities (30%) and face (20%). In 5 of 7 cases (71%), "cyst" was the working clinical diagnosis. The average preoperative lesion area was 3.18 cm, with an average of 1.5 MMS stages required for clearance. Mean postoperative follow-up was 7 years (range, 5-205 months). No tumors treated with MMS recurred, metastasized, or led to disease-related mortality. CONCLUSION: Mohs micrographic surgery seems to be a useful treatment modality for HAC. This is the largest reported series of HAC treated with MMS with long-term follow-up.

Surgical corner. Modified buried suture technique for the scalp.

Large surgical defects on an actinically damaged scalp are notoriously difficult to close primarily. Not only is the skin weak and friable, but the underlying bone often limits the size of "bite" that the surgeon can take with their deep suture. We describe a technique that maximizes the ability to grasp adequate deep tissue with the suture, decreasing the likelihood of tearing through the tissue when the wound edges are brought together.

Delayed wound healing in diabetic (db/db) mice with Pseudomonas aeruginosa biofilm challenge: a model for the study of chronic wounds.

Chronic wounds are a major clinical problem that lead to considerable morbidity and mortality. We hypothesized that an important factor in the failure of chronic wounds to heal was the presence of microbial biofilm resistant to antibiotics and protected from host defenses. A major difficulty in studying chronic wounds is the absence of suitable animal models. The goal of this study was to create a reproducible chronic wound model in diabetic mice by the application of bacterial biofilm. Six-millimeter punch biopsy wounds were created on the dorsal surface of diabetic (db/db) mice, subsequently challenged with Pseudomonas aeruginosa (PAO1) biofilms 2 days postwounding, and covered with semiocclusive dressings for 2 weeks. Most of the control wounds were epithelialized by 28 days postwounding. In contrast, none of biofilm-challenged wounds were closed. Histological analysis showed extensive inflammatory cell infiltration, tissue necrosis, and epidermal hyperplasia adjacent to challenged wounds-all indicators of an inflammatory nonhealing wound. Quantitative cultures and transmission electron microscopy demonstrated that the majority of bacteria were in the scab above the wound bed rather than in the wound tissue. The model was reproducible, allowed localized cutaneous wound infections without high mortality, and demonstrated delayed wound healing following a biofilm challenge. This model may provide an approach to study the role of microbial biofilms in chronic wounds as well as the effect of specific biofilm therapy on wound healing.

Carbon dioxide laser treatment for Hailey-Hailey disease: a retrospective chart review with patient-reported outcomes.

BACKGROUND: Hailey-Hailey disease (HHD) is an autosomal dominant genodermatosis that leads to skin breakdown and blister formation, usually in intertriginous areas. Laser ablation is a known surgical treatment for HHD. OBJECTIVES: We report outcomes in a series of patients with HHD treated with carbon dioxide (CO2 ) laser ablation. METHODS: A retrospective chart review of data for 13 patients who underwent CO2 laser ablation for HHD was conducted. Questionnaires assessing effectiveness, pain, healing time, recurrence, new disease, complications, additional ablation, improvement in quality of life (QoL), and overall satisfaction were completed by all patients. RESULTS: All patients had been recalcitrant to previous treatments prior to CO2 laser ablation. Anatomic sites treated and anesthesia techniques for the procedure varied. The mean ± standard deviation (SD) score for the effectiveness of CO2 laser ablation for HHD was 9.3 ± 0.9 (maximum: 10). All patients reported improved QoL. No patient had recurring disease within the treatment field. Five patients underwent additional CO2 laser treatments at new sites. One patient reported postoperative infection. No other complications were identified. The mean ± SD score for overall satisfaction with CO2 laser ablation was 8.9 ± 1.1. CONCLUSIONS: Treatment with CO2 laser ablation is very effective and can lead to prolonged or permanent remission in most HHD patients. Patients are highly satisfied with the results and report a substantial improvement in QoL.