Bacterial Organisms Colonizing Mohs Surgical Wounds Healing by Second Intention on the Lower Extremities: A Prospective, Controlled Study.

BACKGROUND: Based on recent research, second intention wounds may be at greater risk for postoperative infection compared with sutured wounds. Accurate diagnosis of postoperative wound infections on the lower leg can be challenging and result in unnecessary antibiotic administration. OBJECTIVE: The objective of this study was to identify bacterial organisms that commonly colonize second intention surgical wounds after Mohs micrographic surgery (MMS) and isolate pathogenic organisms. METHODS: Patients with second intention surgical wounds on the lower leg were evaluated 2 weeks after MMS. Wounds were swabbed for bacteria and categorized as infected or not infected based on clinical appearance. Any colonizing bacteria were recorded once the culture results were reported. RESULTS: Twenty-five clinically infected wounds and 26 control wounds were cultured. Staphylococcus aureus was the most common bacteria, colonizing 8 infected wounds (15.7%) and 5 control wounds (9.8%). Eight cultures (32%) from clinically infected wounds grew normal skin flora alone. CONCLUSION: Staphylococcus aureus is the most common bacteria colonizing wounds healing by second intention on the lower extremity. Thirty-two percent of clinically infected wounds grew normal skin flora, demonstrating the challenge of accurately diagnosing infection in lower extremity second intention wounds.

Squamous Cell Carcinoma in Situ Achieves Tumor Clearance in More Mohs Stages Than Invasive Squamous Cell Carcinoma.

BACKGROUND: Squamous cell carcinoma in situ (SCCIS) has more subclinical lateral extension than invasive squamous cell carcinomas (SCC). OBJECTIVE: To determine whether it takes a greater number of Mohs stages for clearance of SCCIS compared with SCC and whether the difference in final defect size and clinical size is larger in SCCIS than SCC. METHODS: All Mohs micrographic surgery cases of SCCIS and SCC performed between January 2011 and December 2021 were identified. Number of Mohs stages were recorded and difference in final defect size and initial clinical size were calculated for SCCIS and SCC. RESULTS: 4,363 cases were included, 1,066 SCCIS and 3,297 invasive SCC. The initial clinical size, final defect size, and the size difference were similar between SCCIS and SCC groups. However, SCCIS underwent more Mohs stages to achieve tumor clearance than invasive SCCs (1.5 ± 0.7 vs 1.4 ± 0.7 respectively, p < .001). In fact, 71% of SCCs were cleared after 1 Mohs stage compared with 61.1% of SCCIS. CONCLUSION: These findings support that SCCIS has more subclinical lateral extension and therefore is appropriate for Mohs surgery.

Procedural and surgical treatment modalities for acne scarring - Part 2.

The optimal treatment of acne scarring is challenging because it involves consideration of several factors, including the type and number of scars, Fitzpatrick skin type, and the amount of downtime permissible to the patient. The second article in this CME series discusses the procedural treatments available for acne scarring, including the use of chemical peels, fillers, radiofrequency microneedling, lasers and surgical procedures. The indications for each modality, evidence for its benefits, and the adverse effects are discussed. This section aims to help guide the reader to select and implement the most appropriate treatment based on the patient's preferences, acne scar and skin type.

Acne scarring-pathophysiology, diagnosis, prevention and education - Part 1.

Acne scarring is common and can occur despite effective acne management. Acne scarring patients suffer from significant psychosocial morbidity including depression and suicidality. Despite availability and advancement of therapeutic modalities, treatment for acne scarring is uncommon and often overlooked in the acne patient encounter. The utilization of acne scarring assessment tools and identification of specific acne scar subtypes allow for a tailored therapeutic approach. Part I of this continuing medical education series covers the pathophysiology and morphology of textural and pigmented acne scars, scarring assessment tools and medical treatment options. The principles reviewed will aid in the approach and initiation of acne scar treatment in the outpatient setting.

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

Recurrence Rate for Melanoma Excised by Mohs Micrographic Surgery Without Immunostaining.

BACKGROUND: Mohs micrographic surgery (MMS) is becoming increasingly popular for the treatment of cutaneous melanoma (CM) as multiple studies have demonstrated favorable outcomes for local recurrence and overall survival. OBJECTIVE: To analyze the outcomes of noninvasive (NIM) and invasive melanomas (IM) using MMS with fresh frozen sections. The primary outcome was local recurrence. The secondary outcome was to identify mean surgical margins based on tumor type and location. METHODS: Retrospective cohort study of 224 cases of CM treated from 2006 to 2016 at a tertiary academic center with MMS and fresh frozen sections by a single Mohs surgeon. RESULTS: The overall recurrence rate was 2.6% with a mean follow-up of 36.2 months. The recurrence rate for NIM versus IM was 1.6% and 7%, respectively. The mean margins for NIM and IM were 7.9 mm and 10.1 mm, respectively. These varied by tumor site and location. CONCLUSION: This study supports the use of MMS in the treatment of CM and highlights how narrower surgical margins for NIM of the head and neck can be achieved without increasing risk of local recurrence.

Evidence-based clinical practice guideline: Reconstruction after skin cancer resection.

A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Midlevel Injectable Practice Patterns in Dermatology and Plastic Surgery Offices.

BACKGROUND: There is limited knowledge on the extent physicians delegate cosmetic procedures to midlevel providers. OBJECTIVE: To assess dermatology and plastic surgery practice patterns for the injections of neurotoxins and dermal fillers. MATERIALS AND METHODS: Four hundred ninety-two dermatology and plastic surgery practices were identified from 10 major US metropolitan areas. These practices were contacted, and staff were asked a series of questions to best characterize the practice patterns in regard to who performs the injectables in the office. RESULTS: Although most dermatology and plastic surgery practices had physicians as the only provider who gives injectables, 18.35% of dermatology and 25.4% of plastic surgery practices had nurse practioners and physician assistants giving injectables both with and without oversight of the supervising physician onsite. CONCLUSION: In a large majority of both plastic surgery and dermatology practices, physicians exclusively perform injections of neurotoxins and fillers. For practices that allow midlevel providers to perform injectables, the level of physician supervision is variable. In a small percentage of plastic surgery practices, surveyed midlevel providers exclusively performed injectables.

Increasing a Dermatologist's Footprint on Instagram: An Analysis of Top Influencers Performing Nonsurgical Cosmetic Procedures.

BACKGROUND: Patients use social media to find information about cosmetic procedures, yet dermatologists historically lack a social media presence. Misleading information from nonexperts is potentially harmful. OBJECTIVE: To identify the top influencers posting about nonsurgical cosmetic procedures on Instagram, verify their credentials, and analyze their content to empower dermatologists to effectively join the online conversation, combat harmful misinformation, and preserve the expertise and influence of board-certified dermatologists. METHODS AND MATERIALS: Using the Klear marketing platform, Instagram influencers with more than 50,000 followers were identified. Influence rating, top posts, and other metrics were extracted using proprietary algorithms. RESULTS: Ninety nine influencers were identified. Of the top 10, 70% were board-certified plastic surgeons. Physicians not board-certified in a core cosmetic specialty had the highest influencer rating and number of followers. The most popular posts were of before and after photographs and personal posts. CONCLUSION: Dermatologists may be able to increase their Instagram footprint by posting frequently, especially of before and after and personal photographs, using hashtags, Instagram live and Instagram television, and Instagram stories. It is important for the dermatology community to find a way to ethically navigate social media to have a seat at the table and meet patients where they are.

Evidence-Based Clinical Practice Guideline: Reconstruction after Skin Cancer Resection.

SUMMARY: A multi-disciplinary work group involving stakeholders from various backgrounds and societies was convened to develop guidelines for the management of reconstruction after skin cancer resection. The goal was to identify areas of common ground and provide evidence-based recommendations to improve patient care. Given the heterogeneity of reconstructive techniques and clinical scenarios, investigation centered around common elements in the process. In some cases, a distinction was made between treatment options in the office-based setting as opposed to those in the facility setting. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology). Final recommendations are related to concepts concerning the timing of reconstruction, management of anticoagulation, use of antibiotics, methods of pain control, and follow-up assessment. At times, there was insufficient evidence to make high-level recommendations. The literature analysis highlights the need for additional methodologically robust studies in this area, to help guide clinical practice.

Weight Loss: How Does It Fit in With Liposuction?

BACKGROUND: Weight loss is traditionally viewed as straightforward counting of calories in and calories out, with little regard to the role of the adipocytes tasked with storing said calories. However, the body executes a complex compensatory response to any intervention that depletes its energy stores. Here, the authors discuss the methods used to attain weight loss, the body's response to this weight loss, and the difficulties in maintaining weight loss. Furthermore, the authors provide an overview of the literature on the physiological effects of liposuction. OBJECTIVE: To describe the role of adipose tissue in energy homeostasis, methods of weight loss, weight regain, and the effect of liposuction on endocrine signaling. METHODS: The authors conducted a narrative review of representative studies. CONCLUSION: A variety of strategies for weight loss exist, and optimizing one's weight status may in turn optimize the aesthetic outcomes of liposuction. This is most apparent in the preferential reaccumulation of fat in certain areas after liposuction and the ability to avoid this with a negative energy balance.

Incidence of Surgical Site Infections in Second Intention Healing After Dermatologic Surgery.

BACKGROUND: There are few studies analyzing the surgical site infection (SSI) rate of second intention wounds after dermatologic surgery, and the results are inconclusive. Yet, the current dogma in dermatologic surgery is that wounds healed by second intention have lower infection rates. OBJECTIVE: To determine the rate of SSI and associated pathogenic organisms of second intention wounds compared with sutured wounds after skin cancer extirpation. MATERIALS AND METHODS: This was a retrospective cohort study of patients who had either Mohs micrographic surgery or wide local excision (WLE) for skin cancer extirpation between 2012 and 2016. Wounds were stratified by closure type, location, and associated organisms. Infection was diagnosed by a positive wound culture. RESULTS: The overall infection rate was 3.9%. The infection rate for sutured and second intention wounds was 3.2% and 6.8%, respectively. Second intention wounds were associated with a significantly higher risk of infection compared with sutured wounds (odds ratio = 2.22, 95% confidence interval 1.63-2.99). The lower extremity (LE) had the highest overall infection rate (10.5%). The face had the lowest overall infection rate (2.5%). CONCLUSION: Mohs micrographic surgery or WLE performed on the LE or lesions allowed to heal by second intention has an increased risk of SSI.

Assessment of Functionality in Elderly Patients When Determining Appropriate Treatment for Nonmelanoma Skin Cancers.

BACKGROUND: The treatment of nonmelanoma skin cancer (NMSC) in the elderly population is a source of significant debate. Mohs micrographic surgery (MMS) is a highly effective treatment option yet not every patient with a cutaneous malignancy that meets appropriate use criteria (AUC) should be treated with surgery. OBJECTIVE: The purpose of this study was to use the Karnofsky Performance Status (KPS) scale to categorize the functional status of patients aged 75 years and older who required treatment of NMSC. The authors wanted to see whether functionality played a role on the treatment selection. METHODS: Patients aged 75 years and older presenting for biopsy of a suspected NMSC that met AUC for MMS were included in the study. Trained medical assistants used the KPS scale to assess patient functionality. Treatment modality was recorded once the biopsy confirmed the NMSC. RESULTS: A cohort of 203 subjects met inclusion criteria for the study. There was a statistically significant difference in utilization of surgical treatments between high and low functionality patients (p = .03). CONCLUSION: Dermatologists consider patient functionality when selecting a treatment for NMSC and use less invasive modalities for patients with poor functional status, even when the tumor meets AUC.

Sebaceous carcinoma: evidence-based clinical practice guidelines.

Sebaceous carcinoma usually occurs in adults older than 60 years, on the eyelid, head and neck, and trunk. In this Review, we present clinical care recommendations for sebaceous carcinoma, which were developed as a result of an expert panel evaluation of the findings of a systematic review. Key conclusions were drawn and recommendations made for diagnosis, first-line treatment, radiotherapy, and post-treatment care. For diagnosis, we concluded that deep biopsy is often required; furthermore, differential diagnoses that mimic the condition can be excluded with special histological stains. For treatment, the recommended first-line therapy is surgical removal, followed by margin assessment of the peripheral and deep tissue edges; conjunctival mapping biopsies can facilitate surgical planning. Radiotherapy can be considered for cases with nerve or lymph node involvement, and as the primary treatment in patients who are ineligible for surgery. Post-treatment clinical examination should occur every 6 months for at least 3 years. No specific systemic therapies for advanced disease can be recommended, but targeted therapies and immunotherapies are being developed.

Patient-Centered Outcomes for Skin Cancer Management: Utilization of a Patient Delphi Process to Identify Important Treatment Themes.

BACKGROUND: Patient-reported outcomes are critical to research directed at maximizing patient benefit. The outcomes patients consider most relevant in the treatment of skin cancer have not been directly investigated. OBJECTIVE: To develop a ranked list of outcomes deemed most important by patients with skin cancer through a proctored Delphi process. METHODS: Twenty-one patients with a history of skin cancer volunteered to participate in the patient summit. The patient members participated in a guided discussion to generate a long list of potentially relevant outcomes. The list was then condensed and ranked through 2 rounds of a proctored Delphi process. RESULTS: Patients were diverse in their skin cancer histories and complexities, ages, and states of residence. Twelve themes were rated as highly important by 70% or more of participants. Most of these themes related to patient education and the collaborative nature of the physician-patient relationship. Fear of recurrence and cosmetic outcome were also highly rated. Limitations include a preponderance of older patients and patients from the midwest and northeast. CONCLUSION: Patients with skin cancer overwhelmingly prioritize a shared decision-making process, in which they are actively engaged and value detailed education regarding their disease. This should inform future research directed at skin cancer treatment and current physician-patient interactions.

Physician-Centered Outcomes for Skin Cancer Treatment: A Single-Day Modified Delphi Process to Assess the Importance of Themes in Skin Cancer Management.

BACKGROUND: Success in skin cancer treatment is determined through outcome measurement. Patients and physicians may prioritize different outcomes of care, and identification of such may enhance patient-centered care. OBJECTIVE: To identify gaps between patient and physician attitudes toward skin cancer outcomes. MATERIALS AND METHODS: A single-day, 21-patient, modified, in-person Delphi process to solicit and rate the importance of skin cancer-related outcomes was conducted. Twelve masked dermatologic surgeons rated patient-generated outcomes in a 2-round modified Delphi process. Each item was rated on a 1 to 9 scale (1, least important; 9, most important) using the Qualtrics web platform (Qualtrics, Provo, UT). Results of the physician ratings were compared with the patient ratings. RESULTS: A list of 53 skin cancer treatment-related themes and outcomes was generated. Eight items were ranked by physicians as "very high" (>80% importance), 5 as "high" (>70% importance), 19 as intermediate, and 21 as low. The physician and patient panels' ratings were concordant for 56% of items, whereas 7 outcome items showed a 2-category discordance. CONCLUSION: Physicians and patients were concordant regarding skin cancer treatment on multiple spheres. Areas of discordance include patient fear of unknown future risk, recurrence, or empowering patients to make treatment choices, and may be areas of continued improvement for delivery of patient-centered care.

Expertise in Head and Neck Cutaneous Reconstructive Surgery.

BACKGROUND: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature. OBJECTIVE: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature. METHODS: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors. RESULTS: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%). CONCLUSION: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

Dermatofibrosarcoma protuberans in a pediatric patient with ataxia telangiectasia syndrome.

Ataxia telangiectasia (AT) is a rare autosomal recessive neurodegenerative disorder caused by a mutation in the ATM gene. An impaired immune response due to the gene mutation leads to an increased risk of infection and malignancy. We present a rare case of dermatofibrosarcoma protuberans arising in a patient with AT.