Bupivacaine to Reduce Pain and Narcotic Use After Mohs Micrographic Surgery.

BACKGROUND: Limited data exists for bupivacaine injection after Mohs micrographic surgery (MMS). OBJECTIVE: Evaluate how bupivacaine affects postoperative pain and narcotic use. MATERIALS AND METHODS: In this multicenter, single-blinded, prospective randomized controlled trial, patients received bupivacaine or saline (placebo) immediately after MMS with flap reconstructions identified by American Academy of Dermatology expert consensus as high-risk for pain and narcotic use. For 48 hours postoperatively, patients logged analgesic use, pain scores (0-10), and whether pain was controlled. RESULTS: One hundred seventy-four patients were included. Narcotic analgesic use was higher in the placebo group during the first 24 hours (odds ratio 2.18; confidence interval [CI]: 1.08-4.41; p = .03), second 24 hours (odds ratio 2.18; CI: 0.91-5.29; p = .08), and 48 hours combined (odds ratio 2.58; CI: 1.28-5.24; p < .01). Pain scores were lower in the bupivacaine group during the first 8 hours (mean difference 1.6; CI: 0.73-2.38; p < .001). Overall analgesic use (narcotic and non-narcotic) and percentage of patients reporting pain under control were similar between groups. There were no significant differences in demographics or surgical characteristics. No adverse events occurred. CONCLUSION: Single-dose bupivacaine decreased postoperative pain and narcotic analgesic use after MMS with reconstructions likely to cause significant pain. Bupivacaine may have a role in postoperative pain management and reducing narcotic use in this population.

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.

Postoperative Infections in Dermatologic Surgery: The Role of Wound Cultures.

BACKGROUND: Dermatologic surgery is associated with low postoperative infection rates, averaging from approximately 1% to 4.25%. Often, postoperative infections are treated empirically based on clinical diagnosis of infection, given it can take 48 to 72 hours for a wound culture to identify a pathogen. OBJECTIVE: We aimed to evaluate the efficacy of empiric antibiotics in dermatologic surgery postoperative infections and if wound cultures change postoperative antibiotic therapy. METHODS: A 7-center, retrospective analysis of postoperative infections, with culture data, in dermatologic surgery patients was performed. RESULTS: Of 91 cases of clinically diagnosed postoperative infection, 82.4% (n = 75) were successfully treated with empiric oral antibiotics (95% confidence interval [0.73-0.89], p < .0001). In 16 (17.6%) cases, initial empiric antibiotics were unsuccessful, and wound culture results altered antibiotic therapy in 9 cases (9.9%) with 6 (6.6%) of these cases requiring additional coverage for methicillin-resistant Staphylococcus aureus (MRSA). CONCLUSION: Empiric antibiotic treatment is usually appropriate for patients with postoperative surgical-site infections with wound cultures altering antibiotic management in a minority of cases. When empiric antibiotics fail, lack of MRSA coverage is usually the cause; therefore, providers should be aware of local MRSA prevalence and susceptibilities.