Efficacy and Safety of Anxiolytics in Mohs Micrographic Surgery: A Randomized, Double-Blinded, Placebo-Controlled Trial.

BACKGROUND: Patient anxiety can complicate surgical outcomes by elevating blood pressure, increasing the need for postoperative pain management, and reducing overall patient satisfaction. Despite the use of anxiolytic medications in outpatient procedures, there is limited comparative evidence on the efficacy and safety of these agents in Mohs micrographic surgery. OBJECTIVE: To compare the effectiveness and safety of different preprocedural anxiolytic agents in Mohs surgery on perioperative patient anxiety and patient satisfaction. MATERIALS AND METHODS: A double-blinded, randomized, placebo-controlled trial was conducted of 6 different preprocedural anxiolytic agents (lorazepam, diazepam, alprazolam, gabapentin, pregabalin, and melatonin) in 350 patients undergoing Mohs surgery. Anxiety and vital signs were recorded. RESULTS: Diazepam demonstrated a statistically significant, sustained reduction in anxiety levels compared with placebo ( p = .03). Gabapentin significantly reduced early anxiety ( p = .02). Alprazolam showed a trend to early anxiety reduction ( p = .08). Lorazepam ( p = .73), pregabalin ( p = .53), and melatonin ( p = .24) failed to reduce patient anxiety compared with placebo at any time point. No anxiolytic significantly impacted any patient vital sign or cognition. CONCLUSION: Although short-acting benzodiazepines and gamma-aminobutyric acid medications may have transient anxiolytic effects, a single oral dose of 5 mg of diazepam can provide a sustained anxiolytic effect in Mohs surgery, with excellent patient safety.

Use of a patient and observer scar assessment scale to evaluate the V-Y advancement flap for reconstruction of medial cheek defects.

BACKGROUND: The V-Y advancement flap (VYF) is not commonly used to reconstruct defects located on the medial cheek. The quantitative assessment of VYF for this indication has not been reported. In evaluation of surgical scarring, the Patient and Observer Scar Assessment Scale (POSAS) has been validated for use in burn and breast surgery scars, but its usefulness in dermatologic surgery has not been determined. OBJECTIVE: To present our experience with the use of the POSAS to assess the success of VYF reconstruction for surgical defects on the medial cheek. METHODS AND MATERIALS: Fourteen patients with medium to large (>5 cm(2) ) medial cheek Mohs defects reconstructed using VYF were assessed. Final cosmetic and functional results were analyzed after a follow-up of 6 months to 2 years (mean follow-up 21 months) using the POSAS. RESULTS: Observers using the POSAS gave a mean score for VYF reconstructions of 9.1 ± 2.3 (5 represents normal skin, 50 represents worst imaginable scar). Patients using the POSAS gave a mean score for VYF reconstructions of 10 ± 4 (6 representing normal skin, 60 representing worst imaginable scar). CONCLUSION: VYF reconstruction of medium to large defects of the medial cheek is a useful option. The POSAS may be a helpful tool for evaluating reconstructive results in dermatologic surgery.

Metastatic zosteriform squamous cell carcinoma in an immunocompetent patient.

BACKGROUND: Although described in several reports of internal malignancies metastasizing to the skin, zosteriform metastases have been reported in only two cases of cutaneous squamous cell carcinoma (SCC). In both of these reports, the patients were immunosuppressed related to renal transplantation. OBJECTIVE: We present a case of an immunocompetent patient with zosteriform metastases originating from a recurrent cutaneous SCC. The lesions were present along the maxillary division of the trigeminal nerve. METHODS: Biopsies from eight lesions were studied using hematoxylin and eosin (H&E) and with immunohistochemistry. RESULTS: Neural involvement was detected in H&E preparations before and during excision of the metastatic nodules by Mohs micrographic surgery. The tumor cells reacted with antikeratin antibodies. The patient has had no evidence of recurrence or metastases 30 months following surgery. CONCLUSION: To our knowledge, this is the first case of cutaneous SCC with zosteriform metastases in a patient with an intact immune system. SCC should be included in the differential diagnosis of lesions presenting in a dermatomal distribution.