Antibiotic adherence in dermatologic surgery: a Multicenter prospective cohort study.

Understanding patient non-adherence to prescribed antibiotics can inform clinical practices, patient counseling, and antibiotic efficacy study design in dermatology. The primary objective was to determine the rate of and reasons for antibiotic non-adherence in the dermatologic surgery setting. The secondary objective was to test the applicability of previously studied survey questions for antibiotic non-adherence screening in the dermatologic surgery setting. Five academic outpatient dermatologic surgery centers across the United States conducted one multicenter prospective cohort study. Dermatologic surgery patients ≥ 18 years of age who were prescribed an antibiotic were included as part of this study. 15.2% (42/276) of patients did not adhere to their antibiotic regimen after dermatologic surgery. Most common reasons for incomplete antibiotic courses included forgotten antibiotics (42.9%,18/42) and side effects (28.6%, 12/42). Previously evaluated questions to identify and predict non-adherence had modest performance in the dermatologic surgery setting (Area under the curve of 0.669 [95% CI (0.583-0.754)]). Antibiotic non-adherence after skin surgery is prevalent and commonly due to reasons that physicians can address with patients.

Top 100 Most Cited Articles in Mohs Micrographic Surgery: A Bibliometric Analysis.

BACKGROUND: Bibliometric analysis is a scientific method that can derive insights into major publications' trends within a field. Currently, no bibliometric study has been conducted for Mohs micrographic surgery (MMS). OBJECTIVE: To characterize the most frequently cited articles in MMS. METHODS: Web of Science was used to identify the 100 most cited publications on MMS between 1970 and 2022. Articles were analyzed by title, authorship, institution, journal, year, citation frequency, originating country, funding, citation index, Altmetric score, impact factor, Eigenfactor score, and article influence score. RESULTS: Since January 2023, the top 100 articles had 9,096 total citations, ranging from 47 to 304. The top cited publication was "Mohs surgery is the treatment of choice for recurrent (previously treated) basal-cell carcinoma" in 1989. The top contributing organization was Harvard University (17%) and top contributing authors were Brodland, DJ (12%) and Zitelli, JA (11%). The year 2005 accounted for most of the articles (12%). Most articles were from the Journal of the American Academy of Dermatology (32%) and Dermatologic Surgery (27%). The United States contributed to 76% of the top articles. CONCLUSION: This bibliometric analysis offers researchers a detailed overview of important MMS publications and provides useful data into current findings steering MMS research and practice.

Postoperative Complications After Interpolated Flap Repair for Mohs Defects of the Nose: A Multicenter Prospective Cohort Study.

BACKGROUND: Dermatologists perform most interpolated flaps after skin cancer resection. Prospective, multicenter data on complications after interpolated flap repair in this setting are limited. OBJECTIVE: To determine the rate of physician-reported complications after interpolated flap repair of the nose. METHODS: Multicenter, prospective cohort study of 169 patients undergoing 2-stage interpolated flap repair of post-Mohs nasal defects. Frequency of bleeding, infection, dehiscence, necrosis, hospitalization, and death in the 30 days after flap placement and flap takedown are reported. RESULTS: Patients experienced 23 complications after flap placement (13.61%) and 6 complications after flap takedown (3.55%) that were related to the surgical procedure. The most frequent complication after flap placement was bleeding (9, 5.33%, 95% confidence interval [CI]: 2.83%-9.82%). The most frequent complication after flap takedown was infection (5, 2.96%, 95% CI: 1.27%-6.74%). There was one hospitalization related to an adverse reaction to antibiotics. There were no deaths. CONCLUSION: Most complications after interpolated flap repair for post-Mohs defects of the nose are minor and are associated with flap placement. Interpolated flap repair for post-Mohs defects can be performed safely in the outpatient setting under local anesthesia.

Outcomes of invasive melanoma of the head and neck treated with Mohs micrographic surgery - A multicenter study.

BACKGROUND: There are no randomized controlled trials to guide surgical margins for invasive head and neck (H&N) melanoma using conventional excision. Mohs micrographic surgery (MMS) has shown improved local recurrence rates and survival for invasive H&N melanomas. OBJECTIVE: Determine local recurrence (LR), nodal recurrence, and distant recurrence rates, and disease specific survival for invasive melanoma of the H&N treated with MMS. METHODS: A retrospective multicenter study of 785 cases of invasive H&N melanoma treated with MMS using frozen sections with melanoma antigen recognized by T-cells 1 immunohistochemical staining was performed to evaluate long-term outcomes over 12-years. RESULTS: 785 melanomas (thickness: 0.3 mm-8.5 mm) were treated with MMS. LR, nodal recurrence, and distant recurrence rates were 0.51% (4/785), 1.0% (8/785), and 1.1% (9/785) respectively. For T1, T2, T3, and T4 tumors LR was 0.16% (1/636), 1.18% (1/85), 2.22% (1/45), and 5.26% (1/19), respectively. Five and 10-year disease specific survival were 96.8% (95% CI 95.0% to 98.5%) and 93.4% (95% CI 88.5% to 98.3%). LIMITATIONS: A nonrandomized retrospective study. CONCLUSION: MMS achieves significant improvements in LR compared to a meta-analysis of historical cohorts of patients treated with conventional excision. MMS should be considered an important surgical option for invasive H&N melanoma.

Patient-Reported Nasal Function and Appearance After Interpolation Flap Repair Following Skin Cancer Resection: A Multicenter Prospective Cohort Study.

Objective: Among patients undergoing two-stage interpolated flap repair of nasal defects, nasal function, and appearance before surgery and at 16 weeks after flap takedown were compared using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ). Design: Multicenter prospective cohort study. Methods: Adult patients with a nasal skin cancer anticipated to require two-stage interpolation flap repair completed the NAFEQ before surgery, at 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Results: One hundred sixty-nine patients were enrolled, with 138 patients completing both presurgical and 16-week post-takedown NAFEQs. Overall NAFEQ score increased by 1.09 points (1.91% improvement, confidence interval [95% CI -0.34 to 2.53]). NAFEQ functional subscale increased by 0.72 points (2.58% increase; 95% CI [0.10-1.35]) and appearance subscale increased by 0.37 points (1.28% improvement, 95% CI [-0.65 to 1.39]). Conclusion: At 16 weeks after flap takedown, patients' perceptions of their nasal function and appearance are similar to or slightly improved when compared with their presurgical assessments.

Patient Quality of Life After Interpolated Flap Repair of Nasal Mohs Surgery Defects: A Multicenter Prospective Cohort Study.

IMPORTANCE: Single-center studies have shown that patients report better skin cancer-specific quality of life (QOL) after Mohs micrographic surgery (MMS), but it is unclear whether this improved QOL applies to patients after MMS and complex reconstruction in cosmetically sensitive areas. OBJECTIVE: To evaluate patient QOL after MMS and interpolation flap reconstruction for patients with nasal skin cancers. DESIGN, SETTING AND PARTICIPANTS: This multicenter prospective survey study used the Skin Cancer Index (SCI), a validated, 15-question QOL questionnaire administered at 4 time points: before MMS, 1 week after flap placement, 4 weeks after flap takedown, and 16 weeks after flap takedown. Patients age 18 years or older with a nasal skin cancer who presented for MMS and were anticipated to undergo 2-stage interpolated flap repair by a Mohs surgeon were recruited from August 9, 2018, to February 2, 2020, at 8 outpatient MMS locations across the United States, including both academic centers and private practices. MAIN OUTCOMES AND MEASURES: Mean difference in overall SCI score before MMS vs 16 weeks after flap takedown. RESULTS: A total of 169 patients (92 men [54.4%]; mean [SD] age, 67.7 [11.4] years) were enrolled, with 147 patients (75 men [51.0%]; mean [SD] age, 67.8 [11.7] years) completing SCI surveys both before MMS and 16 weeks after flap takedown. Total SCI scores improved significantly 16 weeks after flap takedown compared with pre-MMS scores, increasing by a mean of 13% (increase of 7.11 points; 95% CI, 5.48-8.76; P < .001). All 3 SCI subscale scores (emotion, appearance, and social) improved significantly (emotion subscale, increase of 3.27 points; 95% CI, 2.35-4.18; P < .001; appearance subscale, increase of 1.65 points; 95% CI, 1.12-2.18; P < .001; and social subscale, increase of 2.10 points; 95% CI, 1.55-2.84; P < .001) 16 weeks after flap takedown compared with pre-MMS. CONCLUSIONS AND RELEVANCE: Removal of a nasal skin cancer and repair of the resulting defect can be distressing for patients. However, this cohort study suggests that physicians referring patients for MMS can be reassured that their patient's QOL will improve on average after surgery, even when a complex reconstruction is required.

Preferences for Prophylactic Oral Antibiotic Use in Dermatologic Surgery: A Multicenter Discrete Choice Experiment.

BACKGROUND: Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood. OBJECTIVE: To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions. MATERIALS AND METHODS: Multi-center, prospective discrete choice experiment (DCE). RESULTS: Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics. CONCLUSION: Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience.

Bilayer wound matrix-based cutaneous scalp reconstruction: A multidisciplinary case control analysis of factors associated with reconstructive success and failure.

BACKGROUND: Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp. METHODS: A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes. RESULTS: In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm2, and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 - 26.7, and p<0.012). Additionally, subjects who underwent preoperative radiation were more likely to suffer from reconstructive failure (p<0.040) as well as those who require postoperative inpatient admission (p<0.034). CONCLUSION: BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.

Systematic review and meta-analysis of local recurrence rates of head and neck cutaneous melanomas after wide local excision, Mohs micrographic surgery, or staged excision.

BACKGROUND: Prospective trials have not compared the local recurrence rates of different excision techniques for cutaneous melanomas on the head and neck. OBJECTIVE: To determine local recurrence rates of cutaneous head and neck melanoma after wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision. METHODS: A systematic review of PubMed, EMBASE, and Web of Science identified all English case series, cohort studies, and randomized controlled trials that reported local recurrence rates after surgery for cutaneous head and neck melanoma. A meta-analysis utilizing a random effects model calculated weighted local recurrence rates and confidence intervals (CI) for each surgical technique and for subgroups of MMS and staged excision. RESULTS: Among 100 manuscripts with 13,998 head and neck cutaneous melanomas, 51.0% (7138) of melanomas were treated by WLE, 34.5% (4826) by MMS, and 14.5% (2034) by staged excision. Local recurrence rates were lowest for MMS (0.61%; 95% CI, 0.1%-1.4%), followed by staged excision (1.8%; 95% CI, 1.0%-2.9%) and WLE (7.8%; 95% CI, 6.4%-9.3%). LIMITATIONS: Definitions of local recurrence varied. Surgical techniques included varying proportions of invasive melanomas. Studies had heterogeneity. CONCLUSION: Systematic review and meta-analysis show lower local recurrence rates for cutaneous head and neck melanoma after treatment with MMS or staged excision compared to WLE.

Pushing the limits: perinatal outcomes beyond prolonged second stage.

Objective: To evaluate whether extremely prolonged second stage of labor in nulliparous women affects mode of delivery and perinatal outcomes.Methods: We performed a retrospective cohort study of nulliparous women with singleton gestations and cephalic presentation who reached 10 cm of cervical dilation at gestational age 36 0/7-41 6/7. Women were stratified by epidural status. Deliveries were compared by length of second stage: 0-179 min (normal second stage, NSS), 180-299 min (prolonged second stage, PSS), and ≥300 min (extremely prolonged second stage, EPSS). Primary outcome was incidence of vaginal delivery. Secondary outcomes were maternal and neonatal morbidities.Results: Six hundred sixty-one women were evaluated; overall, 92.7% (613/661) of the patients delivered vaginally, with 84.6% (559/661) of women undergoing spontaneous vaginal delivery. In women with epidural anesthesia, 90.6% (446/492) delivered vaginally (97.2% of NSS, 95.1% of PSS, and 69.2% of EPSS). In women without epidural anesthesia, 98.8% (167/169) delivered vaginally (99.3% of NSS, 100.0% of PSS, and 87.5% of EPSS). Women with epidural anesthesia and EPSS had a higher rate of postpartum hemorrhage (aOR: 8.52; 95% CI: 3.99-18.19) and third-degree laceration when compared to NSS (aOR: 5.87; 95% CI: 1.71-20.17). EPSS neonates had a higher rate of CPAP use (OR: 3.99; 95% CI: 1.82-8.74) and significantly higher birth weight (p < .0001) and composite neonatal outcomes (OR: 4.98; 95% CI: 2.34-10.59) compared to NSS.Conclusion: In nulliparous women at term with singleton gestations who reached second stage, the chance of vaginal delivery was 92.7%; even after 5 h of second stage, most women delivered via vaginal delivery (70.4%, 81/115). In those with epidural anesthesia, the PSS group had similar perinatal outcomes as the NSS group, whereas the EPSS group had significantly worse perinatal outcomes. Second stage ≥5 h is a potential tipping point for hazardous perinatal outcomes.

Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members.

BACKGROUND: Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons. OBJECTIVE: To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics. MATERIALS AND METHODS: This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members. RESULTS: The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention. CONCLUSION: Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.

Mohs micrographic surgery for male genital tumors: Local recurrence rates and patient-reported outcomes.

BACKGROUND: Local recurrence rates (LRRs) after Mohs micrographic surgery (MMS) for male genital cancers have been reported in only a few small case series, and patient-reported outcomes (PROs) have not been studied. OBJECTIVE: To determine the LRR and PROs after MMS for male genital skin cancers. METHODS: Retrospective review of all male genital skin cancers removed with MMS between 2008 and 2019 at an academic center. LRR was determined by chart review and phone calls. PROs were assessed by survey. RESULTS: A total of 119 skin cancers in 108 patients were removed with MMS. Tumors were located on the penis (90/119) and scrotum (29/119). Diagnoses included squamous cell carcinoma in situ (n = 71), invasive squamous cell carcinoma (n = 32), extramammary Paget disease (n = 13), melanoma (n = 2), and basal cell carcinoma (n = 1). The LRR was 0.84% (1/119), with a mean follow-up time of 3.25 years (median, 2.36 years). The majority of survey respondents reported no changes in urinary (66%) or sexual functioning (57.5%) after surgery. LIMITATIONS: Retrospective single-center experience; short follow-up time; low survey response rate; no baseline functional data. CONCLUSION: MMS for male genital skin cancer has a low LRR and high patient-reported satisfaction with urinary and sexual function.

Association of Age, Sex, Race, and Geographic Region With Variation of the Ratio of Basal Cell to Cutaneous Squamous Cell Carcinomas in the United States.

Importance: Defining which populations are affected by basal cell carcinoma (BCC) vs cutaneous squamous cell carcinoma (cSCC) may inform targeted public health strategies. Incidence of BCC and cSCC is not reported to national cancer registries, but claims data for the treatment of BCC and cSCC provide insights into the epidemiology of keratinocyte carcinoma. Objective: To define differences in the ratio of BCC to cSCC in adults (age, ≥18 years) in a large database of patients with commercial insurance and Medicare Advantage coverage. Design, Setting, and Participants: This cross-sectional analysis used deidentified data derived from the Optum Clinformatics Data Mart to perform a retrospective evaluation of a large commercially insured cohort based on treatment claims from January 1, 2012, to December 31, 2016. Patients with a diagnosed and treated BCC or cSCC as determined by codes from the International Classification of Diseases, Ninth Revision, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, and Current Procedural Terminology were included. Data were analyzed from November 30, 2019, to March 20, 2020. Exposure: Diagnosis and treatment of BCC or cSCC. Main Outcomes and Measures: The ratio of BCC to cSCC based on age, sex, race, and geographic location. Multivariable logistic regression was used to assess how demographics were associated with the odds of a treated keratinocyte carcinoma being a BCC. Results: Among the 985 317 claims for patients included in the analysis (61.59% for men; mean [SD] age, 69.82 [12.58] years), BCCs were 1.69 (95% CI, 1.6899-1.6901) times more likely than cSCCs to be treated in the United States from 2012 to 2016. Basal cell carcinomas were significantly more prevalent than cSCCs in younger patients (18-39 years, 9.63 [95% CI, 9.6088-9.6574] BCCs per cSCC; 40-64 years, 2.92 [95% CI, 2.9171-2.9187] BCCs per cSCC; and ≥65 years, 1.33 [95% CI, 1.3289-1.3291] BCCs per cSCC; P < .001). Basal cell carcinomas were significantly more prevalent than cSCCs in women vs men, except in adults 65 years or older (odds ratios [ORs], 0.98 [95% CI, 0.97-0.99] vs 1.67 [95% CI, 1.47-1.88] for those aged 18-39 and 1.15 [95% CI, 1.12-1.19] for those aged 40-64 years; P < .001). The difference in BCC:cSCC ratios between men and women diminished with increasing age (OR, 1.67 for 18-39 years, 1.15 for 40-64 years, and 0.98 for 65 years or older). Basal cell carcinoma was more prevalent than cSCC in all races, including Black patients (BCC:SCC ratios, 1.60 for Asian patients, 1.45 for Black patients, 2.00 for Hispanic patients, and 1.69 for White patients of all ages). The BCC:cSCC ratio varied based on geography, with the highest ratio in the West North Central census division (2.12) and the lowest ratio in the South Atlantic census division (1.35). Conclusions and Relevance: In the absence of a national registry, claims data can improve our understanding of the epidemiology of keratinocyte carcinomas. In this cross-sectional study, basal cell carcinomas were more common than cSCCs for all demographics, including in Black patients. In populations younger than 40 years, BCCs were 12.6 times more likely for women and 7.2 times more likely for men. These demographic groups may benefit from public health education focused on the presentation and management of BCCs.