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.

Melanoma developing in a nevoid melanocytoma with myxoid changes: a case report.

Nevoid and myxoid melanoma are rare variants of melanoma; association of the two is a unique finding. Nevoid melanoma is characterized by morphologic resemblance to a nevus, whereas myxoid melanoma demonstrates a basophilic mucinous matrix. We present an atypical case of a melanoma progressing from a nevoid melanocytoma with myxoid changes. A 78-year-old female presented with a pigmented growth on her right thigh. Biopsy demonstrated a biphenotypic melanocytic proliferation composed of a nodule showing epithelioid melanocytes with enlarged nuclei, prominent nucleoli, lack of maturation, and abundant amphophilic cytoplasm with a rare mitotic figure. These findings were suggestive of melanoma along with a nevoid dermal component and myxoid stroma. FISH testing revealed a homozygous loss of 9p21 in the atypical component. SNP-microarray from the nevoid component demonstrated three abnormalities including a gain of whole chromosome 8, as well as loss of a copy of nearly an entire chromosome 9 and 16q most consistent with a melanocytoma.

Guidelines for the use of local anesthesia in office-based dermatologic surgery.

There are an increasing number and variety of dermatologic surgical procedures performed safely in the office setting. This evidence-based guideline addresses important clinical questions that arise regarding the use and safety of local anesthesia for dermatologic office-based procedures. In addition to recommendations for dermatologists, this guideline also takes into account patient preferences while optimizing their safety and quality of care. The clinical recommendations presented here are based on the best evidence available as well as expert opinion.

Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.

IMPORTANCE: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES: To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Evaluation of orbicularis oculi muscle stripping on the cosmetic outcome of upper lid blepharoplasty: a randomized, controlled study.

BACKGROUND: Many variations in the surgical treatment of upper eyelid blepharoplasty have been described, including orbicularis oculi muscle stripping. There is no evidence in the literature to support the efficacy of this technique in improving the aesthetic results of the procedure. OBJECTIVES: To conduct a single-blind, randomized, controlled, split-face pilot study to evaluate the effects of orbicularis oculi muscle stripping on upper lid blepharoplasty. METHODS: Ten subjects were randomized to receive upper lid blepharoplasty with orbicularis oculi muscle stripping on one side and skin-only blepharoplasty on the other. Patients and two blinded physicians evaluated the aesthetics of the eyelids at 1-, 3-, and 17-month follow-up visits. RESULTS: Blinded physician evaluation failed to show a difference in the overall cosmetic appearance of the eyelids between the control and treatment sides at any time point. Analysis of the composite of all patient scores showed a trend favoring the control side at 3 months (p = .28) and the treatment side at 17 months (p = .50), but neither difference was significant. CONCLUSION: Based on the data from this pilot study, orbicularis oculi muscle stripping appears to have no affect on the aesthetic outcome of upper lid blepharoplasty.

Safety precautions in Mohs micrographic surgery for patients with known blood-borne infections: a survey-based study.

PURPOSE: A survey-based study was conducted to gather expert experience on safety procedures used when performing Mohs micrographic surgery (MMS) on patients with known infectious hepatitis or human immunodeficiency virus (HIV). METHODS: Six hundred eighty-four fellowship-trained Mohs surgeons were surveyed to examine the types of safety protocols used when treating patients with known infectious hepatitis or HIV and the frequency of exposure injuries to laboratory and surgical personnel from these patients. RESULTS: One hundred eighty-eight (27.5%) surveys were collected; 64.7% of respondents reported at least one exposure injury to surgical or laboratory personnel in the past year, and 4.8% reported exposure from a patient with known hepatitis or HIV infection. Risk of reporting at least one injury from a patient with known infection within the past year was significantly less when also reporting disposal of the ink applicator after each use (relative risk [RR] = 0.109) and greater when employing laboratory personnel with no medical education or background (RR = 3.857). No exposures were reported from respondents using blunt skin hooks, safety scalpels, safety syringes, smoke evacuators, a separate ink supply, or 24-hour formalin fixation. CONCLUSION: Although firm associations cannot be made from this study, the data suggest that certain measures may help to reduce the rate of exposure injuries in MMS.

The molecular genetics underlying basal cell carcinoma pathogenesis and links to targeted therapeutics.

Mutations in the sonic hedgehog signaling pathway play a key role in the development of basal cell carcinomas. Specifically, mutations in the PTCH1 (also known as PTCH or PTC1) and SMO genes cause tumor formation through constitutive activation of the pathway. Misregulation of the pathway has also been implicated in the nevoid basal cell carcinoma syndrome and other tumors. Understanding the function of the sonic hedgehog pathway has led to novel strategies for treatment. In this review we highlight the role of the pathway in the pathogenesis of basal cell carcinoma and review potential targeted therapies.

Safety of tumescent and laser-assisted liposuction: review of the literature.

BACKGROUND: Tumescent liposuction (TL) allows the removal of large volumes of fat with minimal blood loss or postoperative morbidity, excellent cosmesis, and a remarkable safety profile. OBJECTIVE: To review the literature on the safety of tumescent liposuction, liposuction under general anesthesia and laser-assisted liposuction. RESULTS: Aggregate safety data on liposuction under tumescent anesthesia reveals over 100,000 body areas treated with liposuction. There were no serious complications of death, emboli, hypovolemic shock, perforation of thorax or peritoneum, thrombophlebitis, seizures, or toxic reactions to drugs. In contrast, in the plastic surgery literature, liposuction under general anesthesia was associated with complications of deep venous thrombosis or pulmonary embolus, abdominal or other organ perforation, infection, and bleeding. Most recently, survey data in the European literature analyzed data showed 72 cases of severe complications from liposuction, including 23 deaths in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism. CONCLUSION: Tumescent local anesthesia utilizing lidocaine with epinephrine allows the removal of large volumes of fat with minimal associated blood loss and postoperative morbidity.

Mohs micrographic surgery for the treatment of cutaneous lymphadenoma.

Cutaneous lymphadenoma (CL) is a benign neoplasm commonly presenting on the head and neck of young and middle-aged adults. Complete surgical excision of CL is the treatment of choice and appears to be curative. As compared to local excision without margin control, Mohs micrographic surgery (MMS) may allow for more definitive tumor extirpation for large cases of CL and allow for greater tissue preservation at functionally and aesthetically sensitive sites. We present a case of cutaneous lymphadenoma presenting on the right cheek of a middle-aged male who was successfully treated with MMS.

Subcuticular incision versus naturally sourced porcine collagen filler for acne scars: a randomized split-face comparison.

BACKGROUND: Subcuticular incision is performed to release fibrotic bands beneath acne scars and to stimulate neocollagenesis. Naturally sourced porcine collagen has been approved for filling moderate to deep facial wrinkles and nasolabial folds. To our knowledge, naturally sourced porcine collagen filler has not yet been tried as a treatment for correcting atrophic acne scars. OBJECTIVE: To objectively assess and directly compare the efficacy and safety of subcuticular incision versus naturally sourced porcine collagen dermal filler in correcting atrophic and rolling acne scars. MATERIALS AND METHODS: We performed a prospective, randomized, split-face, single-blind study to evaluate intermediate long-term efficacy of subcision and collagen dermal filler on 20 unilateral faces. Patients and blinded physicians evaluated results. RESULTS: Patients rated subcision as superior to collagen dermal filler at 3 months (p=.03). At 6 months, subcision had a slightly higher rating than collagen dermal filler (p=.12). Blinded evaluators leaned toward subcision at 3 months (p=.12) and at 6 months showed no preference (p=.69). CONCLUSION: Subcuticular incision and naturally sourced porcine collagen dermal filler appear to be efficacious for improving atrophic and rolling acne scars. Patients may prefer subcuticular incision over collagen dermal filler. Blinded evaluators found no significant difference between the treatments.

Optimizing closure materials for upper lid blepharoplasty: a randomized, controlled trial.

BACKGROUND: Although upper eyelid blepharoplasty is a common procedure, subtleties in surgical technique can affect cosmetic outcomes. Suture materials commonly used include polypropylene, monofilament nylon, fast-absorbing gut, and ethylcyanoacrylate (ECA) tissue adhesive. OBJECTIVE: To assess upper lid blepharoplasty scars in participants whose incision had been closed with 6-0 polypropylene sutures, 6-0 fast-absorbing gut sutures, or ECA. MATERIALS AND METHODS: A randomized, split-eyelid, single-blind, prospective study of the short- (1 month) and intermediate-term (3 months) efficacy of polypropylene, fast-absorbing gut, and ECA on 36 consecutive upper lid blepharoplasties. Participants and a blinded physician evaluator evaluated cosmetic outcome 1 and 3 months after the procedure. RESULTS: Three subgroups tested were ECA versus fast-absorbing gut, ECA versus polypropylene, and fast-absorbing gut versus polypropylene. At 1 month, ECA was superior to fast-absorbing gut (p=.03) and had a marginally better outcome than polypropylene (p=.25), and polypropylene had an equivalent outcome to fast-absorbing gut (p=.46). At 3-month follow-up, ECA remained superior to fast-absorbing gut (p=.03). CONCLUSION: Although sutured epidermal closure and tissue adhesive are highly efficacious for upper eyelid blepharoplasty, physicians and participants felt that cosmesis with ECA was superior to that with fast-absorbing gut.

Reduced number of actinic keratoses with topical application of DNA repair enzyme creams.

BACKGROUND: Actinic keratosis is regarded as a carcinoma in situ by some dermatologists and its incidence continues to rise. Exposure to ultraviolet (UV) radiation is considered to be an important risk factor for developing these pre-malignant lesions. DNA repair enzymes have been shown to reverse sun-damage, resulting in reduced rates of actinic keratoses and non-melanoma skin cancers in specific patient populations. METHODS: Seventeen patients were evaluated for differences in actinic keratoses following topical application of T4N5 liposome lotion over 48 weeks. RESULTS: Compared to baseline, a statistically significant reduction in the number of actinic keratoses was seen following the treatment period. DISCUSSION: This study suggests that DNA repair enzyme creams effectively reduce the number of actinic keratoses in normal individuals with moderate-to-severe photodamaged skin.