A Pearl for Pretibial and Forearm Repair Following Mohs Micrographic Surgery.

Wound repair of the pretibial and forearm regions presents a challenge during dermatologic surgery as these areas are under significant tension and exhibit increased skin fragility. Various methodologies have been proposed for the closure and repair of such wounds, however, the use of the bilayered suture technique may be simpler and more effective than other techniques such as the pinch stitch, pully stitch, slip-knot stitch, pulley set-back dermal suture, horizontal mattress suture, pully stitch, and tandem pulley stitch. Our objective was to describe a novel method for the repair of pretibial and forearm wounds following Mohs micrographic surgery utilizing bilayered closure followed by tissue adhesive application.  J Drugs Dermatol. 2024;23(5):380.     doi:10.36849/JDD.7139  .

Dual Energy X-ray Absorptiometry Scanning for Osteoporosis Detection: Analysis of Patients at a Tertiary Care Hospital.

INTRODUCTION: Dual-energy X-ray absorptiometry (DEXA) scanning is a rapid and accurate noninvasive procedure utilized to measure bone mineral density (BMD) and diagnose osteoporosis. The primary objective of this study was to assess the prevalence of osteoporosis in different regions of the body using DEXA scanning in patients attending a tertiary care private hospital. Additionally, we aimed to raise awareness about approved diagnostic methods for osteoporosis. METHODOLOGY: For this retrospective study, a sample size of 384 participants was determined. The selection of participants was based on convenience sampling, considering their availability and accessibility. Data were collected from adult patients aged 18 years and above who underwent DEXA scanning. The information was compiled using Microsoft Excel, obtained from the patient's treating physicians, and evaluated by two medical graduates. Statistical analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). RESULTS: The findings unveiled an overarching osteoporosis prevalence of 38.5%, accompanied by distinctive figures of 38.7%, 8.9%, and 38.4% in the lumbar, hip, and forearm regions, respectively. Furthermore, the occurrence of osteopenia was found in 33% of participants in the lumbar region, 35.1% in the hip region, and 39.7% in the forearm region. Additionally, no significant association was found between gender and overall osteoporosis prevalence, suggesting that the susceptibility to osteoporosis did not significantly differ between genders. Moreover, the study emphasized the variations in bone density across different skeletal regions, with the forearm region displaying the lowest mean T-score and Z-score. CONCLUSIONS: The results of this study on osteoporosis prevalence in the lumbar, hip, and forearm regions indicate varying rates among these skeletal sites. Notably, both male and female patients demonstrated an equal susceptibility to developing osteoporosis. Interestingly, the forearm region emerged as the most common site for osteoporosis in males (34.6%), while the lumbar region was the most common in females (41.6%).

Impact of the COVID-19 Pandemic on Surgical Education and Training: A Resident Survey in a Developing Country.

Background The COVID-19 pandemic has adversely affected medical education and training programs worldwide. Early investigations have shown that surgical residents face a lot of challenges in these unprecedented times. This study aims to assess the impact of the COVID-19 pandemic on surgical education and training in a developing country. Methods This cross-sectional study was conducted in Allied Hospitals of Rawalpindi Medical University, Rawalpindi, Pakistan from June 2021 to July 2021. A structured questionnaire designed by the researchers was distributed to all surgery departments, and surgical residents who consented to participate in this study were included. Results A total of 152 residents participated in this study, of which 53 (34.9%) were in general surgery and 99 (65.1%) in various surgical allied specialties. Of the residents, 14.5% reported full transfer from the parent unit to the COVID-19 unit. An increase in emergency surgical procedures was reported by 52.8% of general surgery residents as compared to surgical allied specialties (P = 0.037). Of the residents, 90.1% reported increased stress and anxiety levels, with the number of allied residents significantly higher than general surgery residents (P = 0.031). A total of 125 (82.2%) respondents claimed that fear of contracting the virus affected proper patient evaluation. Conclusion The COVID-19 pandemic has severely impacted the training and psychological well-being of surgical residents.

OnabotulinumtoxinA versus PrabotulinumtoxinA-xvfs: A Randomized, Triple-blind, Split-face Study on the Time to Onset, Rhytid Appearance, and Patient Satisfaction in Forehead and Glabellar Lines.

Background: Both onabotulinumtoxinA and prabotulinumtoxinA-xvfs are FDA-approved formulations of botulinum toxin A for the treatment of glabella and forehead rhytids. Objective: We sought to compare the onset to action and patient satisfaction of onabotulinumtoxinA and prabotulinumtoxinA-xvfs in treating dynamic rhytids of the forehead and glabella. Methods: Fifteen patients, aged 28 to 74, were enrolled and completed the study. Patients were randomly assigned to receive equal amounts of onabotulinumtoxinA and prabotulinumtoxinA-xvfs injected to opposite sides of the face in the glabella and forehead at Day 0 by a blinded injector. Glabellar and frontalis muscle onset to action and rhytid appearance were blindly evaluated using photographs at Days 0, 2, 4, 6, 8, 10 post-injection. Patients rated their satisfaction of left and right sides using a standardized scale. Results: There was no statistically significant difference in onset to action, rhytid appearance, and patient satisfaction after injection with onabotulinumtoxinA versus prabotulinumtoxinA-xvfs in the corrugator and frontalis muscles. Although not statistically significant, a trend existed towards increased patient satisfaction with onabotulinumtoxinA. Conclusion: Both onabotulinumtoxinA and prabotulinumtoxinA-xvfs are equally efficacious formulations of botulinum toxin type A for the treatment of glabellar and forehead rhytids.

Characterization of radiofrequency ablated myocardium with optical coherence tomography.

Certain types of cardiac arrhythmias are best treated with radiofrequency (RF) ablation, in which an electrode is inserted into the targeted area of the myocardium and then RF electrical current is applied to heat and destroy surrounding tissue. The resulting ablation lesion usually consists of a coagulative necrotic core surrounded by a rim region of mixed viable and non-viable cells. The characterization of the RF ablated lesion is of potential clinical importance. Here we aim to elaborate optical coherence tomography (OCT) imaging for the characterization of RF-ablated myocardial tissue. In particular, the underlying principles of OCT and its polarization-sensitive counterpart (PS-OCT) are presented, followed by the knowledge needed to interpret their optical images. Studies focused on real-time monitoring of RF lesion formation in the myocardium using OCT systems are summarized. The design and development of various hybrid probes incorporating both OCT guidance and RF ablation catheters are also discussed. Finally, the challenges related to the transmission of OCT imaging systems to cardiac clinics for real-time monitoring of RF lesions are outlined.

Investigating The Role of Inflammatory Markers at Admission in Defining the Severity of Moderate-to-Critical COVID-19: A Cross-Sectional Analysis.

Background and aims: The spectrum of Coronavirus disease-2019 (COVID-19) has been clinically defined from asymptomatic carriers to critical illness. Different inflammatory markers have been used to account for the severity and outcomes of this disease in different settings. Our study aims to investigate the role of these inflammatory markers in defining COVID-19 severity. Methods: This cross-sectional study included 200 confirmed cases of COVID-19. Inflammatory markers including lymphocyte count, D-Dimers, Ferritin, CRP, LDH were noted at admission. The moderate-to-critical disease was defined according to the WHO criteria. Descriptive statistics were applied. Mann-Whitney U-test was applied to compare the difference of markers between moderate-severe and critical patients. ROC was plotted to determine the cut-off values of these markers. Binary logistics regression analysis was used to assess which markers significantly predict the severity of COVID-19. Results: A D-dimer value of >775 ng/ml and LDH >495 U/L had a sensitivity of 72.9% and 79.2% and specificity of 57.9% and 53.6% respectively for critical COVID-19 illness. CRP levels of >100.5 mg/dl has a sensitivity of 66.7%. All inflammatory markers were significantly higher in a critical group of patients (p < 0.05) except for lymphopenia. Binary logistics regression analysis shows that LDH levels and D-dimers were only significant predictors of severity in COVID-19 patients. Conclusion: Inflammatory markers at admission are very useful in defining the severity of COVID-19 in addition to the clinical criteria. This is also useful in predicting adverse outcomes.

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.

Tracheostomy dislodgement: Are obese patients at increased risk?

BACKGROUND: Obesity is a risk factor for tracheostomy-related complications. We aimed to investigate whether obesity was associated with a risk of unplanned tracheostomy dislodgement or decannulation (DD). METHODS: Retrospective review of patients undergoing tracheostomy at a single institution from 2013 to 2019 was performed. The primary outcome was unplanned DD within 42 days. Obesity was assessed by body mass index (BMI) and skin-to-trachea distance (STT) measured on computed tomographic images. RESULTS: 25 (12%) episodes of unplanned DD occurred in 213 patients within 42 days. BMI ≥35 kg/m2 was associated with STT ≥80 mm (p < 0.0001). On multivariate analysis, STT ≥80 mm but not BMI was an independent predictor of unplanned DD (hazard ratio = 8.34 [95% confidence interval 2.85-24.4]). CONCLUSIONS: STT ≥80 mm was a better predictor of unplanned DD than BMI. Assessment of STT in addition to BMI may be useful to identify patients that would benefit from extended length tracheostomy tubes.

Correlation of biochemical profile at admission with severity and outcome of COVID-19.

BACKGROUND: COVID-19 was detected in China in December 2019. The rapid dissemination and novelty of the disease resulted in an epidemic. This study aimed to identify biochemical parameters at admission that can be used to categorize severity and outcome of COVID -19 infection. MATERIALS AND METHODS: This cross-sectional study was conducted at Allied Hospitals of RMU from April 2020 to July 2020. It included 128 randomly selected confirmed COVID-19 patients. At admission, biochemical profile (total bilirubin, alanine aminotransferases {ALT}, aspartate aminotransferases {AST}, urea, creatinine, uric acid, sodium, potassium, and chloride were correlated with severity and outcome of COVID-19 by employing t-tests and ANOVA where required. Cut-off values to predict disease severity and outcome were calculated using ROC curve. RESULTS: The study comprised 46.1% non-severe, 29.7% severe, and 24.2% critical COVID-19 patients. 84.4% patients improved and 15.6% expired. Urea was increased in critical disease patients (p < 0.000). Higher ALT (p 0.030) and AST (p 0.004) levels were noted in severe and critical disease. Sodium (p 0.001) and chloride (p 0.026) were decreased in critical disease. Patients who expired had increased urea (p 0.000), ALT (p 0.040) and AST (p 0.002). At admission, urea >42.7 mg (sensitivity of 64.7%, specificity of 87.5%), AST >43.5 IU/L (64% sensitivity, 60% specificity), and sodium <136.9 mmol/L (sensitivity of 70.6%, specificity of 71.2%) predicted critical COVID-19 infection. CONCLUSION: At admission, increased urea, AST, and ALT along with decreased sodium can help in identifying COVID-19 patients with severe illness and poor outcome.

Comparison of chest HRCT severity score in PCR positive and PCR negative clinically suspected COVID-19 Patients.

Background: The limitations and false-negative results of Real-time Polymerase chain reaction (RT PCR) in diagnosing COVID-19 infection demand the need for imaging modalities such as chest HRCT to improve the diagnostic accuracy and assess the severity of the infection. Objectives: The study aimed to compare the chest HRCT severity scores in RT-PCR positive and negative cases of COVID-19. Methods: This cross-sectional study included 50 clinically suspected COVID-19 patients. Chest HRCT and PCR testing of all 50 patients were done and the chest HRCT severity scores for each lung and bronchopulmonary segments were compared in patients with positive and negative PCR results. Chi-square and Mann Whitney U test were used to assess differences among study variables. Results: Chest HRCT severity score was more in PCR negative patients than in those with PCR positive results. However, the difference was not significant (p=0.11). There was a significant association in severity scores of the anterior basal segment of the left lung (p=0.022) and posterior segment upper lobe of right lung (p=0.035) with PCR results. This association was insignificant for other bronchopulmonary segments (p>0.05). Conclusion: CR negativity does not rule out infection in clinically suspected COVID-19 patients. The use of chest HRCT helps to determine the extent of lung damage in clinically suspected patients irrespective of PCR results. Guidelines that consider clinical symptoms, chest HRCT severity score and PCR results for a confirmed diagnosis of COVID-19 in suspected patients are needed.

Comparison of Open Appendectomy and Laparoscopic Appendectomy in Perforated Appendicitis.

Introduction Laparoscopic appendectomy for nonperforated appendicitis is associated with improved outcomes. This study compares laparoscopic appendectomy and open appendectomy in cases of a perforated appendix by assessing surgical site infection, mean operating time, and length of hospital stay. Materials and methods This study was a prospective randomized study conducted at the Department of Surgery, Holy Family Hospital, Rawalpindi, Pakistan, from January 2016 to January 2017, by randomly allotting the laparoscopic or the open appendectomy technique to 130 patients by the lottery method. Patients having a perforated appendix were included after they provided informed consent. Data were entered and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, US). Results The frequency of wound site infection was significantly higher in open appendectomy (27.69%) than in the laparoscopic approach (10.77%; p=0.01). Mean hospital stay was slightly longer in the laparoscopic approach (4.38 ± 1.09 days) than in open appendectomy (4.18 ± 0.77 days; p=0.23). Mean operating time for laparoscopic appendectomy and open appendectomy was 46.98 ± 2.99 minutes and 53.02 ± 2.88 minutes, respectively (p<0.000). Conclusion Laparoscopic appendectomy was associated with fewer surgical site infections and shorter mean operating time than an open appendectomy.

A Spectrum of Hematological Disorders in Children with Pancytopenia Based on Bone Marrow Examination in a Tertiary Care Hospital.

Introduction Pancytopenia is a common presentation in the pediatric population. It is a manifestation of various diseases, and its etiology can be explained on the basis of bone marrow examination. The study aims to determine the etiological factors leading to pancytopenia via bone marrow examination in pediatric patients presenting in our hospital. Materials and methods This retrospective cross-sectional study was conducted in the Department of Pathology at a public sector tertiary care hospital. Data were recorded by convenience sampling from the patients' database from January 2015 to April 2018. Patients aged 2 months to 15 years who had pancytopenia on peripheral blood smear and were admitted for bone marrow examination were included in the study. Patients who were beyond these age limits, diagnosed cases of aplastic anemia and leukemia, and those with a recent history of blood transfusion were excluded from the study. The analysis was done via the Statistical Package for Social Sciences (SPSS) v.23.0 (IBM SPSS Statistics, Armonk, NY, USA), and descriptive statistics were applied. Results Of 115 cases, 58 (50.4%) were males and 57 (49.6%) were females. Megaloblastic anemia was present in 32 (27.8%) patients, and it was the most common cause of pancytopenia. Non-malignant disorders were seen in 95 cases (82.6%) and malignant disorders were seen in 20 (17.4%) cases. Conclusion Megaloblastic anemia is the most common cause, and acute lymphoblastic leukemia is the most common malignant cause of pancytopenia in children. There was no significant gender predilection among causes of pancytopenia.

Epidemiology, Bacteriological Profile, and Antibiotic Sensitivity Pattern of Burn Wounds in the Burn Unit of a Tertiary Care Hospital.

INTRODUCTION:  Burn wounds are commonly infected by organisms which delay wound healing. Therefore, it is necessary to evaluate the flora obtained from wounds of burn patients in order to determine the most effective treatment. The aim of this study was to determine the frequencies of various bacteria isolated from burn wounds and to determine their antimicrobial susceptibility.  Materials and methods: This descriptive cross-sectional study was conducted from January 2018 to November 2018 which included consecutive samples of burn wounds from patients admitted to the burn ward of a tertiary care hospital. Bacteria and their antimicrobial susceptibility were determined by swab cultures and sensitivity tests by standard aseptic techniques. Data were analysed via the Statistical Package for Social Sciences (SPSS), v23.0 (IBM SPSS Statistics, Armonk, NY). Chi-square tests were applied between qualitative variables, while the Kruskal-Wallis test was applied to compare the means of asymmetrical data. Bacterial isolates and their susceptibility pattern were represented as frequencies and pie charts. RESULTS:  A total of 178 samples were obtained from 109 patients from burn wounds. One hundred and twenty-two wounds (68.5%) showed growth and 56 (31.4%) showed no growth after 24 hours of incubation. Positive cultures were significantly more frequent in wounds of greater than one-week duration (p < 0.002). Out of 158 bacterial isolates, the most common isolate was Pseudomonas aeruginosa - 41 specimens (24.91%), followed by Staphylococcus aureus - 38 specimens (24.05%), Acinetobacter - 27 (17.09%), Klebsiella - 24 (15.19%), Escherichia coli - 13 (8.23%), Proteus - 7 (4.43%), other coliforms - 6 (3.8%), Enterococcus - 1 (0.63%), and Enterobacter - 1 (0.63%). Drug resistance to penicillin G, ampicillin, Augmentin, ceftazidime, cefotaxime, ceftriaxone, meropenem, and piperacillin+tazobactam was exceptionally high. CONCLUSION:  The most common bacterial isolates are Pseudomonas aeruginosa and Staphylococcus aureus. Piperacillin+tazobactam against Pseudomonas aeruginosa and vancomycin and linezolid against Staphylococcus aureus are highly effective and can be used as empirical therapies.

Bacteriological Profile and Antibiogram of Cultures Isolated from Tracheal Secretions.

Background Respiratory infections are associated with high morbidity and mortality, especially in critically ill patients. The excessive use of broad-spectrum antibiotics has led to the development of drug resistance, thus resulting in the emergence of pathogens which are difficult to treat. The aim of this study was to identify common pathogens in tracheal secretions and to study the patterns of their sensitivity and resistance to various antibiotics. Materials and methods This descriptive cross-sectional study was conducted in the Department of Pathology and Microbiology, Holy Family Hospital, Rawalpindi, Pakistan, from August 2017 to December 2017, using the convenient sampling technique. Tracheal secretions from patients in the intensive care unit (ICU), tested in the Pathology and Microbiology Department of Holy Family Hospital, were included in the study. The culture was done on blood and MacConkey agar and the sensitivity pattern was performed on Muller Hinton agar. Data were analyzed using SPSS v.23.0. Results Out of the bacteria isolated from positive growth cultures, Acinetobacter (45; 53.6%) was the most common isolate followed by Klebsiella (11; 13.1%). Acinetobacter was most sensitive to tigecycline (94.7%), and gram-negative bacteria such as Acinetobacter, Klebsiella, and Pseudomonas showed resistance to higher generation cephalosporins. Conclusion Acinetobacter was the most common gram-negative bacilli isolated. Tigecycline was found to be effective against Acinetobacter.

Factors associated with renal dysfunction in hepatitis C-related cirrhosis and its correlation with Child-Pugh score.

OBJECTIVES: To assess factors associated with renal dysfunction (RD) in hepatitis C virus (HCV) cirrhosis, correlate renal parameters with Child-Pugh score (CPS) and find a cut-off value of CPS to determine RD. MATERIALS AND METHODS: It was a cross-sectional study that included 70 cases of liver cirrhosis secondary to HCV from a period of 6 months at Combined Military Hospital, Multan. Diagnosis of HCV was confirmed by serological assay and liver cirrhosis by ultrasonography. CPS was determined and lab reports were taken. Patients were divided into two groups as not having RD (serum creatinine≤1.5 mg/dL) and having RD (serum creatinine≥1.5 mg/dL). Estimated glomerular filtration rate (eGFR) was calculated by chronic kidney disease epidemiology collaboration (CKD-EPI) formula. Data were analyzed using SPSS V.23.0. χ2, Kruskal-Wallis test and Pearson coefficient of correlation were applied. ROC curve was drawn to evaluate cut-off value of CPS for the presence of RD. Level of significance was set at p<0.05. RESULTS: Patients with CP grade B or C develop RD as compared to patients with CP grade A (p=0.000). Mean age, urea, creatinine and eGFR varies significantly among patients who develop RD and patients who do not (p=0.02, p=0.000, p=0.000 and p=0.000, respectively). eGFR negatively correlates with CPS (r=-0.359, p=0.002). Creatinine, urea and ALBI score positively correlates with CPS (r=+0.417, p=0.000; r=+0.757, p=0.000; r=+0.362, p=0.002, respectively). CONCLUSION: Ascites and encephalopathy are associated with RD in HCV cirrhosis.

Role of Preoperative Administration of Vitamin D and Calcium in Postoperative Transient Hypocalcemia after Total Thyroidectomy.

Introduction Thyroid surgery is one of the most frequently performed surgical procedures worldwide. Total thyroidectomy is a recommended procedure for most of the thyroid diseases. The most common complication resulting after this surgery is transient hypocalcemia - the incidence is 24% - which increases the morbidity rate and increases the length of stay in the hospital. The objective of our study was to compare the frequency of transient hypocalcemia after vitamin D and calcium supplementation with the control group for patients undergoing total thyroidectomy. Patients and methods It was a randomized controlled trial conducted at Department of Surgery, Pakistan Atomic Energy Commission General Hospital, Islamabad, Pakistan from January 2017 to July 2017. A total of 92 patients of both genders undergoing total thyroidectomy were included in the study. Patients undergoing reoperation for thyroid disease, American Society of Anesthesiologists (ASA) grade 3 or above, patients with chronic renal failure, preoperative hypocalcemia or hypercalcemia were excluded. The patients were sorted into two groups by lottery method; Group 1 in which Vitamin D (2,00,000 IU) and calcium (1 gm) was given 24 hours preoperatively. Group 2 was the control group. Total thyroidectomy was done and serum calcium levels were evaluated immediately after surgery on day two, seven and on the 30th day. The final outcome was measured at one month. Data was analyzed via the Statistical Package for Social Sciences version 22.0 (IBM Corp, Armonk, NY, USA). P value ≤ 0.05 was considered significant. Results The age ranged from 18 to 65 years with the mean age of 38.673 ± 8.63 years in group 1 while 41.217 ± 9.52 years in group 2, mean preoperative calcium level was 9.482 ± 0.49 mg/dl in group 1 and 9.678 ± 0.54 mg/dl in group 2. Hypocalcemia was seen in 3 (6.5%) in group 1 as compared to 12 (26.1%) patients in group 2 (p = 0.011). Conclusion Preoperative oral calcium and vitamin D supplements may prevent postoperative hypocalcemia, allowing a safe and early discharge. This will ultimately lead to improved patient satisfaction and significant cost savings.

"Deep" vertical Mohs and closure with a tumor-free flap for dermatofibrosarcoma protuberans: A case report.

Dermatofibrosarcoma protuberans is an uncommon low-grade malignant tumor that can invade locally and rarely metastasize. Dermatofibrosarcoma protuberans has a high rate of local recurrence due to incomplete excision, especially in deep tissues. Morbidity is often related to multiple local recurrences and removal of excessive tissue with large, complex repairs. We present a case of incompletely excised dermatofibrosarcoma protuberans after initial wide local excision. We subsequently employed a "deep" vertical Mohs micrographic surgical technique to remove the remaining tumor while creating a flap with the tumor-free superficial portion to preserve tissue and avoid a complicated repair. The patient is tumor-free for 7 years.