The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas.

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s. Mohs micrographic surgery (MMS) with frozen section melanocytic immunostains (MMS-I) and slow Mohs with paraffin sections decrease complications of surgery of specialty site melanomas by detecting upstaging and confirming complete tumor removal with comprehensive microscopic margin assessment before reconstruction. This article reviews information important for counseling melanoma patients about surgical treatment options and for developing consensus guidelines with clear indications for MMS-I or slow Mohs.

Evolution of Excisional Surgery Practices for Melanoma in the United States.

IMPORTANCE: National Comprehensive Cancer Network guidelines for melanoma have consistently recommended wide local excision as the standard of care since their inception. Although surgery with more comprehensive margin assessment (eg, Mohs surgery) has been advocated for certain subsets of melanoma, how often these techniques are used in clinical practice is uncertain. OBJECTIVE: To examine trends in the use of comprehensive margin assessment surgery for melanoma by tracking claims data for Mohs surgery. DESIGN, SETTING, AND PARTICIPANTS: This national cross-sectional analysis examined claims data from the Optum Clinformatics Data Mart, a nationally representative database. The study cohort consisted of 79 108 patients undergoing surgical excision for melanoma from January 1, 2001, through December 31, 2016. Data were analyzed from January 1, 2001, through December 31, 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was the likelihood of a melanoma being treated with Mohs surgery over time, evaluated by multivariable logistic regression and expressed as the odds of treatment per additional calendar year. RESULTS: Among 79 108 patients with melanoma (median age, 63 years [interquartile range {IQR}, 51-73]; 47 407 men [59.9%]), 75 047 were treated with conventional excision (median age, 62 years [IQR, 50-73 years]; 44 786 men [59.7%]) and 4061 with Mohs surgery (median age, 67 years [IQR, 56-76 years]; 2621 men [64.5%]). Mohs surgery was used in 5.1% of all surgical cases, with the rate of Mohs surgery increasing 304% from 2.6% in 2001 to 7.9% in 2016. Odds of receiving Mohs surgery for melanoma increased significantly in more recent calendar years (odds ratio [OR], 1.02 per calendar year; 95% CI, 1.01-1.03; P < .001). Immunohistochemistry (IHC) use was only coded with Mohs surgery in 1087 cases (26.8%), and the odds of receiving Mohs surgery with IHC increased in more recent calendar years (OR, 1.13 per calendar year; 95% CI, 1.10-1.15; P < .001). Use of Mohs surgery and Mohs surgery with IHC for melanoma differed widely across geographic census divisions with greater than 3-fold variation between the regions with highest and lowest use in every period (eg, for 2013 through 2016, the East South Central region used Mohs surgery in 8.8% of melanoma excisions compared with 2.6 in the New England region). CONCLUSIONS AND RELEVANCE: Despite stable guidelines for melanoma surgery, the results of this study suggest that surgical practices for melanoma are evolving. Wide variations in surgical practice patterns for melanoma are present in the United States. This study's findings suggest that the effect of variations in surgical techniques on outcomes requires scrutiny and further study.

Crescentic Modification to Island Pedicle Rotation Flaps for Defects of the Distal Nose.

BACKGROUND: Island pedicle flaps based on a lateral sling of the nasalis have difficulty reaching distal nasal defects due to tethering of the muscle to its insertion point. The authors hypothesized that reach could be improved by modifying a crescentic flap to rotate around a pivot point equidistant to the flap and the defect. OBJECTIVE: To describe the design, execution, and results with a modified crescentic island pedicle rotation flap for repair of distal nasal defects after Mohs micrographic surgery. METHODS: The authors performed a retrospective analysis of patients who had distal nasal defects repaired with a modified crescentic island pedicle rotation flap over an 8-year period. All charts and photographs were examined. Sex and age of the patient, type of cutaneous carcinoma, location and size of the defect, and complications were recorded. RESULTS: Forty-eight patients were included. The flap was used to successfully reconstruct defects on the distal nose ranging in size from 0.25 cm to 3.8 cm. Complications involved one wound infection and one episode of postoperative bleeding. CONCLUSION: The authors' modifications to the island pedicle flap may be reliably used to reconstruct small- to medium-sized defects of the distal nose in a single stage with minimal risk of complications.