Reply to Letter: Effectiveness of Mohs and Close.

The following is a response to the Letter to the Editor by Konda, Francis, and Patel regarding the article "Mohs and Close" Technique (MCT) for selected cases to increase the efficiency of Mohs micrographic surgery.1,2 The letter raises questions about our utilization of MCT that require clarification.

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry.

BACKGROUND: In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty. OBJECTIVE: The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS). METHODS: A Delphi process was used to reach consensus on the complications to be recorded. RESULTS: Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection. LIMITATIONS: This article addresses only one aspect of registry development: identifying and defining surgical complications. CONCLUSION: The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

Effectiveness of the "Mohs and Close Technique" in Increasing the Efficiency of a Mohs Micrographic Surgery.

INTRODUCTION: Mohs micrographic surgery (MMS) is successful and cost effective, but may be time consuming as patients are required to wait for final wound repair until margins are clear. We propose for selected cases the "Mohs and Close technique" (MCT), in which the defect is immediately repaired after tumor resection rather than waiting until margins are clear. METHODS: MCT was only performed on tumors that had clearly de ned borders, low risk histology, whose resulting defect after exci- sion required either a primary or partial closure, and whose repair wouldn't change to a different repair option if further stages of exci- sion were necessary. Tumor data was recorded for all cases. Time elapsed from tumor resection to completion of wound closure was recorded with and without performing MCT for comparable wounds. RESULTS: MCT was performed for 456 of 898 cases. Time required without MCT was significantly longer than with MCT when only one stage was performed (P<0.001). There was no statistical difference (P=0.3358) between the two separate techniques for cases which required 2 or more stages. CONCLUSION: MCT significantly reduces the time needed for selected Mohs cases that require only one stage of excision and therefore can increase the efficiency of MMS. J Drugs Dermatol. 2016;15(12):1481-1483.

Laboratory errors leading to nonmelanoma skin cancer recurrence after Mohs micrographic surgery.

BACKGROUND: Compared with standard surgical excision, Mohs micrographic surgery (MMS) provides superior cure rates for nonmelanoma skin cancer (NMSC). Although cure rates of NMSC approach 99% with MMS, local recurrences occasionally occur. OBJECTIVE: The authors sought to identify histological features during frozen section examination that were associated with local recurrence of NMSC after MMS. MATERIALS AND METHODS: A retrospective chart review was performed of patients undergoing a second MMS procedure to treat locally recurrent NMSC over a 20-month period. Histological slides were reviewed to assess for possible causes of local recurrence. RESULTS: Of 3,169 NMSCs treated, 22 were locally recurrent. Possible causes of recurrence identified after MMS included dense inflammation in the final margin at sites affected by tumor in prior slides (27%), visible remaining tumor (23%), missing epidermal or dermal tissue (23%), and actinic keratosis (4%). One recurrence was possibly explained by incorrect mapping. No abnormality could be detected in 18% of cases. Possible limitations include the small sample size, retrospective design, and the possibility that some patients may have been lost to follow-up. CONCLUSION: Local recurrences after MMS are extremely rare. When recurrences do occur, they can be attributed to errors in histological interpretation or tumor mapping.

Comparison of the prevalence of surgical site infection with use of sterile versus nonsterile gloves for resection and reconstruction during Mohs surgery.

BACKGROUND: The prevalence of surgical site infection (SSI) is low with Mohs micrographic surgery (MMS). It has not been determined whether sterile gloves (SG) or nonsterile gloves (NSG) should be used for resection and reconstruction during MMS. OBJECTIVE: To compare the SSI rate with the use of SG and NSG for MMS, including reconstruction, and to determine whether SG help prevent SSI. MATERIALS & METHODS: Data were collected and recorded for Mohs cases in which SG or NSG were used. Infected cases and SSI rate for SG and NSG were also recorded. Chi-square analysis was performed to compare SSI. RESULTS: There were 1,004 tumors in 942 patients in the SG group and 1,021 tumors in 941 patients in the NSG group. The prevalence of infection was 0.50% in the SG group and 0.49% in the NSG group (p = .82). The cost of gloves was $5.66 for one SG case and $1.63 for one NSG case. CONCLUSION: The prevalence of infection with SG and NSG was almost identical. The cost to use SG was 3.5 times as great as for NSG. The use of NSG for MMS and reconstruction is safe and cost effective.

The efficacy of second-intention healing in the management of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery.

BACKGROUND: The type of repair chosen to manage defects on the dorsal aspects of the hands and fingers can affect overall hand function. Preservation of manual function in these areas is critical. OBJECTIVE: To evaluate the efficacy of second-intention healing of defects on the dorsal surface of the hands and fingers after Mohs micrographic surgery and to define optimal wound parameters for choosing second-intention healing. METHODS: Fifty-nine patients who had undergone second-intention healing of a Mohs defect on the dorsum of a hand or finger were contacted and their records obtained; 48 patients completed the study. Healing by second intention was assessed according to self-evaluation and retrospective review of medical records based on six outcome variables, including functional ability, durability, sensation, and cosmetic result. RESULTS: Defects ranged in size from 0.8 to 6.0 cm. Patient records revealed no documented problems with function, durability, sensation, cosmesis, or wound infection. All patients reported excellent or good functional results and normal sensation within the scar, and most reported excellent or good scar durability and cosmesis. CONCLUSION: Second-intention healing is an effective option for repairing defects on the dorsum of the hand and fingers. Large defect size is not a contraindication for second-intention healing.

Layered closure versus buried sutures and adhesive strips for cheek defect repair after cutaneous malignancy excision.

BACKGROUND: Primary closure of surgical defects after excision of cutaneous malignancies has been traditionally accomplished with layered closure. OBJECTIVE: We sought to compare the cosmetic outcome of cheek defects repaired with layered closure versus buried sutures and adhesive strips. METHODS: In all, 38 patients underwent excision of a cutaneous malignancy on the cheek by primary excision or Mohs micrographic surgery. Patients were prospectively randomized to receive layered closure to one half of the repair and buried sutures with adhesive strip closure for the other half of the repair. Follow-up assessment was performed by a blinded evaluator using a visual analog scale. RESULTS: There were no differences in scar contour, erythema, or overall cosmesis between closure types. LIMITATIONS: All study participants were Caucasian, with a mean age of 68 years, limiting generalizability of results. CONCLUSION: Layered closure does not have a cosmetic advantage over buried sutures and adhesive strips for the primary repair of cheek defects.

Is levofloxacin necessary to prevent postoperative infections of auricular second-intention wounds?

BACKGROUND: Surgeons may prescribe oral quinolones after auricular procedures to prevent postoperative infections, especially those caused by Pseudomonas aeruginosa. OBJECTIVE: This study compares the efficacy of levofloxacin and local wound care to local wound care alone in preventing postoperative infection of auricular second-intention wounds. MATERIALS AND METHODS: This study was a prospective, randomized trial of 84 consecutive patients (82 in the final analysis) who underwent Mohs micrographic surgery for an auricular neoplasm and had a wound left to heal by second intention. After surgery, patients were randomly assigned to receive either local wound care or local wound care with concurrent 500 mg of levofloxacin by mouth daily. RESULTS: Overall, 85.4% of patients had no complications. Complications included 12.2% of patients with inflammatory chondritis and 2.4% of patients with infection. No infections with P. aeruginosa were observed. No statistical significance was observed between the two treatment groups. CONCLUSION: Levofloxacin is not necessary to prevent postoperative infections of auricular second-intention wounds after Mohs surgery.

Skin cancer in skin of color.

UNLABELLED: Skin cancer is less common in persons with skin of color than in light-skinned Caucasians but is often associated with greater morbidity and mortality. Thus, it is crucial that physicians become familiar with skin cancer in persons of color so as to maximize the likelihood of early detection of these tumors. In dark-skinned ethnic groups, squamous cell carcinoma is most common; squamous cell carcinoma and melanoma usually occur on nonsun-exposed sites; and ultraviolet radiation is not an important etiologic factor for skin cancer with the exception of basal cell carcinoma. Races of intermediate pigmentation, such as Hispanics and Asians, share epidemiologic and clinical features of dark-skinned ethnic groups and Caucasians. Skin cancers pose a significant risk in skin of color and clinicians should focus on preventive measures in these groups such as regular skin exams, self-examination, public education, and screening programs. LEARNING OBJECTIVE: At the completion of this learning activity, participants should be familiar with the epidemiology and unique clinical features of skin cancer in skin of color and be aware of strategies to prevent skin cancer in skin of color.

Atypical Mycobacterium furunculosis occurring after pedicures.

Mycobacterium fortuitum complex are rapidly-growing nontuberculous mycobacteria found ubiquitously in the environment including, water, soil, dust, and biofilms. M fortuitum has been reported to cause skin and soft-tissue infections in association with nail salon footbath use during pedicures. Four cases of M fortuitum complex furunculosis are reported that occurred after pedicures in the Cincinnati, Ohio/Northern Kentucky area. Dermatologists and clinicians should consider mycobacterial infections from the M fortuitum complex when patients present with nonhealing furuncles on the lower legs and should inquire about recent pedicures. Early recognition and institution of appropriate therapy are critical. Public health measures should be explored to protect against such infections, given the recent popularity of the nail care industry.