Randomized Controlled Trial of Preoperative Topical Decolonization to Reduce Surgical Site Infection for Staphylococcus aureus Nasal Swab-Negative Mohs Micrographic Surgery Patients.

BACKGROUND: Surgical site infection (SSI) is mainly due to endogenous bacteria. Topical decolonization is a preoperative intervention currently advised for proven nasal carriers of Staphylococcus aureus (S. aureus). OBJECTIVE: The authors assessed whether topical decolonization could be of benefit for patients who are not nasal carriers of S. aureus. METHODS AND MATERIALS: The authors performed a randomized controlled trial of S. aureus nasal swab-negative patients. Five days before Mohs surgery topical decolonization with nasal mupirocin and chlorhexidine, body wash was started. The control group had no intervention. RESULTS: In the week after Mohs surgery, the infection rate in the intervention group was 2% (n = 661, 14) and that of the control group was 4% (n = 689, 29). CONCLUSION: Topical decolonization reduces SSI in nasal swab-negative Mohs surgery patients.

Tangential excision debulking with vertical sections prior to Mohs micrographic surgery.

The tangential excision technique for removal of skin tumours has been previously described for truncal superficial BCCs but never before as an option for debulking prior to Mohs micrographic surgery (MMS). Tangential excision debulking with vertical sections represents an alternative to traditional curettage debulking and offers many advantages, most notably a far better tissue specimen for histopathological analysis.

Bupivacaine as an Adjunct to Lidocaine in Mohs Micrographic Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: In Mohs micrographic surgery (MMS), the standard local anesthetic agent used is lignocaine with adrenaline. However, MMS can be prolonged; thus reinjections of local anesthetics are often required. OBJECTIVE: Is 0.5% bupivacaine with 1:200,000 epinephrine a useful adjunctive treatment when compared with the use of 1% lidocaine with 1:100,000 epinephrine in MMS for the nose? METHODS: Participants undergoing MMS received 2.5 mL of 1% lidocaine with 1:100,000 epinephrine before commencement of Stage 1. At the end of Stage 1, participants were randomized sequentially to either 2.5 mL 0.5% bupivacaine with 1:200,000 epinephrine (Group A) or 2.5 mL of 1% lidocaine with 1:100,000 epinephrine (Group B). Effectiveness of anesthesia was assessed using 30 G needle to 5 points of the wound before further stage or repair. RESULTS: Fifty-one patients were randomized, 26 to Group A, and 25 to Group B. No differences between the 2 groups in size of defect and time lapse between time of injection and time of testing were observed. Seven of 25 were tested positive in Group B. Zero of 26 tested positive in Group A (p = .003, 95% confidence interval: 10%-46%). CONCLUSION: Adjunctive use of 0.5% bupivacaine with 1:200,000 epinephrine is effective in prolonging anesthesia in MMS.

Periocular Mohs micrographic surgery in Western Australia 2009-2012: A single centre retrospective review and proposal for practice benchmarks.

BACKGROUND/OBJECTIVES: Periocular skin tumours pose management challenges with literature supporting a multidisciplinary approach. This retrospective review identifies trends in multidisciplinary management, ascertaining potential benchmarks for practice review. METHODS: A retrospective review of 720 patients with periocular tumours, treated with Mohs micrographic surgery (MMS) at a single free standing Day Surgery Facility between 2009 and 2012. RESULTS: In all, 690 patients were included, with mean age 65 and slight male preponderance. Basal cell carcinoma was the most commonly excised tumour (85.4%) and lower eyelid most common tumour site (58%). Of the cases repaired by Mohs surgeons, 2% involved more than one cosmetic subunit, compared with 23% by oculoplastic surgeons. Of the cases repaired by MMS, 1% had eyelid margin involvement, compared with 64% of the cases by oculoplastic surgeons. Mean preoperative lesion size for cases repaired by Mohs and oculoplastic surgeons was 0.5 cm2 . Mean postoperative defect size was smaller for cases repaired by Mohs surgeons compared with oculoplastic surgeons (1.5 and 1.9 cm2 ). Mean number of stages was less for Mohs surgeon repairs (n = 1.5) compared with oculoplastic surgeon repairs (n = 1.9). Cases repaired by oculoplastic surgeons were more often combination repairs. CONCLUSIONS: This study identifies potential benchmarks for Mohs surgeons when reviewing or establishing a periocular Mohs surgery practice and for doctors referring periocular tumours for surgical removal. These include the proportion of periocular cases managed jointly and the location, size of defect and number of stages involved in tumors repaired by Mohs surgeon alone compared to those repaired by oculoplastic surgeons.

Malignant fibrous histiocytoma masquerading as pyogenic granuloma.

A 68-year-old gentleman presented with a lesion that resembled a pyogenic granuloma in his inferior fornix. The lesion was excised and biopsy demonstrated a proliferation of malignant spindle cells. Three weeks following initial excision, the lesion recurred and was removed via wedge excision of the eyelid. Definitive clearance was achieved through Mohs micrographic surgery. The patient received adjuvant postoperative radiotherapy and remains disease-free. This case demonstrates the need to consider sinister pathology in the setting of recurrent periocular lesions.

Oral antibiotics versus topical decolonization to prevent surgical site infection after Mohs micrographic surgery--a randomized, controlled trial.

BACKGROUND: The optimal method of reducing the risk of surgical site infection (SSI) after dermatologic surgery is unclear. Empiric, preoperative antibiotic use is common practice but lacks supporting evidence for its efficacy in preventing SSI. Risk stratification for patients at high risk of postoperative SSI based on a nasal swab is a viable strategy when coupled with topical decolonization for positive carriers. We compared the rates of infection in patients undergoing Mohs micrographic surgery (MMS) with nasal carriage of Staphylococcus aureus who received oral antibiotics or topical decolonization. METHODS: A randomized, controlled trial with 693 patients was conducted over a 30-week period at a single surgical practice. Patients were stratified into nasal carriers or noncarriers of S. aureus based on a preoperative nasal swab. Nasal carriers of S. aureus were randomized to receive topical decolonization with intranasal mupirocin twice daily plus 4% chlorhexidine gluconate body wash daily for 5 consecutive days before surgery or statim pre- and postoperative doses of oral cephalexin. RESULTS: One hundred seventy-nine patients (25.8%) were identified as carriers of S. aureus. Ninety received topical decolonization, and 89 received oral antibiotics. These groups were compared with a swab-negative Mohs surgical cohort over the same time period. There were no significant differences between the groups in terms of demographic characteristics or comorbidities. Nine percent of patients receiving oral antibiotic prophylaxis and 0% receiving topical decolonization developed early SSI (p = .003). CONCLUSION: In patients with demonstrable carriage of S. aureus, topical decolonization resulted in fewer SSI than in patients receiving perioperative oral antibiotics. Antibiotics should be reserved for clinically suspected and swab-proven infections rather than being prescribed empirically. Further efforts should be directed toward optimizing endogenous risk factor control for all patients presenting for MMS.

Nasal carriage of Staphylococcus aureus in patients undergoing Mohs micrographic surgery is an important risk factor for postoperative surgical site infection: a prospective randomised study.

BACKGROUND: Surgical site infection (SSI) can be a problematic complication of Mohs micrographic surgery (MMS). Previous reports have cited nasal Staphylococcus aureus (S. aureus) carriage as a risk factor for SSI, but none thus far in dermatologic surgery. OBJECTIVE: The aim was to determine the difference in infection rates between nasal carriers of S. aureus and non-carriers, and whether decolonisation with intranasal mupirocin ointment and chlorhexidine wash would reduce the infection rate in nasal carriers. METHODS: In all, 738 patients presenting for MMS at the Oxford Day Surgery and Dermatology underwent a nasal swab to determine their S. aureus carriage status. S. aureus carriers were randomised for decolonisation with intranasal mupirocin ointment and chlorhexidine body wash. Non-carriers were untreated. All patients were followed up for SSI. RESULTS: The rate of SSI was 11 per cent in untreated S. aureus carriers, 4 per cent in treated carriers, and 3 per cent in non-carriers. The difference in infection rate between carriers and non-carriers was significant (P < 0.001). The difference between treated and untreated carriers was also significant (P = 0.05). CONCLUSION: Nasal S. aureus carriage is an important risk factor for SSI in MMS, conferring an over threefold increase in SSI risk. A pre-operative nasal swab provides a simple and effective risk stratification tool. The use of a topical decolonisation regimen reduces the infection rate in carriers to a level approaching non-carriers without exposure to systemic antibiotics.

Assessment and management of chemical exposure in the Mohs laboratory.

BACKGROUND: The correct handling, storage, and disposal of chemicals used in the processing of tissue for Mohs micrographic surgery are essential. OBJECTIVES: To identify the chemicals involved in the preparation of Mohs frozen sections and assess the associated occupational health risks. To quantify exposure levels of hazardous chemicals and ensure that they are minimized. METHODS: A risk assessment form was completed for each chemical. Atmospheric sampling was performed at our previous laboratory for formaldehyde and volatile organic compounds. These data were used in the design of our new facility, where testing was repeated. RESULTS: Twenty-five chemicals were identified. Ten were classified as hazardous substances, 10 were flammable, six had specific disposal requirements, four were potential carcinogens, and three were potential teratogens. Formaldehyde readings at our previous laboratory were up to eight times the national exposure standard. Testing at the new laboratory produced levels well below the exposure standards. CONCLUSION: Chemical exposure within the Mohs laboratory can present a significant occupational hazard. Acutely toxic and potentially carcinogenic formaldehyde was found at high levels in a relatively standard laboratory configuration. A laboratory can be designed with a combination of physical environment and operational protocols that minimizes hazards and creates a safe working environment.

Mohs surgery in Australia: a survey of work practices.

BACKGROUND: Mohs micrographic surgery is the preferred treatment for certain skin cancers. It had already been considerably refined prior to its introduction into Australia in 1978, refinement has continued since. Documenting the work practices of Australian Mohs surgeons serves to clarify the current role of Mohs surgery and may help tailor future Mohs fellowship programs. METHODS: A survey was conducted to investigate the characteristics and clinical practices of Australian Mohs surgeons, particularly as they relate to skin cancer management and aesthetic dermatology. RESULTS: The typical Australian Mohs surgeon is male (90%), works in a group private practice (70%), and is aged 40-44 years (37%). Mohs surgery is generally reserved for tumours that are located on the head, neck, digits or genitals (98%), and flap reconstructions are the commonest repair types performed (48%). Laser and cosmetic injectable treatments form part of many Mohs surgeon's repertoires. CONCLUSION: Australian Mohs surgeons make an important contribution to the management of skin cancer in Australia and many are skilled in laser and cosmetic procedures. The increasing number of cases performed annually and the familiarity with laser and cosmetic therapies reinforces Australian dermatologists as leaders in these important areas of dermatology.