Efficacy and Safety of Anxiolytics in Mohs Micrographic Surgery: A Randomized, Double-Blinded, Placebo-Controlled Trial.

BACKGROUND: Patient anxiety can complicate surgical outcomes by elevating blood pressure, increasing the need for postoperative pain management, and reducing overall patient satisfaction. Despite the use of anxiolytic medications in outpatient procedures, there is limited comparative evidence on the efficacy and safety of these agents in Mohs micrographic surgery. OBJECTIVE: To compare the effectiveness and safety of different preprocedural anxiolytic agents in Mohs surgery on perioperative patient anxiety and patient satisfaction. MATERIALS AND METHODS: A double-blinded, randomized, placebo-controlled trial was conducted of 6 different preprocedural anxiolytic agents (lorazepam, diazepam, alprazolam, gabapentin, pregabalin, and melatonin) in 350 patients undergoing Mohs surgery. Anxiety and vital signs were recorded. RESULTS: Diazepam demonstrated a statistically significant, sustained reduction in anxiety levels compared with placebo ( p = .03). Gabapentin significantly reduced early anxiety ( p = .02). Alprazolam showed a trend to early anxiety reduction ( p = .08). Lorazepam ( p = .73), pregabalin ( p = .53), and melatonin ( p = .24) failed to reduce patient anxiety compared with placebo at any time point. No anxiolytic significantly impacted any patient vital sign or cognition. CONCLUSION: Although short-acting benzodiazepines and gamma-aminobutyric acid medications may have transient anxiolytic effects, a single oral dose of 5 mg of diazepam can provide a sustained anxiolytic effect in Mohs surgery, with excellent patient safety.

Interpolation Flaps in the Outpatient Mohs Surgery Setting: A Prospective Cohort Study of Patient Pain, Anxiety, and Satisfaction.

BACKGROUND: Staged interpolation flaps (SIFs) have historically been performed under general anesthesia by specialties outside of dermatologic surgery. However, SIFs performed under local anesthesia by dermatologic surgeons have shown lower or equal complication rates. OBJECTIVE: To date, no studies have evaluated pain, anxiety, satisfaction, and use of perioperative analgesics in patients undergoing SIFs in an outpatient setting under local anesthesia. METHODS/MATERIALS: This is a prospective cohort study of 39 patients who received Mohs micrographic surgery and subsequent SIF repair in an outpatient setting under local anesthesia. Pain, anxiety, and satisfaction scores were recorded using 100-point validated visual analog scales. Perioperative analgesic use was quantified. RESULTS: The defect size was ≥4 cm2 in 72% of patients; 41% had full-thickness (skin/cartilage/mucosa) defects. All pain and anxiety measures were minimal to mild. Pain scores ranged from highest (mean = 39 ± 4.1) on postoperative Day (POD) 1 to lowest (mean = 12.3 ± 2.0) on POD 7. Anxiety scores ranged from highest (mean = 42 ± 4.5) on POD 1 to lowest (mean = 18.5 ± 3.7) on POD 7. Perioperative patient satisfaction was high (mean = 95 ± 1.7). Postoperative narcotic analgesics were prescribed in 15% of patients. CONCLUSION: Staged interpolation flaps performed under local anesthesia in the outpatient setting are well tolerated with low pain and anxiety, high patient satisfaction, and minimal analgesic use.

Gaining Large Coverage With Small Island Pedicle Flaps in Tight Cosmetic Subunits: Taking Advantage of Rotation and Pincer Principles on the Nasal Ala.

BACKGROUND: Island pedicle flaps (IPFs) are widely used in reconstructive surgery due to their versatility, tissue efficiency, and excellent clinical outcomes. While IPF rotations and 'pincer flap' modifications have previously been sparsely described, they are not often discussed in the literature. OBJECTIVE: We demonstrate the use of both rotating IPFs and pincer techniques for defects traditionally considered too large for classic IPF design on the nasal ala. METHODS: Forty-four patients underwent alar repair using the rotation or combined rotation with pincer modification to the standard IPF technique from August 2014 to May 2017. Our technique is described and case examples are presented with photographs. RESULTS: Forty-four patients with an average alar defect size of 1.2 cm underwent repair using rotation only or rotation with pincer modification of the classic IPF approach. CONCLUSIONS: Reconstruction of large defects in small facial cosmetic subunits such as the nasal ala can be performed using principles of both rotating IPFs and the 'pincer flap' technique. The degree of rotation is directly related to the length of coverage. Modifications to the flap are straightforward to perform. Using these techniques, larger defects that previously would have been reconstructed using flaps that cross cosmetic boundaries can now be reconstructed within the same cosmetic unit, thus, improving aesthetic outcomes.

Defining skin cancer local recurrence.

Definitions of skin cancer recurrence are variable and nonstandardized, which can lead to inconsistent and potentially inappropriate management of tumors of uncertain recurrence status. Defining recurrence is important given the potential association with metastasis in both melanoma and nonmelanoma skin cancer. A review of the literature across multiple disciplines involved in the care of skin cancer patients reveals that although criteria for recurrence are provided in the majority of cases, most are vague and inconsistent. Given the presumably increased morbidity and mortality associated with recurrent tumors, accurate identification and appropriate management is paramount. In addition, value-based health care necessitates validated and relevant outcome measures that are standardized and, thus, enable tracking of comparable and corresponding outcomes. A universal definition of localized skin cancer recurrence would ultimately allow for improved surveillance and informed therapeutic strategies to decrease morbidity and mortality of patients afflicted with skin cancer, the most common cancer nationwide.

Amelanotic Lentigo Maligna Melanoma: Mohs Surgery as the Definitive Treatment of an Invisible Tumour.

Amelanotic lentigo maligna melanoma represents <2% of melanomas. Diagnosis is delayed owing to the lack of lesion pigmentation and advanced disease at presentation. Excision with appropriate margins is the treatment standard, but the starting point for such margins is often unclear. We describe 2 patients with amelanotic melanoma treated by Mohs micrographic surgery (MMS) that would not have been cleared by wide local excision alone and provide an extensive review of the literature. Both patients presented with histologic diagnoses of malignant melanoma, one with a barely perceptible biopsy site scar on the left infraorbital cheek/lower eyelid (Breslow 1.8 mm) and the second with an amelanotic tumour on the right helix (Breslow 10 mm). Due to location, aggressive histology, amelanotic appearance, and no apparent surrounding skin surface changes, MMS was elected to maximise margin control. For patient 1, invasive and in situ tumour was found at the American Joint Committee on Cancer-recommended margin of 1.5 cm, and the final defect measured 8.5 × 4.8 cm. Patient 2 had a significant invasive and amelanotic lentigo maligna component, resulting in a 9.0 × 6.5-cm defect. MMS allows for immediate histologic feedback on tumour margins of a clinically invisible tumour and thus offers the most definitive treatment.

Determinants and Timeline of Perioperative Anxiety in Mohs Surgery.

BACKGROUND: Patients undergoing Mohs micrographic surgery (MMS) exhibit anxiety relating to cancer cure or the expected cosmetic outcome. OBJECTIVE: To obtain quantitative measurements of perioperative cancer and cosmetic anxiety levels in first-time MMS patients. Parameters influencing anxiety and its natural course were assessed. METHODS: Prospective, single-blinded, questionnaire study of 173 patients undergoing MMS of the face. Anxiety levels were assessed using a visual analog scale preoperatively and postoperatively over 6 months. RESULTS: Mohs patients demonstrate a trend to greater or equal anxiety about cancer over cosmesis at all measured time points, but differences only reached statistical significance beginning 1 week postoperatively. Clinically relevant lowering of cancer anxiety levels is delayed until 3 months postoperatively. Cosmetic anxiety reaches a clinically relevant improvement by 1 week. The intuitive predictors of cosmetic anxiety, namely female gender and younger age, were quantitatively reinforced in this study. The predictor of cancer anxiety was the use of preoperative lorazepam. CONCLUSION: To maximize patient care, Mohs surgeons must be aware of covert patient anxieties and the parameters, which influence these anxieties. Identifying and anticipating the course of cancer- and cosmetic-related anxieties will reduce patient fears, improving their satisfaction with the MMS experience.

Lidocaine contact allergy is becoming more prevalent.

BACKGROUND: Allergic contact dermatitis (ACD) to lidocaine is rising in prevalence. This is due to a growing number of over-the-counter (OTC) products containing topical amide and ester anesthetics. The phenomenon poses a real threat to the authors' surgical anesthetic options. OBJECTIVE: To investigate the epidemiology of topical anesthetic ACD in British Columbia, Canada and provide an approach for clinicians to deal with this problem. MATERIALS AND METHODS: A retrospective chart review of 1,819 patients who underwent patch testing at the University of British Columbia Contact Dermatitis Clinic between January 2009 and June 2013 was completed. The authors also performed a detailed review of Canadian OTC preparations containing lidocaine in 2013. RESULTS: The prevalence of ACD to local anesthetics is significant at 2.4%. The most common allergen is benzocaine (45%) followed by lidocaine (32%) and dibucaine (23%). CONCLUSION: The proportion of ACD caused by lidocaine is higher than expected. This is likely secondary to an increase in OTC medicaments containing lidocaine. Patients who are patch test-positive to a local anesthetic should be challenged intradermally to confirm clinical relevance. Because ACD is a delayed Type IV hypersensitivity reaction (localized dermatitis), the risk of anaphylaxis is not a concern.

Proinflammatory cytokines inhibit human placental 11beta-hydroxysteroid dehydrogenase type 2 activity through Ca2+ and cAMP pathways.

Excessive fetal exposure to glucocorticoids has been implicated in the etiology of adult metabolic and cardiovascular disease. Placental 11beta-hydroxysteroid dehydrogenase type 2 (11beta-HSD2) may protect the fetus from excessive glucocorticoid exposure. Maternal stress may be accompanied by elevated levels of cortisol and increased proinflammatory cytokines [interleukin (IL)-1beta, IL-6, and tumor necrosis factor-alpha (TNF-alpha)]. We hypothesize that proinflammatory cytokines inhibit human placental 11beta-HSD activity. We incubated explant cultures of term human placental villi in the presence or absence of 10 ng/ml IL-1beta, IL-6, or TNF-alpha, with or without agonists or antagonists of intracellular Ca2+ and adenylyl cyclase. Activity for 11beta-HSD2 was estimated using a radioisotope assay, and mRNA was measured using quantitative RT-PCR. All cytokines significantly (P < or = 0.05) reduced 11beta-HSD2 activity (>75% suppression); maximal inhibition occurred within 2 h and was maintained for at least 24 h. The IL-1beta-induced inhibitory activity was attenuated using a Ca2+ channel blocker (nifedipine), an intracellular Ca2+ antagonist [8-(N,N-diethylamino)octyl-3,4,5-trimethoxybenzoate], or the adenylyl cyclase stimulant forskolin. Conversely, 11beta-HSD2 activity was diminished in the presence of the Ca2+ ionophore A-23187 or the adenylyl cyclase inhibitor SQ-22536. mRNA levels for 11beta-HSD2 were not changed by any of the treatments. Proinflammatory cytokines inhibit human placental 11beta-HSD2 activity through a mechanism that involves increased intracellular Ca2+ and inhibition of adenylyl cyclase. This could result in excessive fetal exposure to maternal cortisol. This mechanism might mediate part of the increased risk of metabolic and cardiovascular disease in adult offspring.