Risk factors for developing depressive symptoms in the immediate postoperative period after Mohs micrographic surgery.

PURPOSE: Mohs micrographic surgery (MMS) is a highly efficacious, tissue sparing method of skin cancer removal. Nevertheless, in the months to years after MMS, psychosocial distress has been described. The present study addressed the immediate period after MMS and assessed the frequency and risk factors for development of depressive symptoms. METHODS: Subjects undergoing MMS at two physician practices (JL, FS) were included in this prospective cohort study. Preoperatively, a standardized depression screening, the Patient Health Questionnaire-8 (PHQ-8), was administered. After MMS, the PHQ-8 was readministered at weeks 1, 2, 4, 6, and 12. Average PHQ-8 score by week and change from baseline PHQ-8 score were the primary outcomes. RESULTS: Sixty-three subjects were included of which 49 (78%) had a facial site. Twenty-two subjects (35%) had some increase in score during the 12-week follow-up period, of which 18 had a facial site. The oldest subjects (83-99 years, n = 14) had significantly higher PHQ-8 scores at week 4 (p < 0.01) and week 6 (p = 0.02) than all other age groups. There were no differences in scores between location groups. CONCLUSIONS: One-third of subjects had some increase in score during the follow-up period. Those in the oldest age cohort were at highest risk of increased score. In contrast to prior literature, those with facial sites were not at higher risk. This difference may be explained by increased masking during the ongoing COVID-19 pandemic. Ultimately, consideration of patients' psychologic status in the immediate postoperative period after MMS, particularly in the elderly population, may enhance perceived patient outcomes.

Appearance-related psychosocial distress after facial non-melanoma skin cancer surgery: A 1-year prospective study.

OBJECTIVE: Patients undergoing Mohs Micrographic Surgery (MMS) for facial non-melanoma skin cancer (NMSC) experience appearance-related psychosocial distress due to its post-surgical esthetic changes. However, little is known about its development over a longer follow-up period. This study prospectively assessed appearance-related psychosocial distress in patients undergoing MMS for facial NMSC over a 1-year follow up period. METHODS: Patients who had MMS for facial NMSC between September 2020 and October 2021 were invited to answer the FACE-Q Skin Cancer - appearance-related psychosocial distress scale preoperatively, 2 weeks, 6 months, and 1 year after surgery. RESULTS: A total of 217 patients completed the questionnaire at baseline. In addition, 158 (72.8%), 139 (64.1%), and 120 (55.3%) questionnaires were successfully answered 2 weeks, 6 months, and 1 year after surgery, respectively. Patients with a peripheral lesion presented higher appearance-related psychosocial distress scores at baseline than patients with a central lesion (p = 0.02). There was a decreasing trend in appearance-related psychosocial distress over time, but without a significant result (baseline-2-week; p = 0.73, 2-week-6-month; p = 0.80, 6-month-1-year; p = 0.17, baseline-1-year; p = 0.23). Patients with secondary intention healing and graft reconstruction methods experienced more appearance-related psychosocial distress over time than patients with primary wound closures (p = 0.03). CONCLUSIONS: Patients still experience appearance-related psychosocial distress 1 year after MMS. These patients may benefit from targeted counseling. Additionally, predictors of more appearance-related psychosocial distress, such as secondary intention healing and graft reconstruction methods, may benefit from additional psychological care.

Patient Anxiety Related to Patient-Perceived Delays in Surgical Treatment of Skin Cancer.

BACKGROUND: Patients undergoing dermatologic surgery report higher anxiety levels than those undergoing nonsurgical treatments. However, little is known about the association between patient-perceived delays in skin cancer surgery and patient-reported anxiety. OBJECTIVE: To examine the relationship between patient-perceived delays in surgery and patient-reported anxiety. METHODS MATERIALS: Patients undergoing wide local excision or Mohs micrographic surgery were recruited to complete a survey to assess perception of surgical delay and anxiety related to skin cancer surgery using the validated Psychosocial Screen for Cancer-Revised. Demographic and surgical characteristics were collected through chart review. Chi-square and Student t -tests were used to compare demographic and surgical information between patients who did and did not perceive a surgical delay. Differences in anxiety and depression scores for patients who did and did not report a delay were assessed using univariate and multivariate regressions. RESULTS: Twenty-seven percent ( N = 33) of patients perceived a surgical delay. Perception of surgical delay was associated with increased time between biopsy and surgery ( p = .0001) and increased self-reported anxiety scores after controlling for various demographic and surgical factors ( p = .038). CONCLUSION: Patient-perceived delays in dermatologic surgery are associated with increased time to surgery and patient-reported anxiety.

Brief Educational Video Improves Patient Understanding of Mohs Surgery: A Randomized Controlled Trial.

BACKGROUND: Patient's retention and recall of material discussed in a medical consultation is often inadequate. OBJECTIVE: To assess patient's knowledge, anxiety, and understanding of Mohs surgery after viewing a brief educational video. METHOD: A prospective, investigator-blinded, randomized controlled trial of 120 consecutive patients before the first Mohs surgery procedure. Sixty subjects viewed an instructional video and 60 subjects did not. A survey was administered to both groups, measuring knowledge, anxiety, and understanding of Mohs surgery. RESULTS: The video group scored higher than the control group on the knowledge portion of the survey (median score 78% vs 56%, p < .01), but there were no differences in anxiety or understanding scores between groups. The percentage of subjects who answered each knowledge question correctly was greater in the video group than in the control group. In the subgroup of patients who had not previously had a consultation with a Mohs surgeon, the video group had higher median knowledge scores (67% vs 44%, p < .01), higher median understanding scores (8 vs 6, p = .05), and lower median visual analogue anxiety scores (4 vs 6, p = .01) compared with the control group. CONCLUSION: A brief educational video increases patient's knowledge of Mohs surgery. For patients who have not yet had a consultation with a Mohs surgeon, the video may also reduce anxiety.

Pharmacologic and Nonpharmacologic Interventions for Perioperative Anxiety in Patients Undergoing Mohs Micrographic Surgery: A Systematic Review.

BACKGROUND: Perioperative anxiety is associated with negative patient outcomes in Mohs micrographic surgery (MMS). Both pharmacologic and nonpharmacologic therapies have been used to alleviate perioperative anxiety in MMS. OBJECTIVE: To systematically evaluate the efficacy of therapies aimed at reducing perioperative anxiety in MMS. METHODS AND MATERIALS: Eligible articles were identified using PubMed MEDLINE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. All available studies investigating interventions to reduce perioperative anxiety during MMS were considered. RESULTS: Of the 183 abstracts identified and screened, 5 studies met inclusion criteria. Three studies reported a postintervention reduction in patient anxiety (midazolam, educational video, and personalized music). Two studies reporting on similar interventions did not find an effect. CONCLUSION: There is currently limited evidence to support either pharmacologic or nonpharmacologic therapy for alleviation of perioperative patient anxiety in MMS. Midazolam may provide patients a short-term benefit, though any estimate of the effect is very uncertain. Personalized music may be a promising nonpharmacologic intervention for future research.

Factors Associated With Patient-Initiated Communication After Mohs Micrographic Surgery.

BACKGROUND: Despite extensive counseling, patients commonly call with postoperative concerns after Mohs micrographic surgery (MMS). OBJECTIVE: We sought to determine the incidence, reasons, and patient and surgical characteristics that lead to patient-initiated communication after MMS. MATERIALS AND METHODS: A retrospective chart review of 1,531 patients who underwent MMS during the observational period was conducted. Demographics and perioperative characteristics of patients who initiated communication were compared with a random sample of matched controls. RESULTS: Of the 1,531 patients who underwent MMS, 263 patients (17.2%) initiated 412 communication encounters within 90 days of surgery. Top reasons for patient-initiated communication included wound concerns, bleeding, and postoperative pain. Female patients and those with a larger surgical defect size (cm) were more likely to call postoperatively. Patients who underwent second intention healing, grafts, and interpolation flaps were more likely to initiate communication compared to patients repaired with a linear closure. CONCLUSION: This study identifies the incidence, reasons, and patient and surgical factors predictive of patient-initiated communication after MMS, which may allow for targeted improvements in postoperative counseling, ameliorating patient anxiety, augmenting patient satisfaction, and improved efficiency for the health care team.

Patient quality of life fluctuates before and after Mohs micrographic surgery: A longitudinal assessment of the patient experience.

BACKGROUND: Changes in patient perceptions of quality of life (QOL) after Mohs micrographic surgery (MMS) may benefit from different counseling or treatment. OBJECTIVE: To measure QOL before and after MMS and to identify risk factors associated with impaired QOL. METHODS: Prospective observational study of 727 patients with skin cancer who self-reported QOL via the Skin Cancer Index immediately before and at 1 to 2 weeks and 3 months after MMS. RESULTS: QOL fluctuated after MMS. At 1 to 2 weeks after surgery, overall QOL remained unchanged compared with before MMS. Patients reported reduced anxiety about skin cancer but had increased distress about social interactions and physical appearance. At 3 months after surgery, patients reported an overall improvement in QOL compared with before MMS (P = .0007). Age younger than 65 years (P = .0001), female sex (P = .0001), and tobacco use (P = .03) were associated with lower QOL scores at all assessment points. LIMITATIONS: Single-site observational study. Significant loss to follow-up at both time points after MMS. CONCLUSION: Patients with skin cancer had persistent concerns about social interactions and physical appearance 1 to 2 weeks after MMS, but all aspects of their QOL improved by 3 months after surgery. Patients who underwent MMS that were younger than 65 years, were female, or smoked were at increased risk for longitudinally impaired QOL.

Web App- and Text Message-Based Patient Education in Mohs Micrographic Surgery-A Randomized Controlled Trial.

BACKGROUND: Consent and wound care (WC) videos are used for education in Mohs micrographic surgery (MMS). Postoperative text messaging is poorly studied. OBJECTIVE: Develop and evaluate perioperative resources for MMS patients-video modules (DermPatientEd.com) and postoperative text messaging (DermTexts.com). MATERIALS AND METHODS: A study was conducted on 90 MMS patients. Patients were randomized 1:1:1:1 to videos with text messages, videos-only, text messages-only, or control. Primary outcomes included preoperative anxiety and knowledge of MMS and postoperative care. The secondary outcome included helpfulness/preference of interventions. RESULTS: Patients experienced a 19% reduction in anxiety as measured by a visual analog scale after the MMS video (p = .00062). There was no difference in knowledge after the WC video (p = .21498). Patients were more likely to report the WC video "very helpful" when compared with the pamphlet in understanding postoperative WC (p = .0016). Patients in text messaging groups were not more likely to report the service as "very helpful" when compared with the pamphlet (p = .3566), but preferred to receive WC instructions by text message for future visits (p = .0001). CONCLUSION: These resources proved helpful and effective in reducing preoperative anxiety. Patients prefer text message-based WC instructions over pamphlets after experiencing the service, but do not find them more helpful.

Preoperative telephone consultation does not decrease patient anxiety before Mohs micrographic surgery.

BACKGROUND: Many factors influence anxiety and satisfaction of patients undergoing Mohs micrographic surgery (MMS). OBJECTIVE: We sought to determine the effect of a preoperative educational telephone call on anxiety and satisfaction for patients undergoing same-day office consultation and MMS. METHODS: Patients with skin cancer (N = 104) scheduled for same-day office consultation and MMS were randomly assigned to receive or not to receive an educational telephone call during the week before surgery. All patients rated their anxiety levels immediately before and after the same-day office consultation and MMS by completing the State-Trait Anxiety Inventory and an anxiety visual analog scale. Patients also rated satisfaction immediately after MMS by completing the Visit-Specific Patient Satisfaction Questionnaire. RESULTS: Patients undergoing same-day office consultation and MMS reported similar levels of increased anxiety and high satisfaction, regardless of whether they received a preoperative educational telephone call. LIMITATIONS: Lack of control for patients' prior surgery or self-education is a limitation. CONCLUSION: Preoperative educational telephone calls did not relieve anxiety or improve satisfaction for patients undergoing same-day office consultation and MMS. Preoperative education and counseling has uncertain benefits to anxiety and satisfaction of patients undergoing MMS.

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.

Anxiety levels of patients undergoing common dermatologic procedures versus those seeking general dermatologic care.

Patients undergoing Mohs micrographic surgery frequently experience anxiety as a result of multiple potential factors. There is currently no data regarding how this anxiety compares to other common procedures performed in dermatology offices, such as shave biopsy and excision, relative to a general dermatology visit. Herein, we conducted a survey of 471 dermatology patients at an academic medical center, using a validated tool (Visual Analogue Scale from 1 "no anxiety at all" to 10 "extremely anxious").

2015 Arte Poster Competition First Place Winner: Assessing the Correlation Between Patient Anxiety and Satisfaction for Mohs Surgery.

Skin cancer and the surgical treatment thereof have the potential to be sources of great anxiety for patients. Examination of patient satisfaction, anxiety, and contributing factors has the potential to provide information surgeons can use to implement practices that have an impact on patient anxiety and satisfaction regarding dermatologic surgery. This study used a prospective interview to catalog patients' anxiety and experiences before and during the surgical process. Our results indicate that several pre- and perioperative factors have the potential to decrease a patient's overall anxiety. Notably, 33% of surgical patients reported a decrease in anxiety from the time of diagnosis until the day of surgery. Factors that contributed to this included a call discussing the diagnosis and what to expect on the day of surgery as well as reading written material or searching the internet for more information regarding the procedure. Furthermore, a call from the physician compared to a call from a nurse or other team member showed a greater effect on decreasing anxiety. During the surgical procedure, our results highlight several factors that can decrease a patient's anxiety. Most notably, eating, watching TV, bringing a guest, and engaging in small talk with surgeon and staff during the procedure subjectively decreased patients' anxiety. In summary, our results suggest that patients respond to a variety of factors to reduce anxiety and that each patient derives relief from anxiety in different manners. Therefore, offering a spectrum of comforting or distracting activities during the Mohs procedure is ideal and may reduce the need for pharmacologic anxiolytics.

Postoperative preferences in cutaneous surgery: a patient-centered investigation from an academic dermatologic surgery practice.

BACKGROUND: Little is known about postoperative preferences regarding dermatologic surgery. OBJECTIVE: To determine patient preferences for postoperative follow-up after dermatologic surgery, desired follow-up interval, reasons for desired follow-up or lack thereof, and factors that may be associated with these preferences. MATERIALS AND METHODS: Patients who underwent Mohs micrographic surgery or excision within 24 months of Mohs micrographic surgery or excision were retrospectively surveyed regarding their postoperative follow-up preferences. Procedure, tumor attributes, complications, and medications were recorded. RESULTS: Eighty-nine percent of patients considered postoperative follow-up important, with 55% opting for follow-up within 4 weeks and an additional 29.1% within 2 to 3 months. After multivariate analyses, there were no significantly associated covariates of interest regarding preference for follow-up. Reasons for desiring follow-up included to ensure the wound healed well (50%), to ensure the cancer had not returned (27.9%), and to examine the rest of the skin (18.6%). CONCLUSION: A majority of patients desired postoperative follow-up visits for a variety of reasons. Anticipation of postoperative concerns should be included in dermatologic surgery planning.