The traditional paramedian forehead flap (FHF) is an axial flap based on the supratrochlear artery (STA). Doppler examination is often used to ensure inclusion of the STA within the flap. The authors ...hypothesized that a FHF pedicle design could be simplified to extend from the midline of the glabella to 1.2 cm lateral to the midline without compromising outcomes.
To compare clinical outcomes and vessel densities of 2 FHF designs.
Two FHF designs were used to repair fifty nasal defects. One was based on Doppler identification of the STA; the other on clinical measurements from the glabellar midline (with no effort to identify the STA). Clinical outcomes, complication rates, and pedicle vasculature of both groups were compared.
There was no significant difference in flap survival or complication rate. Forehead flaps designed on the paramidline glabella had more arteries within their pedicles than Doppler-based FHFs (p < .05). Small arteries predominated, whereas larger arteries were infrequent in both groups. Size and number of arteries were not related to flap survival.
A paramidline FHF has equivalent clinical outcomes as a flap based on the STA. A simple and reproducible design of the FHF using only surface landmarks is described.
Extramammary Paget's disease (EMPD) is a rare intraepithelial malignancy with high recurrence rates following standard surgical treatments, ranging from 22% to 60% in large retrospective reviews.
To ...evaluate the local recurrence rate of Mohs micrographic surgery (MMS) supplemented with intraoperative immunohistochemistry for cytokeratin-7 (MMS + CK-7) for primary and recurrent EMPD.
Retrospective, multi-center, cross-sectional study of patients treated using MMS + CK-7. Demographic, clinicopathologic, treatment, and follow-up data were obtained by chart review.
The observed local recurrence rate for MMS + CK-7 is 3.3% (2/61 tumors) with a mean follow-up of 43.5 months (1-120 months). Local recurrence occurred in 2.3% (1/43) of primary tumors and 5.6% (1/18) of recurrent tumors. Kaplan-Meier 5-year tumor-free rates are 94.6% overall, 97.1% for primary tumors, and 80.0% for recurrent tumors. The Kaplan-Meier 5-year tumor-free rates for all EMPD tumors treated with MMS + CK-7 versus a historical cohort of MMS alone are 94.6% versus 72.0% (p = .012).
MMS + CK-7 is an effective treatment for EMPD, demonstrating improved outcomes compared with historical controls.
Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence.
To provide opioid prescription recommendations after Mohs ...micrographic surgery (MMS) and reconstruction.
This was a multi-institutional Delphi consensus study consisting of a panel of members of the American College of Mohs Surgery from various practice settings. Participants were first asked to describe scenarios in which they prescribe opioids at various frequencies. These scenarios then underwent 2 Delphi ratings rounds that aimed to identify situations in which opioid prescriptions should, or should not, be routinely prescribed. Consensus was set at ≥80% agreement. Prescription recommendations were then distributed to the panelists for feedback and approval.
Twenty-three Mohs surgeons participated in the study. There was no scenario in which consensus was met to routinely provide an opioid prescription. However, there were several scenarios in which consensus were met to not routinely prescribe an opioid.
Opioids should not be routinely prescribed to every patient undergoing MMS. Prescription recommendations for opioids after MMS and reconstruction may decrease the exposure to these drugs and help combat the opioid epidemic.
A systematic approach to Mohs surgery and reconstruction from renowned skin cancer surgeons
More than 5.4 million cases of nonmelanoma skin cancer, most notably basal cell, squamous cell carcinoma, ...and melanoma, occur annually in the United States alone. The Mohs technique, developed in the 1950s and refined over the years, has the highest cure rate of any treatment for nonmelanoma skin cancer, is used increasingly for melanoma, and the lowest recurrence rate. Mohs Micrographic Surgery: From Layers to Reconstruction by renowned dermatologic and Mohs surgeons Christopher Harmon and Stanislav Tolkachjov provides a detailed yet succinct road map to learning and mastering Mohs and reconstruction.
The algorithmic organization coupled with instructive photographs and illustrations provide a reader-friendly format conducive to learning. The two opening chapters describe the principles of Mohs surgery including: progressive layer excision to determine if wound margins are cancer free, associated pitfalls, recurrences, special sites, reconstructive principles, and general considerations. The subsequent eight chapters are organized by facial site, from the nose to the eyelid/eyebrow. The final two chapters discuss combination reconstructions stretching over multiple subunits and perioperative management and wound care.
Key Highlights
*An impressive group of global Mohs and reconstruction experts provide firsthand pearls that guide optimal treatment
*Relevant anatomical aspects that impact excision and reconstruction are detailed, including structures, skin tension lines, tissue planes, and dangers zones
*More than 20 procedural videos provide hands-on guidance on how to perform specific steps in Mohs and reconstruction
*This unique resource will help residents, fellows, and surgeons in dermatology, plastic surgery, and facial plastic surgery master nuances of Mohs reconstructive techniques to achieve the most functional and aesthetically pleasing outcomes for patients.
This book includes complimentary access to a digital copy on https://medone.thieme.com.
Background: Optimal treatment of primary Merkel cell carcinoma (MCC) is unknown. High local recurrence rates after excision alone compel some physicians to advocate postoperative radiation therapy to ...improve local control.
Objective: We wondered whether marginal recurrence and survival rates differed between patients with primary MCC treated with Mohs surgery alone and those treated with Mohs surgery and adjuvant postoperative radiation.
Methods: A collaborative retrospective study was performed; the study group consisted of 45 patients with stage I MCC who were histologically and clinically free of disease after Mohs excision. Twenty patients subsequently received elective postoperative radiation to the primary site, and 25 patients had no adjuvant radiation therapy.
Results: One marginal recurrence (4%) and 3 in-transit metastases were observed in the Mohs surgery alone group, whereas none were observed in the Mohs surgery and radiation group. The proportion of patients with these events was not significantly different between treatment groups. Overall survival, relapse-free survival, and disease-free survival were not significantly different between treatment groups.
Conclusion: Adjuvant radiation appears unessential to secure local control of primary MCC lesions completely excised with Mohs micrographic surgery. Adjuvant radiation is recommended for patients unable to have complete excision or if complete histologic margin control is unavailable and should be considered for patients with large or recurrent tumors. (J Am Acad Dermatol 2002;47:885-92.)
Objective
Over 50% of newly diagnosed cutaneous squamous cell carcinoma (cSCC) lesions occur in the head and neck (cSCC‐HN), and metastasis to nodal basins in this region further complicates surgical ...and adjuvant treatment. The current study addressed whether the 40‐gene expression profile (40‐GEP) test can predict metastatic risk in cSCC‐HN with improved accuracy and provide independent prognostic value to complement current risk assessment methods.
Study Design
Multicenter, retrospective cohort study.
Methods
Formalin‐fixed paraffin‐embedded primary tumor tissue and associated clinical data from patients with cSCC‐HN (n = 278) were collected from 33 independent centers. Samples were analyzed via the 40‐GEP test. Cases were staged per American Joint Committee on Cancer, Eighth Edition (AJCC8) and Brigham and Women's Hospital (BWH) criteria after comprehensive medical record and pathology report review. Metastasis‐free survival (MFS) rates were determined, and risk factors were analyzed via Cox regression.
Results
The 40‐GEP test classified the cohort into low (Class 1, n = 126; 45.3%), moderate (Class 2A, n = 134; 48.2%), and high (Class 2B, n = 18; 6.5%) metastatic risk at 3 years postdiagnosis. Regional/distant metastasis occurred in 54 patients (19.4%). MFS rates were 92.1% (Class 1), 76.1% (Class 2A), and 44.4% (Class 2B; p < .0001). Multivariate analysis of 40‐GEP results with AJCC8 or BWH tumor stage, or clinicopathologic risk factors, demonstrated independent prognostic value of the 40‐GEP test (p < .03). Accuracy of predicting metastatic risk was also improved using 40‐GEP classification (p < .02).
Conclusions
Improved metastatic risk stratification through the 40‐GEP test could complement cSCC‐HN risk assessment for better‐informed decision‐making for treatment and surveillance and ultimately improve patient outcomes.
Level of Evidence
3
Cutaneous squamous cell carcinoma of the head and neck (cSCC‐HN) can be aggressive with subsequent metastasis to parotid and cervical lymph node basins, where the presence of sensitive underlying structures can require extensive treatment. More accurate prediction of metastatic risk is a critical unmet need in cSCC‐HN. The 40‐gene expression profile (40‐GEP) test has significant prognostic value for metastatic risk assessment in cSCC‐HN and can complement current tumor classification systems and clinicopathologic factor–based assessment for better‐informed decision‐making and risk‐appropriate patient management.
Margins for standard excision of melanoma in situ Kunishige, Joy H., MD; Brodland, David G., MD; Zitelli, John A., MD
Journal of the American Academy of Dermatology,
07/2013, Letnik:
69, Številka:
1
Journal Article
The appropriate use criteria process synthesizes evidence‐based medicine, clinical practice experience, and expert judgment. The American Academy of Dermatology in collaboration with the American ...College of Mohs Surgery, the American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery has developed appropriate use criteria for 270 scenarios for which Mohs micrographic surgery (MMS) is frequently considered based on tumor and patient characteristics. This document reflects the rating of appropriateness of MMS for each of these clinical scenarios by a ratings panel in a process based on the appropriateness method developed by the RAND Corp (Santa Monica, CA)/University of California–Los Angeles (RAND/UCLA). At the conclusion of the rating process, consensus was reached for all 270 (100%) scenarios by the Ratings Panel, with 200 (74.07%) deemed as appropriate, 24 (8.89%) as uncertain, and 46 (17.04%) as inappropriate. For the 69 basal cell carcinoma scenarios, 53 were deemed appropriate, 6 uncertain, and 10 inappropriate. For the 143 squamous cell carcinoma scenarios, 102 were deemed appropriate, 7 uncertain, and 34 inappropriate. For the 12 lentigo maligna and melanoma in situ scenarios, 10 were deemed appropriate, 2 uncertain, and 0 inappropriate. For the 46 rare cutaneous malignancies scenarios, 35 were deemed appropriate, 9 uncertain, and 2 inappropriate. These appropriate use criteria have the potential to impact health care delivery, reimbursement policy, and physician decision making on patient selection for MMS, and aim to optimize the use of MMS for scenarios in which the expected clinical benefit is anticipated to be the greatest. In addition, recognition of those scenarios rated as uncertain facilitates an understanding of areas that would benefit from further research. Each clinical scenario identified in this document is crafted for the average patient and not the exception. Thus, the ultimate decision regarding the appropriateness of MMS should be determined by the expertise and clinical experience of the physician.
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