Search

Supplemental Digital Content is Available in the Text. BACKGROUND: Tissue preservation and tumor clearance are hallmarks of Mohs micrographic surgery, but no standardized method currently exists to guide trainees on how to balance the two. OBJECTIVE: The authors provided residents and fellows with additional histologic information to enhance their surgical decision-making without changing the standard methodology of Mohs surgery. METHODS AND MATERIALS: Trainees were provided initial biopsy slides (IS) and frozen vertical sections (VS) of the first Mohs layer. All Mohs layers were excised in standard fashion, and vertically oriented sections were taken from the layer without disturbing the surgical margins to obtain VS. Surveys were used to assess trainees' confidence in performing Mohs surgery with and without these tools. RESULTS: Trainees reported increased confidence in performing Mohs surgery when they reviewed IS before surgery and viewed VS of the first layer. CONCLUSION: Reviewing IS and VS improved trainees' confidence in performing Mohs surgery. This additional histological information was obtained while maintaining the usual steps of Mohs surgery. Objective information obtained from IS and VS may explain why trainees' confidence increased using this technique. Both IS and VS can be valuable teaching tools that may enhance trainees' ability to perform Mohs surgery. [ABSTRACT FROM AUTHOR]

This article discusses the repair of a large defect on the earlobe, conchal bowl, inferior helix, and antihelix caused by the removal of a malignant melanoma. The authors describe the challenges of reconstructing such a complex and multi-subunit defect and outline the surgical techniques used. They ultimately used a combination of a full-thickness skin graft and a superiorly based banner transposition flap to restore the natural contour and bulk of the earlobe, helical rim, and antihelix. The patient achieved a functionally and cosmetically acceptable result with no complications or recurrence of the disease. [Extracted from the article]

BACKGROUND: The use of Mohs surgery for melanoma on the trunk and extremities is not supported in the guidelines of dermatology, but is widely used in the real world. OBJECTIVE: The purpose of this article is to expose the value of Mohs surgery for melanoma on the trunk and extremities for consideration of updating the guidelines. MATERIALS AND METHODS: This was a retrospective review of a prospectively maintained database 7 to identify patients whose melanomas would likely have recurred using standard surgical margins. A prediction model was used to evaluate the value of Mohs surgery. RESULTS: The model predicted that 2,847 (2%) patients with melanoma on the trunk and extremities would likely recur each year with standard surgical margins even after re-excision when positive margins were identified, compared with 0.1% after Mohs surgery. This likely would result in the upstaging of 27% of melanoma in situ patients and 13% of patients with invasive melanoma. The upstaging would also result in a decrease in melanoma-specific survival and the death of 1% of patients with true local recurrences of melanoma. CONCLUSION: Mohs surgery has value for melanoma on the trunk and extremities by minimizing local recurrence and death from disease progression. [ABSTRACT FROM AUTHOR]

BACKGROUND It is recommended to excise adnexal neoplasms with standard local excision or Mohs micrographic surgery (MMS), although many occur on high-risk sites such as the head and neck (H&N) and exhibit subclinical extension. Minimal evidence exists on the efficacy of standard excisions for these tumors. OBJECTIVE To evaluate the rate of positive surgical margins after standard excision of adnexal tumors. METHODS Retrospective cohort study of cutaneous adnexal malignancies from the National Cancer Database diagnosed from 2004 to 2019. RESULTS The authors identified a total of 4,402 cases treated with standard excision. Tumors on the H&N were approximately twice as likely as those on the trunk and extremities (T&E) to be excised with positive margins (odds ratio 2.146, p <, .001), with the highest estimated rate for eccrine adenocarcinoma (12.1%, SE: 2.3%). The subtype with the highest positive margin rate on the T&E was microcystic adnexal carcinoma (8.0%, SE: 2.9). Positive margins were associated with poorer overall survival on multivariable survival analysis (hazard ratio 1.299, p 5 .015). CONCLUSION The authors present subtype- and site-specific positive margin rates for adnexal tumors treated with standard excision, which suggest that tumors on the H&N and some T&E subtypes, should be considered for MMS. [ABSTRACT FROM AUTHOR]

This article discusses the repair of a total scrotal defect that extended into the perianal area. The patient had extramammary Paget disease on the scrotum, and three stages of Mohs micrographic surgery were required to remove the tumor. To reconstruct the scrotal defect, two full-thickness skin grafts (FTSGs) were performed, while secondary intention healing was chosen for the right inguinal fold and perineum. The bilateral upper inner arms were chosen as the donor sites for the FTSGs. The article also discusses considerations for scrotal repair and alternative techniques for large scrotal defects. [Extracted from the article]

BACKGROUND: Mohs micrographic surgery, involving pathology of the surgical margin, has the lowest recurrence rate for skin cancer. Moreover, because of technological advances, digital pathology systems are gradually being adopted in hospitals. Yongin Severance Hospital was the first hospital to construct a fully digitalized pathology system in Korea. OBJECTIVE: To evaluate the efficiency and characteristics of the digital pathology system for Mohs micrographic surgery. METHODS: The medical records of 80 patients with skin cancer who underwent Mohs micrographic surgery from March 2020 to August 2022 were analyzed for the number of frozen margins, number of stages, operation time, and recurrence rate to compare cases based on the pathology system. RESULTS: Overall, 23 and 57 patients were examined using the conventional and digital pathology systems, respectively. The mean number of final stages was 0.494 lower (p -value =.008), the time from the previous to the next stage was 0.687-fold shorter (p =.002), and the rate of switching from positive to negative margins was 1.990 times higher (p =.044) in the digital than the conventional group. LIMITATIONS: Retrospective single-center experience; short follow-up time. CONCLUSION: Digital pathology reduces operative time and increases accuracy in Mohs micrographic surgery. [ABSTRACT FROM AUTHOR]

This article discusses a case of invasive conjunctival melanoma discovered during Mohs micrographic surgery for melanoma in situ of the medial canthus skin. The patient, an 82-year-old man, initially presented with a brown macule in the right medial canthus. Biopsy results revealed a combined nevus with atypical features, and subsequent excision showed melanoma in situ. During the Mohs surgery, a dark nodule was found in the conjunctiva, which was confirmed to be invasive melanoma. The patient underwent additional resection and reconstruction, and adjuvant pembrolizumab therapy was recommended. The article highlights the rarity of conjunctival melanoma, its variable clinical presentation, and the importance of early detection and appropriate treatment. [Extracted from the article]

This article discusses the use of Slow Mohs Micrographic Surgery (sMMS) for the treatment of genital Dermatofibrosarcoma Protuberans (DFSP). DFSP is a rare type of cutaneous sarcoma that often recurs locally. The authors describe five cases of genital DFSP treated at their hospital using sMMS. The results showed satisfactory outcomes with no local recurrences. The article emphasizes the importance of a multidisciplinary approach to diagnosis and management for optimal outcomes. [Extracted from the article]

This article discusses a rare case of squamous cell carcinoma in situ (SCCIS) of the nipple and its successful treatment with Mohs micrographic surgery (MMS). SCCIS of the nipple is a rare condition, with only 10 reported cases. The patient in this case presented with a flaky lesion on the nipple, and a biopsy confirmed the diagnosis of SCCIS. MMS was performed, and the surgical margins were found to be clear of SCCIS. The patient opted for healing by second intention and did not require reconstructive surgery. The article also mentions other treatment options for SCCIS of the nipple, such as photodynamic therapy, wide local excision, and mastectomy with sentinel lymph node biopsy. MMS is a promising treatment option for SCCIS of the nipple as it allows for complete assessment of margins and offers a good cure rate while minimizing tissue removal and the need for reconstruction. [Extracted from the article]

BACKGROUND: With an improved understanding of tumor biology and behavior, the recommended margins for the surgical treatment of melanoma have evolved. OBJECTIVE: We describe the progression of these surgical margins, detailing the historical basis for the 5-cm margin and transitioning to current practice, in which Mohs micrographic surgery (MMS) with immunohistochemistry (IHC) has become increasingly used. METHODS/MATERIALS: We searched PubMed and Google Scholar for articles published between January 2019 and April 2023 describing the use of MMS for melanoma in situ (MIS) and invasive melanomas. RESULTS: We identified 12 articles focusing on the use of MMS for MIS and invasive melanomas: 3 meta-analyses and 9 retrospective studies. Two retrospective analyses documented no differences in overall survival between MMS and wide local excision (WLE) and 2 found improved overall survival for MMS compared with WLE. Three retrospective analyses and 3 meta-analyses demonstrated low recurrence rates after the use of MMS for both MIS and invasive melanomas. Finally, 2 retrospective studies documented the success of MMS with IHC using MART-1. CONCLUSION: Over the past century, the surgical margins for the treatment of melanoma have undergone a marked transformation. MMS with IHC has become increasingly popular given its ability to reliably produce superior clinical outcomes. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. BACKGROUND: Vulvar melanoma is a rare malignancy with frequent recurrence and poor prognosis. National guidelines recommend wide local excision of these tumors with allowances for narrower margins for anatomic and functional limitations, which are common on specialty sites. There is presently a lack of data of margin positivity after standard excision of vulvar melanomas. OBJECTIVE: We aim to evaluate the rate of positive margins after standard excision of vulvar melanomas. MATERIALS AND METHODS: Retrospective cohort study of surgically excised vulvar melanomas from the NCDB diagnosed from 2004 to 2019. RESULTS: We identified a total of 2,226 cases. Across surgical approaches and tumor stages, 17.2% (Standard Error [SE]: 0.8%) of cases had positive surgical margins. Among tumor stages, T4 tumors were most commonly excised with positive margins (22.9%, SE: 1.5%). On multivariable survival analysis, excision with positive margins was associated with significantly poorer survival (Hazard Ratio 1.299, p =.015). CONCLUSION: We find that positive margin rates after standard excision of vulvar malignancies are higher than for other specialty site melanomas. Our data suggest that use of surgical approaches with complete margin assessment may improve local control and functional outcomes for patients with vulvar melanoma as they have for patients with other specialty site melanomas. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. BACKGROUND: Few prospective studies have evaluated local recurrence rates (LRR) after excision of desmoplastic melanoma (DM); however, several retrospective studies have reported high LRR. OBJECTIVE: To determine LRR after excision of DM and evaluate factors affecting LRR. MATERIALS AND METHODS: Systematic review of the PubMed, Embase, and Web of Science databases was performed to identify studies reporting local recurrence after excision of DM with conventional wide local excision (WLE), Mohs micrographic surgery (MMS), or staged excision (SE). Meta-analysis was performed to calculate summary LRR and pooled risk ratios (RR). RESULTS: Literature search identified 4 studies evaluating MMS or SE (total n = 61 DM). 53 studies assessed WLE (n = 3,080) and were analyzed quantitatively. The overall LRR after WLE of DM was 21% (95% CI, 0.16–0.28; n = 2,308). Local recurrence rate was higher with positive/unknown histologic excision margins (49%, 95% CI, 0.25–0.74; n = 91) versus negative histologic margins (11%, 95% CI, 0.07–0.17; n = 1,075; [ p <.01]). Neurotropism was also associated with increased LRR (RR, 1.79; 95% CI, 1.34–2.38, p <.01; n = 644). CONCLUSION: DM has high LRR after WLE. Local recurrence risk was greatest with positive excision margins, indicating the importance of achieving negative microscopic margins. Greater study of MMS and SE for DM is required. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. BACKGROUND: Current consensus guidelines have discouraged the use of sub-0.5-cm (in situ) and sub-1-cm (invasive) margins when performing Mohs micrographic surgery (Mohs) for melanoma, with minimal evidence to guide this recommendation. OBJECTIVE: To compare melanoma local recurrence rates after Mohs based on initial margin size. MATERIALS AND METHODS: A systematic review and meta-analysis was conducted with search terms including Mohs micrographic surgery, surgical margin, recurrent disease, and melanoma. RESULTS: Forty-three studies were included. The 5- to 10-mm margin category had a statistically significant lower local recurrence compared with 1- to 5-mm and 5-mm categories. Recurrence for 1- to 5-mm, 5-mm, 5- to 10-mm, and 10-mm categories were 2.3% (CI 0.8–3.5, p <.001), 1.4% (CI 0.6–2.2, p <.001), 0.3% (CI 0.2–0.5, p <.001), and 6.1% (CI -6.7 - 18.8, p =.349), respectively. Number of stages for 1 to 5, 5, 5 to 10, and 10-mm categories were 1.8, 1.8, 1.6, and 1.6, respectively. There was no statistically significant difference between the groups (p =.694). CONCLUSION: Five- to 10-mm margins were associated with the lowest local recurrence rates. A 5- to 10-mm initial margin should be considered where other factors (tumor characteristics, anatomical or functional considerations) allow. [ABSTRACT FROM AUTHOR]

This article discusses the influence of sex on outcomes in basal cell carcinoma (BCC). The study found that men have a higher incidence of BCC compared to women, and they also have poorer outcomes, including higher rates of local recurrence and poor outcomes. The reasons for these differences remain unclear, but it is suggested that factors such as sex hormones, immune response, and responses to oxidative stress and ultraviolet-induced damage may play a role. The study acknowledges its limitations and calls for further research to better understand the role of sex in BCC outcomes. Additionally, the article briefly mentions the need for a national registry to collect data on rare skin tumors, as current registries are not optimized for this purpose. [Extracted from the article]

BACKGROUND: Incomplete excision of squamous cell carcinoma (cSCC) is associated with an increased risk of recurrence, metastasis, and mortality. OBJECTIVE: To determine the rate and characteristics of incompletely excised cSCC in a dermatological daily practice setting. METHODS: Prospective study of all patients who gave informed consent, with a cSCC treated with standard excision (SE) at 1 of 6 Departments of Dermatology in the Netherlands between 2015 and 2017. Pathological reports were screened to detect all incompletely excised cSCCs. RESULTS: A total of 592 patients with 679 cSCCs were included, whereby most cases were low risk cSCC (89%). The rate of incompletely excised cSCC was 4% (n = 26), and the majority were high-risk cSCCs of which 24 invaded the deep excision margin. CONCLUSION: This prospective study showed that in a dermatological setting, the risk of an incompletely excised cSCC is low (4%) for a cohort that was dominated by low-risk cSCCs. Most incompletely excised cSCCs were of high risk, and incompleteness was almost always at the deep margins. These results suggest that for high-risk cSCC, one should pay attention especially to the deep margin when performing SE, and/or microscopic surgery should be considered. [ABSTRACT FROM AUTHOR]

The secondary defect of the superior V-Y advancement flap was closed first, then the lateral advancement flap was sutured to meet the superior V to Y flap. Guiding sutures could decrease wound size to accelerate healing and allow granulation to provide a wound bed for a delayed graft, but also could lead to eyebrow asymmetry and an atrophic, hypopigmented, round, large scar. Second intention would be an option, but in a defect of this size, this could cause eyebrow asymmetry from wound contracture and require longer wound care. [Extracted from the article]

An interpolated forehead flap would have provided an excellent resolution, however, would have required a second stage to divide and inset the flap and possibly a third stage to reduce the flap thickness further to approximate that of the normal tissue at this site. Conundrum Keys (1) Repair of a large defects of the upper nasal bridge is possible with a melolabial transposition flap as an alternative to an interpolated forehead flap. Two tacking sutures were placed, one at the right nasofacial sulcus and the second at the nasal root to restore normal contour.[2] The flap was then inset with the same sutures used to repair the secondary defect. [Extracted from the article]

Supplemental Digital Content is Available in the Text. BACKGROUND: Mohs micrographic surgery (MMS) is becoming increasingly popular for the treatment of cutaneous melanoma (CM) as multiple studies have demonstrated favorable outcomes for local recurrence and overall survival. OBJECTIVE: To analyze the outcomes of noninvasive (NIM) and invasive melanomas (IM) using MMS with fresh frozen sections. The primary outcome was local recurrence. The secondary outcome was to identify mean surgical margins based on tumor type and location. METHODS: Retrospective cohort study of 224 cases of CM treated from 2006 to 2016 at a tertiary academic center with MMS and fresh frozen sections by a single Mohs surgeon. RESULTS: The overall recurrence rate was 2.6% with a mean follow-up of 36.2 months. The recurrence rate for NIM versus IM was 1.6% and 7%, respectively. The mean margins for NIM and IM were 7.9 mm and 10.1 mm, respectively. These varied by tumor site and location. CONCLUSION: This study supports the use of MMS in the treatment of CM and highlights how narrower surgical margins for NIM of the head and neck can be achieved without increasing risk of local recurrence. [ABSTRACT FROM AUTHOR]

BACKGROUND: When treating Merkel cell carcinoma (MCC), the relation between wide local excision (WLE) margin and recurrence or survival is unclear. Mohs micrographic surgery (MMS) is an alternative surgical option for MCC, but it is unknown whether the local recurrence rate differs between MMS and WLE. OBJECTIVE: To systematically assess the available literature to determine the recurrence and survival rates when treating MCC with MMS and different clinical excision margins. MATERIALS AND METHODS : The MEDLINE, EMBASE, and CENTRAL databases were searched. Two independent reviewers selected studies that defined clear excision margins and either recurrence or survival. When possible, individual cases were extracted from case series and included in the analyses. Other studies were reviewed narratively. RESULTS : Overall, 1108 studies were identified; of which, 19 case series (168 cases) and 12 cohort studies were eligible. None of the cohort studies showed significant differences in recurrence or survival for either excision margins or MMS. Equally, logistic and Cox regression analyses of the case series revealed no significant differences in recurrence or survival between different excision margins and MMS. CONCLUSION : Synthesis of the available data does not indicate differences in recurrence and/or survival rates for MCC between different clinical excision margins and MMS. [ABSTRACT FROM AUTHOR]

The secondary defect from mobilizing the Bridge Flap was closed using 4-0 poliglecaprone 25 buried vertical mattress sutures to subcuticular tissues and 6-0 fast absorbing catgut continuous running suture to skin. shows the immediate postoperative result at the time of removal of sutures. The Bridge Flap was then developed by making a midline vertical forehead incision from the glabella to the frontal hairline, which was carried to the supraperiosteal plane. (2) Large defects of the lateral forehead region may benefit from the addition of a bridge flap to a laterally based flap repair to generate more movement from the medial forehead and reduce tension. [Extracted from the article]

Flap design: cervicofacial rotation flap with a retroauricular transposed lobe. (2) The cervicofacial rotation flap/retroauricular scalp bilobed transposition is a reconstructive option that can be used to repair large central cheek defects. A cervicofacial rotation flap and retroauricular scalp transposition flap were planned as depicted in. [Extracted from the article]

BACKGROUND: Optimal surgical treatment modality for invasive melanoma (IM) and melanoma in situ (MIS) has been debated with proponents for standard wide local excision (WLE), serial disk staged excision, and Mohs micrographic surgery. OBJECTIVE: The purpose of this study is to identify the recurrence rates and surgical margins of invasive stage 1 melanoma and MIS lesions using serial disk staged excision technique with rush permanent processing and "bread loafing" microscopic analysis. MATERIALS AND METHODS : Recurrence rates and surgical margins of 63 IM and 207 MIS at the University of California Dermatology Surgery Unit were retrospectively reviewed. RESULTS : No recurrences were observed with average follow-up of 34 and 36 months for IM and MIS, respectively (range, 10-92 months). Average surgical margins were 19.8 mm (SD 9.7) for IM and 12.1 mm (SD 12.2) for MIS. CONCLUSION: This SSE technique for the treatment of IM and MIS is comparable in efficacy to other SSE techniques, and it offers physicians a simple and accessible alternative to WLE and MMS. [ABSTRACT FROM AUTHOR]

BACKGROUND: Perusal of the literature of cutaneous squamous cell carcinoma (SCC) reveals that the role of the desmoplastic subtype is indistinct. Data on local infiltration and recurrence are inconsistent dependent on surgical technique, histological method, and investigated collective. OBJECTIVE: The aim of the study was to analyze local infiltration and locoregional recurrence of the desmoplastic subtype under a uniform procedure. METHODS AND MATERIALS: Between 2005 and 2015, 320 SCCs were analyzed and histological sections of all tumors were examined. Data collection included locoregional recurrence, metastasis rate, and tumor-specific death. The median follow-up was 36.5 months. RESULTS : The desmoplastic subtype required significant more re-excisions (70.0% vs 23.9%, p <.001), more interventions until tumor-free margins were achieved (maximal 6 vs 2; p <.001), showed more widespread tumor infiltration with larger excisional margins (median 9 mm, 2-51 mm vs median 4 mm, 1-10 mm; p <.001), and a 5-fold higher local recurrence rate (26.7% vs 5.0%, p <.001). The metastasis rate (16.6% vs 2.3%, p <.001) was increased. CONCLUSION : The desmoplastic subtype is characterized by a widespread local infiltration associated with perineural infiltration. It seems to be a marker for decreased histological detectability with a high rate of locoregional recurrence and metastasis. [ABSTRACT FROM AUTHOR]

BACKGROUND: Amputation has been the standard treatment for subungual melanoma. Although there is growing attention toward a more conservative functional surgery, specific operative techniques are not yet available. OBJECTIVE: We aimed to provide objective measurements for use in functional surgery by analyzing the anatomy of the nail apparatus obtained from 21 cadavers. MATERIALS AND METHODS: Nailbed thickness was histologically measured in each subunit, and skin surface anatomy was evaluated to determine the proximal resection margin. Immunohistochemical staining was performed to analyze microvessel distribution according to the nail subunit. RESULTS: The nailbed thickness was the thinnest at the most proximal point of the nail matrix (thumbs, 1.10 ± 0.42 mm; big toes, 1.15 ± 0.37 mm) and the thickest at the hyponychium (thumbs, 2.86 ± 0.82 mm; big toes, 2.72 ± 0.84 mm). The distance from the eponychium to the skin surface closest to the bony cortex of extensor tendon insertion was 6.92 ± 5.13 mm in thumbs and 5.14 ± 1.59 mm in big toes. The median microvessel density was the highest at the hyponychium (25.74 vessels/mm2) and lowest at the germinal matrix (16.26 vessels/mm2) (p <.05). CONCLUSION: This histological study offers practical tips, including those to help decide the proximal and deep resection margins, in functional surgery. [ABSTRACT FROM AUTHOR]

Fisher and colleagues[4] described a combined cutaneous island pedicle flap and mucosal advancement flap for a large partial-thickness lateral lower lip defect, illustrating common themes to our case. To repair the defect, we combined both a mucosal island pedicle advancement flap with a cutaneous island pedicle advancement flap. A similar bilateral island pedicle advancement flap approach has been described for smaller partial-thickness defects on the upper lip,[3] but not for large full-thickness defects on the lower lip. [Extracted from the article]

Three fellowship-trained Mohs surgeons excised the surgical margins in all cases, and 5 Mohs technicians processed the A layers. The principal benefit of Mohs surgery over other treatment modalities for skin cancer is that it allows for complete microscopic examination of circumferential and deep margins. For each threshold layer (referred to as Layer A) encountered, the Mohs surgeon excised an additional layer (Layer B) to determine tumor status. [Extracted from the article]

BACKGROUND The gold standard of treatment for cutaneous squamous cell carcinoma (cSCC) is surgery radiation therapy (RT) is used selectively as definitive treatment for low-risk tumors or as adjuvant/salvage treatment for high-risk tumors. There is a lack of standardized studies evaluating the efficacy of RT in either clinical scenario. OBJECTIVE To determine the efficacy of primary and adjuvant/salvage RT for the treatment of cSCC. MATERIALS AND METHODS A systematic review of PubMed, Embase, Cochrane, and Web of Science was performed for studies that reported outcomes of cSCC treated with RT to the primary site alone. Outcomes included local control (LC), local recurrence (LR), nodal metastases (NM), distant metastases (DM), disease-specific death (DSD), and recurrence-free survival (RFS). RESULTS Forty-six studies with 4,141 tumors were included. Pooled LC and LR rates were 87.3% and 8.6%, respectively. The rates of NM, DM, DSD, and RFS were 4.8%, 3.5%, 5.3%, and 73.5%, respectively. Local recurrence was significantly higher for T3 and T4 tumors, with rates above 25.9%. CONCLUSION LR after RT to the primary site increased with increasing tumor stage, highlighting the importance of clear surgical margins for high-risk tumors. Prospective randomized studies characterizing outcomes by tumor stage for RT compared with surgery are needed to inform guidelines. [ABSTRACT FROM AUTHOR]

BACKGROUND Several studies have reported the presence of hypopigmentation in extramammary Paget disease (EMPD). However, an in-depth analysis regarding its clinical implication is lacking. OBJECTIVE To evaluate the clinical characteristics of EMPD in the Korean population and to determine the implication of hypopigmentation on clinical outcomes. METHODS We retrospectively reviewed 124 cases of EMPD who underwent surgical treatment from a single tertiary hospital from December 2005 to March 2019. Baseline characteristics of the patients and hypopigmentation patterns were analyzed. Moreover, the number of stages of Mohs micrographic surgery (MMS) and recurrence rate were evaluated in relation to the hypopigmentation. RESULTS A total of 67.7% (n 5 84) of the patients showed hypopigmentation. The adjusted odds ratio for recurrence in the hypopigmented group was 5.980, which was statistically significant (95% confidence interval51.347–26.553, p-value 50.019). Furthermore, the average number ofMMSstages was 2.92 in the hypopigmentation group, compared with 1.82 in the nonhypopigmentation group (p-value 5 .0016). CONCLUSION Hypopigmented lesions may disguise the tumor margin, thus raising the recurrence rate after surgery and the number of stages of MMS. The hypopigmentation status must be considered when deciding the surgical margin. [ABSTRACT FROM AUTHOR]

BACKGROUND Melanoma in situ (MIS) can have poorly defined borders and subclinical extension that makes margin control challenging. Reflectance confocal microscopy (RCM) is a promising noninvasive technique that can be used to assess subclinical spread. OBJECTIVE To optimize surgical margins of histology-proven MIS using RCM mosaics. MATERIALS AND METHODS Prospective review of 22 patients with histology-proven MIS who underwent RCM margin mapping prior to staged excision, between August 1, 2018, and August 13, 2020, at the Department of Dermatology, University of New Mexico, School of Medicine. RESULTS Twenty patients (91%) had tumor clearance on the first stage using a 3-mm surgical margin after confocal margin mapping. CONCLUSION Reflectance confocal microscopy margin mapping using the mosaic device tends to clear MIS in one stage, and the use of the handheld device may improve the accuracy for difficult anatomic areas. Current Procedural Terminology codes for RCM do not reflect the time required and complexity of the procedure. Reflectance confocal microscopy margin mapping prior to excision has the potential to decrease the number of stages needed for melanoma removal, reduce treatment time, and cost. [ABSTRACT FROM AUTHOR]

First, using a standard posterior approach, a cartilage strut was harvested from the posterior conchal bowl and secured with 5.0 polyglactin 910 sutures onto the residual antihelical cartilage of the defect (Figure 2). This latter option offers significantly less risk of flap impingement as the cartilage graft removal helps create a wider space for the flap pull-through. Whereas antihelical cartilage graft obtained from the contralateral ear might be longer and better able to span the height of the defect than an ipsilateral conchal bowl graft, by contrast, an ipsilateral conchal bowl cartilage graft harvested with a posterior approach would be more advantageous for tunnel development and pull through of a mastoid flap. [Extracted from the article]

Background: Nonpigmented intradermal melanocytic nevi (IMN) are benign lesions often removed for cosmetic reasons. There is no consensus as to the best technique for IMN excision. Objective: To compare cosmetic outcomes and risk of recurrence after shave excision versus elliptical excision of IMN. Materials and methods: In this randomized clinical trial, patients underwent shave excision or elliptical excision with sutured closure of IMN of the face or back. Recurrence, patient satisfaction, cosmetic outcome, postoperative discomfort, scar size, discoloration, and presence of hypertrophic or keloid scars were evaluated at 3, 6, and 9 months. Results: Overall, 145 nevi were removed from 45 patients (86.7% women, mean age 52.1 ± 12.5 years). The recurrence rate was 11.7%, occurring only after shave excision; 94.1% of recurrences were observed at 3-month follow-up. Shave excision was associated with less discomfort 48 hours after intervention but a greater likelihood of involved lateral and deep margins (p < .001). Scars were larger after elliptical excision and suture than after shave excision (p < .01). The mean patient satisfaction was higher in the shave excision group (p < .004). Conclusion: Shave excision of IMN is associated with higher rates of involved surgical margins and recurrence than elliptical excision but provides superior cosmesis and patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: The primary endpoint for surgical excision of skin cancer is the positive margin status. Tumor characteristics may explain much of this risk, but other important factors can include physician specialty. Objective: To determine the variables affecting the success of a basal cell carcinoma (BCC) or melanoma in situ (MIS) excision. Methods/materials: An 8-year, multicenter, retrospective study of 5,800 BCC or MIS excisions performed at 13 different Kaiser Permanente medical centers. The margin status was determined by searching final pathology diagnosis texts for phrases associated with positive margins. Results: An incomplete excision rate was found in 23% of all specimens (BCC-22%, MIS-25%). Per specialty, the proportion of specimens with positive tumor margins was 24% for dermatology, 26% for plastic surgery, 28% for otolaryngology, and 12% for general surgery. General surgeons most often excised large tumors and tumors from truncal regions, 2 variables conferring lower odds of an incomplete excision. For non-Mohs procedures, dermatologists were no different than otolaryngologists or plastic surgeons in performing an incomplete BCC or MIS excision in all multivariate models (all p > .05). Conclusion: Intrinsic tumor characteristics may influence the success of achieving tumor-free resection margins more than the specialty of the provider. [ABSTRACT FROM AUTHOR]

Background: Obtaining conventional wide surgical margins is challenging in melanomas occurring at anatomically complex sites (e.g., hands and feet). Objective: We investigated the potential benefits of slow Mohs micrographic surgery (MMS) for acral melanomas. Materials and methods: This single-center retrospective study investigated 210 patients who underwent slow MMS (n = 66) or wide local excision (WLE, n = 144) for melanomas during 2005 to 2015. Slow MMS was used for melanomas in anatomically complex locations and for high-risk lesions. Results: Acral melanoma (166/210) was the most common lesion observed in patients, in addition to head and neck (21/210) and trunk (23/210) melanomas. Slow MMS was more commonly performed for acral, and head and neck melanomas (32.5% and 52.4%, respectively) than for trunk melanomas (4.3%, p = .002). Local recurrence of acral melanomas occurred in 3.7% of patients after slow MMS and in 10.7% of patients after WLE. Multivariate analysis showed comparable prognostic outcomes between slow MMS and WLE used for acral melanomas. Compared with WLE, slow MMS resulted in a smaller postoperative defect after acral lesion excision (p < .001). Conclusion: Slow MMS is an effective alternative to WLE for acral melanomas in anatomically complex sites, as evidenced by superior outcomes and maximum tissue conservation. [ABSTRACT FROM AUTHOR]

Background: The local recurrence rates of malignant skin tumors after micrographic controlled surgery using complete circumferential peripheral and deep margin assessment (CCPDMA) are reported to be low. However, in daily practice, tumor entities with a significantly higher recurrence rate are found. Objective: The aim of the investigation was to identify these high-risk tumors to develop approaches for risk stratification. Patients and methods: We included different malignant tumors that were surgically treated and examined with CCPDMA using paraffin sections and H&E staining. Re-excisions were performed until the tumor was completely removed. Results: Ninety-nine thousand three hundred seventy-two tumors were included in the study; the follow-up period was 4 years (median). Eight tumor entities were identified as high-risk entities, showing a significantly higher local recurrence rate of over 20%: desmoplastic squamous cell carcinoma, desmoplastic melanoma, Merkel cell carcinoma, microcystic adnexal carcinoma, pleomorphic sarcoma, liposarcoma as well as angiosarcoma, and extramammary Paget's disease. Conclusion: Complete circumferential peripheral and deep margin assessment allows complete control of the resection margins and enables skin-sparing resections with low recurrence rates for basal cell carcinomas, nondesmoplastic squamous cell carcinomas, lentiginous melanomas, and dermatofibrosarcoma protuberans. However, other tumors show significantly higher recurrence rates and therefore need to be classified as high-risk tumors. [ABSTRACT FROM AUTHOR]

Background: Surgery is the best treatment for basal cell carcinoma (BCC); however, incomplete excisions are possible. Objective: Assessment of the accurateness of dermoscopy and clinical evaluation in the detection of borders of BCC and description of dermoscopic findings in clinically healthy tissue surrounding BCC. Materials and methods: Eighty-eight lesions with clinical dermoscopic diagnosis of BCC were examined clinically and dermoscopically, to delineate the correct site of surgical incision, demarcating the respective margins with colred dermographic pencils. Specific dermoscopic features were searched in the skin adjacent to the demarcated clinical margin. Results: In 29 of 88 lesions, clinical and dermoscopic margins of the tumor coincided. In the remaining 59 (67%), 10 (16.9%) presented, in the lesion area identified under dermoscopy, classical criteria for BCC and 57 (96.6%) nonclassical criteria. Differences between clinical and dermoscopic margins were significantly more frequent in superficial BCCs (p = .006). The frequency was not significantly different (p = .85) in relation to body sites. Conclusion: Dermoscopy improves the identification of margins for surgical excision in BCC. The observation of nontraditional dermoscopic criteria of BCC, mainly pink-white areas and short telangiectasias in the area between clinically and dermoscopically detected margins, helps to define the actual tumoral margins and to achieve a really radical excision. [ABSTRACT FROM AUTHOR]

Processing eyelid skin can be extremely difficult using frozen sections, particularly when the eyelid specimen is full thickness. This commonly occurs with eyelid tumors abutting the conjunctiva at the eyelid margin. Technique When taking eyelid layers, we often use gentian violet tattoos in lieu of hashes given the delicate nature of eyelid skin. [Extracted from the article]

A 49-year-old man with a medical history of migraines presented for MMS after a local recurrence of a biopsy-proven right occipital scalp DFSP treated outside our institution with wide local excision (WLE). Before bone resection, plastic surgery placed a continuous external tissue expander under local anesthetic (). Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive tumor that predominantly occurs on the trunk (50%-60%), extremities (20%-30%), and infrequently on the head and neck (10%-15%).[1] More scarcely reported in the literature are DFSP cases on the scalp invading the skull.[2] We present a case of recurrent DFSP on the scalp with bone invasion, treated with Mohs micrographic surgery (MMS) and neurosurgery for tumor clearance, followed by plastic surgery for reconstruction using the combination of a continuous external tissue expander and an advancement flap. [Extracted from the article]

Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/10/2021 Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/10/2021 surgical treatment including MMS, dermatologists and dermatologic surgeons should also consider diagnostic imagingandfurtherwork-upinamultidisciplinarysetting. Subtype analysis for subsequent stages of MMS showed 36.7% superficial BCC compared with 29.2% infiltrative/sclerosing and 31.1% mixed subtypes (of which 8.4% were nonaggressive mixed BCC) (Table 1). Analysis of histologic subtype after the first stage of MMS showed 36.7% superficial BCC compared with 34.9% infiltrative/sclerosing and 22.6% mixed subtypes (of which 6.6% were nonaggressive mixed and 16% aggressive mixed BCC). Cases of metatypical BCC, Basosquamous cell carcinoma, and where further MMS stages were taken for pathology other than BCC were excluded. [Extracted from the article]

1 Previous studies using conjoint analysis in skin cancer patients show that patients highly value improvements in cosmetic appearance 2 and oncologic outcomes, such as local recurrence risk. NumberofCasesperBCCSubtype Nodular BCC Superficial BCC SuperficialandNodular BCC Infiltrative BCC Micronodular BCC High-RiskMixed BCC* 3stages Tip 0 13 1 6 1 5 Ala 1 8 5 16 1 9 4stages Tip 0 3 2 2 1 2 Ala 0 4 1 2 0 3 5$stages Tip 0 10 0 3 0 2 Ala 0 1 0 2 0 2 *High-risk mixed BCCis defined as mixedBCC with at least oneaggressive BCCsubtype (infiltrative, sclerosing, or micronodular). Cases of metatypical BCC, Basosquamous cell carcinoma, and where further MMS stages were taken for pathology other than BCC were excluded. Therewasnostatisticallysignificantdifference inthenumberofstagesrequiredtoachievetumorclearance between superficial BCC and infiltrative/sclerosing BCC subtypes or nonaggressive versus aggressive BCC subtypes (p5.15,p5 .55, respectively). [Extracted from the article]

Suture highlighted in blue, suture needle highlighted in yellow and white arrows denote movement of suture. The biggest limitation for use of this flap would be foundintallerdefectsinthecontextoflimitedinferiorear laxity,butitisimpressivethatthisflapwasabletorepair defectsastallas2cm.Largerand/ordeeperdefectsmay benefitfromadditionalstructuralsupportintheformofa cartilage strut or even a cartilage hinge flap. Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/10/2021 Downloaded from http://journals.lww.com/dermatologicsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 04/10/2021 CommentaryonAntihelicalRotationFlapsfortheRepairofSurgicalDefectsof theAuricularAntihelix D yson and colleagues 1 should be commended for reportingtheirexperience withanantihelicalrotation flap to repair small-to-medium size defects of the antihelix. Wedge repairs, multi-staged procedures, transcartilage island pedicle flaps, and bipedicle advancement flaps have also been described for the repair of antihelicaldefects. [Extracted from the article]

The skin flap is reapproximated in 2 layers with interrupted buried vertical mattress sutures and simple interrupted sutures. The volar skin flap is advanced over the stump, and the first suture is placed centrally to avoid a club deformity of the digit. Positive deep surgical margins are one of the main sources of trepidation when performing nail procedures including Mohs micrographic surgery. [Extracted from the article]

In more recent years, reflectance confocal microscopy (RCM) has been used successfully to diagnose and map EMPD.[1] The standard treatment of EMPD is surgery with either wide local excision (WLE) or Mohs micrographic surgery (MMS); however, both are associated with high recurrence rates.[2] We present a case of EMPD diagnosed and mapped with the aid of RCM and subsequently treated successfully with MMS. We report a novel approach to optimize the management of EMPD, which combines RCM tumor mapping, followed by MMS. Extramammary Paget disease (EMPD) is a rare intraepithelial adenocarcinoma of pluripotent keratinocyte stem cells that typically affects the genital region. [Extracted from the article]

Resolution The final defect involved the earlobe, tragus, antitragus, intertragal notch, preauricular cheek, and superolateral neck. Procedure Donor skin inferior to the defect was marked out to match the size and shape of the new folded earlobe to cover the defect. An 84-year-old Caucasian man presented to our clinic after diagnosis of a stage T2a lentigo maligna melanoma with a Breslow thickness of at least 1.4 mm on the left earlobe. [Extracted from the article]

Follow-up of patient series suggested that up to 75% of these patients may develop skin cancers. The differential diagnosis includes atypical fibroxanthoma, spindle-cell SCC, leiomyosarcoma, desmoplastic malignant melanoma, and angiosarcoma. Xeroderma pigmentosum (XP) has been established as an autosomal recessive disorder which is caused by the defect in the repair of DNA due to the ultraviolet (UV) light. [Extracted from the article]