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Background: The trigeminocardiac reflex is a common but underreported occurrence that can vary from benign to life threatening. This reflex can be elicited by placing direct pressure on the globe of the eye or from traction of the extraocular muscles, stimulating the trigeminal nerve., Objective: To provide a review of potential stimuli for the trigeminocardiac reflex within dermatologic surgery and to discuss management options for the treatment of the trigeminocardiac reflex., Methods: PubMed and Cochrane were used to identify articles and case reports that established scenarios in which the trigeminocardiac reflex was provoked and subsequently how the reflex was managed., Results: Within the field of dermatologic surgery, the trigeminocardiac reflex can be stimulated during biopsies, cryoablations, injections, laser treatments, Mohs micrographic surgery, and oculoplastic interventions, most often occurring in an office setting. The most common presentations include significant bradycardia, hypotension, gastric hypermobility, and lightheadedness. The most definitive treatment is cessation of the inciting stimulus, monitoring, and symptomatic management. Glycopyrrolate and atropine are common treatments for severe, intractable cases of the trigeminocardiac reflex., Conclusion: The trigeminocardiac reflex, while underreported and underrepresented in dermatologic literature and dermatologic surgery settings, should be considered in the setting of bradycardia and hypotension during dermatologic procedures., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Subcuticular suture is an important technique for achieving optimum wound closure, and there has been no comprehensive summary of subcuticular sutures to date., Objective: To summarize the origin and development of interrupted subcuticular suture to help clinicians improve their wound closure skills., Materials and Methods: A comprehensive review of subcuticular suture techniques was conducted in PubMed to summarize the advantages and disadvantages of various methods and clinical indications., Results: Buried suture is the oldest subcuticular suture technique, followed by buried vertical mattress suture, intracutaneous butterfly suture, modified/variant buried vertical mattress suture, intradermal buried vertical mattress suture, buried horizontal mattress suture, wedge-section and modified buried vertical mattress suture, set-back suture, and modified buried horizontal mattress suture, which have gradually been applied in clinical practice. Buried vertical mattress suture is currently the most widely used subcuticular suture technique., Conclusion: Patients can certainly benefit from the appropriate application of subcuticular suture. There is also no single ideal method for achieving optimal results in all cases. Fully understanding the history of subcuticular suture can help doctors improve their wound closure technique., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society for Dermatologic Surgery, Inc.)

Background: The COVID-19 pandemic has caused an increasing shift toward the utilization of telehealth services. There are limited data on patient preferences for these services in dermatologic surgery., Objective: To evaluate patient preferences regarding telehealth in dermatologic surgery for pre- and postsurgical care., Methods: A survey was administered to patients in an academic dermatology practice., Results: Two hundred twenty-four patients participated. An in-person presurgical consultation was preferred by 62.1%, and a postsurgical in-person visit was preferred by 67.7%. The most commonly cited reason was desire for physical interaction with their surgeon. For each 10-year increase in age, there was a 1.26-fold and 1.12-fold increase in preference for in-person consultation and follow-up, respectively. Eighty-seven percent felt safe during office visit, and 41% reported no anxiety regarding fear of contracting COVID-19. The proportion of patients preferring in-person pre- or postsurgical visits was similar regardless of sex, presence of an immunocompromising condition, prior dermatologic surgery, anxiety level for contracting COVID-19, and perceived level of office safety., Conclusion: A majority of patients prefer in-person visits for pre- and postsurgical care. Older patients have a greater preference for in-person care. Anxiety level regarding COVID-19 and perceived level of office safety were not related to preference for in-person visits., Competing Interests: The authors have indicated no significant conflict of interest with commercial supporters., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: There are limited published data regarding the incidence and risk factors for infection after minor dermatologic procedures, such as skin biopsy, shave, and curettage. Prior studies of infection risk after dermatologic procedures have often not specified the method of preparation of local anesthetic., Objective: To assess the incidence and risk factors for infection after minor procedures performed in a general dermatology clinic using buffered lidocaine prepared in office., Materials and Methods: In this retrospective case-control study, the medical record was searched for cases of infection after skin biopsies, shaves, conventional excisions, and destructions performed in a general dermatology clinic over a 4-year period. Patient and procedure characteristics were compared with uninfected controls., Results: Of 9,031 procedures performed during the study period, there were 34 infections (0.4%). The odds of infection for procedures on the arm and leg were 5.29 and 9.28 times higher, respectively, than those on the head/neck. There was no significant effect of age, sex, smoking, immunosuppression, diabetes, or anticoagulation., Conclusion: The incidence of infection is low after minor dermatologic procedures performed with local anesthesia using buffered lidocaine prepared in office. There is a higher risk of infection on the arm and leg compared with the head and neck., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antibiotics are often prescribed after dermatologic surgery for infection prophylaxis, but patient preferences about prophylactic antibiotics are not well understood., Objective: To understand patient preferences about taking antibiotics to prevent surgical site infection (SSI) relative to antibiotic efficacy and antibiotic-associated adverse drug reactions., Materials and Methods: Multi-center, prospective discrete choice experiment (DCE)., Results: Three hundred thirty-eight respondents completed the survey and DCE. 54.8% of respondents preferred to take an antibiotic if it reduced the SSI rate from 5% to 2.5% and if the risk of adverse drug reactions was low (1% risk gastrointestinal upset, 0.5% risk itchy skin rash, 0.01% risk emergency department visit). Even if an antibiotic could eliminate SSI risk (0% risk SSI) and had a low adverse drug reaction profile, 26.7% of respondents prefer not to take prophylactic oral antibiotics., Conclusion: Risk-benefit thresholds for taking antibiotics to prevent SSI vary widely. Clinical trials are needed to better characterize the effectiveness and risks of oral antibiotic SSI prophylaxis to guide decision-making. Future studies should also evaluate whether shared decision-making can improve the patient experience., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hidradenitis suppurativa (HS) is a chronic dermatologic condition that often necessitates surgical treatment. Surgical approaches vary substantially with little data on efficacy and safety., Objective: Summarize the literature on HS surgery with regards to patient characteristics, surgical approaches, and study quality. Compare postsurgical recurrence rates with a meta-analysis., Methods: PubMed, Embase, and Scopus were searched for studies on surgical HS management published after 2004. A random effects meta-analysis of recurrence rates was performed on eligible studies., Results: Of 715 identified studies, 59 were included in the review and 33 in the meta-analysis. Twenty-two studies of wide excision had the lowest pooled recurrence rate at 8% (95% confidence interval [CI] 2%-16%); local excision had the highest at 34% (95% CI 24%-44%). For studies of wide/radical excision, flap repair had the lowest pooled recurrence rate at 0% (95% CI 0%-4%); delayed primary closure had the highest at 38% (95% CI 20%-59%)., Conclusions: Wide excision and flap-based reconstruction are associated with a lower postsurgical HS recurrence, although this must be balanced against potentially higher morbidity of extensive procedures. Heterogeneity and methodological limitations of the evidence limit the ability to make a strong conclusion about the relative recurrence rates associated with surgical techniques., Registration: PROSPERO ID: CRD42020159948., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Dermatologic surgery services are largely absent in Africa and in Afro-Caribbean counties. In the USA, studies of people of African ancestry have demonstrated health care gaps, but there are no data for Africa nor a Afro-Caribbean country. Dermatology surgery has been largely absent from global health because there are few data to demonstrate the need. We sought to determine skin cancer tumor types, and local knowledge and perception in an Afro-Caribbean country., Objective: We sought to determine whether there exist knowledge gaps and whether a dermatology surgery medical missions program would improve the health of Afro-Caribbean people., Methods: First, we conducted a survey of knowledge and behaviors related to skin cancer. Second, we analyzed the number and types of tumors treated during a multi-year surgical dermatology project., Results: In the survey, 62% did not know what melanoma was. Eighty-one percent did not think skin cancer is preventable. Of 163 surgical specimens, 64 were malignancies with 91% related to UV exposure., Conclusion: There is a need for a skin cancer treatment and education program in a country of mostly African-ancestry people., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Society for Dermatologic Surgery, Inc.)

Background: Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective., Objective: To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy)., Materials and Methods: Systematic literature review and meta-analysis of combination treatment for keloids., Results: After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099)., Conclusion: Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Background: Platelet-rich plasma (PRP) is an increasingly popular treatment modality for various dermatologic conditions, but there are limitations in both the published literature and clinician knowledge., Objective: To create a high-yield, in-depth analysis of PRP in procedural dermatology by reviewing available data on its role in hair restoration, soft-tissue remodeling, resurfacing, and rejuvenation; identifying practice gaps and controversies; and making suggestions for future research that will establish dermatologists as pioneers of regenerative medicine., Materials and Methods: A 2-part systematic review and expert analysis of publications before October 2018., Results and Conclusion: Most studies on PRP report favorable outcomes with the strongest level of evidence existing for androgenetic alopecia followed by postprocedure wound healing, scar revision, striae, rejuvenation, and dermal filling. There is a dearth of large randomized controlled trials, considerable heterogeneity in the variables studied, and lack of specificity in the preparatory protocols, which may influence clinical outcomes. Future investigations should use consistent nomenclature, find ideal solution parameters for each cutaneous indication, determine significant outcome metrics, and follow double-blinded, randomized, controlled methodologies. Addressing these deficiencies will take sound scientific inquiry but ultimately has the potential to benefit the authors' specialty greatly.

Background: Cicatricial ectropion occurs when tension of a scar below the eye has sufficient downward pull to evert the lower eyelid. There are many surgical techniques to repair cicatricial ectropion., Objective: To review the published literature on the repair of cicatricial ectropion, review relevant anatomy, and review surgical considerations for patients with cicatricial ectropion from the perspective of a dermatologic surgeon., Materials and Methods: A search of PubMed was conducted to identify articles on cicatricial ectropion repair through December 1, 2017. Articles were individually reviewed for applicability to dermatologic surgery., Results: Forty-one articles were reviewed. Many articles report significant differences in outcomes when comparing 1 cicatricial ectropion repair technique to another; however, 1 single surgical approach has not been shown to be superior to the rest for most patients., Conclusion: There is a lack of consensus among the literature about the optimal approach to repairing cicatricial ectropion. The selection of surgical technique will vary depending on several factors including the lateral or medial extent of the ectropion, the degree of scarring and tissue density of potential donor sites for a skin flap, and the severity of lid laxity.

Background: The large number of transposition flap geometries available for cutaneous reconstruction often makes the design of these flaps difficult for less experienced dermatologic surgeons., Objective: To present a conceptual approach to designing transposition flaps based on 2 elementary angles., Materials and Methods: First, a simplified framework for designing transposition flaps is presented, based on: (1) the takeoff point of the flap, (2) the angle between the primary limb and the primary defect (Angle A), and (3) the angle between the secondary limb and the primary limb (Angle B). Next, a comprehensive literature review highlights applications of the above conceptual approach in the design of z-plasties and single-lobed and multi-lobed transposition flaps., Results: Different types of transposition flaps all share the same key design elements, and modifications to Angle A and Angle B predict flap biomechanics., Conclusion: The design of transposition flaps can be simplified by understanding how 2 elementary angles influence the geometry and biomechanics of various transposition flaps.

Background: Recent advances in diagnostic and therapeutic modalities have made oncologic care ever more challenging, and multidisciplinary tumor boards (MTBs) are increasingly being used as a forum to discuss and coordinate care for complex oncology patients. Literature on the use of MTBs specific to cutaneous oncology and dermatologic surgery remains limited., Objective: To share our experiences with cutaneous oncology MTBs at the University of Vermont Medical Center (UVMMC)., Methods: We describe the formation, timing, participation, clinical discussion, case follow-up, and coordination of care of our MTBs., Results: A log of all cases discussed at cutaneous oncology MTBs from August 2018 to August 2019 is presented as an example. Five specific cases are described in further detail to demonstrate critical components of multidisciplinary care., Conclusion: The MTBs at UVMMC has created a collaborative environment for providers in multiple specialties to jointly formulate and coordinate optimal treatment plans for difficult cases, particularly when treatment guidelines do not exist or are insufficient. Furthermore, MTBs can serve as an educational forum for all participants.

Background: Recent studies suggest that there are different fistular subtypes in hidradenitis suppurativa (HS) patients who are associated with variable therapeutic outcomes., Objective: To describe clinical and ultrasound features that characterize the different fistular patterns in HS and to evaluate the response to medical therapies., Methods: A retrospective study developed by a well-recognized center specialized in HS analyzing both clinical and ultrasound (US) aspects of fistular structures in HS patients was performed. Medical therapy response was evaluated through follow-up visits at Week 24., Results: A total of 117 fistulas detected in the skin of 40 patients were evaluated. Four different types of fistulas were described: dermal fistula (Type A), dermoepidermal fistula (Type B), complex fistula (Type C), and subcutaneous fistula (Type D). Fistulas Type A and B showed a complete resolution after 6 months of different medical therapies in up to 95% and 65% of cases, respectively. Contrary to this, fistulas Type C and D showed no significant response after a medical intervention., Conclusion: The US evaluation seems to play an important role to define these important structures that will help the clinician in elaborating a personalized combined medical and surgical management of the HS patient.

Background: It remains controversial if Mohs surgery is superior to surgical excision in treating localized sebaceous carcinoma., Objective: To compare Mohs surgery and surgical excision for treating patients with localized sebaceous carcinoma., Materials and Methods: The US National Cancer Database was used to identify patients with histologically confirmed Stage 0 to 2 sebaceous carcinoma from 2004 to 2014. Clinicopathologic and socioeconomic factors were compared between treatment groups using the chi-square test. Overall survival (OS) was evaluated by log-rank test, multivariable Cox proportional hazard regression, and propensity score-matched analysis. Relative survival analyses compared with age- and sex-matched US population were performed., Results: Of 1,265 patients, 234 received Mohs surgery and 1,031 received surgical excision. Mohs surgery had a higher rate of negative margin (p = .004). On multivariate Cox regression analysis, Mohs surgery was associated with longer OS than surgical excision (HR: 0.703, 95% CI: 0.496-0.995, p = .047). The survival benefit of Mohs surgery persisted on relative survival analysis and propensity score-matched analysis (p = .0385), after matching the 2 groups on patient and disease characteristics., Conclusion: Patients who received Mohs surgery had significantly longer OS when compared with those who received surgical excision. Prospective clinical trials comparing these treatment paradigms are warranted.

Background: The role of adjuvant radiotherapy (ART) for cutaneous squamous cell carcinoma (cSCC) following negative surgical margins is unclear., Objective: To retrospectively examine the clinical outcomes in a cohort of patients with cSCC who completed ART after Mohs micrographic surgery or wide local excision with negative margins., Methods and Materials: After the institutional review board approval, a retrospective review was conducted of all patients with cSCC treated in the Mayo Clinic Department of Radiation Oncology from March 10, 1998, through April 26, 2013. Inclusion criteria were age >18 years, resection with negative histologic surgical margins, and completion of ART., Results: Thirty-two patients met the inclusion criteria: 15 patients died, 12 without evidence of disease related to cSCC. Three patients developed recurrent disease, all with poorly differentiated cSCC, > 2 cm in clinical diameter, perineural invasion, and Brigham and Women's (BWH) stage T2b/T3; 2 of 3 patients were immunosuppressed; and 2 of 3 patients died of cSCC-related causes., Conclusion: These data suggest that the combination of surgical resection and ART is a reasonable option for Brigham and Women's T2b/T3 tumors.