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BACKGROUND The infraorbital cheek is a common location for cutaneous malignancy and thus surgical defects. Reconstruction in this region must maintain nearby free margins to ensure optimal cosmetic and functional outcomes. Large defects may require a flap using lateral or inferior tissue reservoirs. OBJECTIVE To examine outcomes of inferiorly based rotation flaps in the repair of infraorbital cheek defects and highlight pearls for optimal long-term results. METHODS Chart review of patients with a defect of the infraorbital cheek repaired with an inferiorly based rotation flap between February 2010 and December 2018 at a single academic institution. The Visual Analog Scale (VAS) was used for scar assessment. RESULTS Sixty-five patients underwent extirpation of a cutaneous malignancy resulting in defects ranging from 1.0 × 1.0 to 4.5 × 5.5 cm (mean area = 4.8 cm2). Most of the patients did not experience complications. Ectropion occurred in 7 patients. The mean VAS score was 11.6. CONCLUSION An inferiorly based rotation flap yields acceptable outcomes for infraorbital cheek defects and can be considered for defects as large as 5.5 cm. Using pearls for surgical execution presented in this article may allow reconstructive surgeons to include this flap in their repertoire.

There is limited data on non-adherence for surgical treatment in non-melanoma skin cancer (NMSC) patients. The objective of this single-center, retrospective cohort study is to compare rates of non-adherence of surgical treatment options, determine factors associated with non-adherence, and identify barriers for non-adherence. All adult patients with NMSC (> 18 years) seen between 2015 and 2017 recommended surgical treatment (surgical excision and electrodessication and curettage (ED&C) or Mohs surgery) were eligible. Non-adherence was defined as not completing recommended treatment and reasons for non-adherence were collected. Out of 427 patients that met inclusion criteria, patients recommended surgical excision and ED&C had a lower non-adherence rate of 3.4% compared to those recommended Mohs (11.4%) (p = 0.006). Factors associated with non-adherence included self-pay patients (19.07% adherent vs. 43.24% non-adherent, p = 0.004). Multivariate logistic regression analysis confirmed that Mohs patients were more likely to be non-adherent (odds ratio (OR) = 3.839, 95% confidence interval (CI) (1.435-10.270), p = 0.007) compared to surgical excision and ED&C patients. Males were more likely to be non-adherent (OR = 2.474, 95% CI (1.105-5.542), p = 0.028) to females, and self-pay patients were more likely to be non-adherent than those with other payers (OR = 3.050, 95% CI (1.437-6.475), p = 0.004). Of the 37 patients who were non-adherent, the most common reasons were loss to follow-up (46%), social reasons (41%), medical reasons (38%), and financial reasons (22%). There was a significant difference in non-adherence rates between surgical treatments for NMSCs in our cohort. Our study suggests the need for future interventional studies that implement strategies and patient education to decrease non-adherence rates.

Organ transplant recipients (OTRs) are at a significantly elevated risk for developing cutaneous malignancies. In recent years, the advent of dermatology clinics dedicated to this specific patient population has aimed to provide increased access and specialized care, including important sun-protective behavior education. It has been shown that OTRs tend to have poor sun-protective practices, and care at these specialized dermatology clinics has facilitated an improvement in sun-protective behavior. Previously, sun-protective behavior of patients within these specialized clinics has been characterized longitudinally, though only for a short duration of 3 months. We retrospectively analyzed a cohort of 230 OTRs seen at a single academic institution’s transplant clinic between 2016–2020 and sought to characterize sun-protective behavior at baseline and longitudinally. 78 patients returned for at least one follow-up visit, and the median follow-up duration was 15.1 months (IQR 8.4–24.3 months). Sun-protective behavior was quantified using the average score of questions addressing sunscreen usage frequency, consistency, circumstance of application, reapplication, and sun avoidance. We utilized paired Wilcoxon signed-rank tests to analyze changes in sun-protective behavior between initial visits and subsequent follow-up visits. Sun-protective behavior was increased at the first follow-up visit (median change in sun-protective score − 0.04, p = 0.017) and second follow-up visit (median change in sun-protective score − 0.25, p = 0.026) compared to the initial visit. Multivariable logistic regression and mixed effects modeling were employed to quantify patient features associated with increased sun-protective behavior. Female sex [OR 3.79, 95% CI (1.83, 8.04)] and personal history of skin cancer [OR 3.06, 95% CI (1.25, 7.76)] were associated with stronger sun-protective behaviors at baseline. Female sex [OR 13.77, 95% CI (2.44, 77.52)] was the only characteristic associated with increased sun-protective behavior over time. Our findings identify patient characteristics that are associated with increased sun-protective behavior after education in a dermatology clinic dedicated to OTRs.

BACKGROUND Mohs micrographic surgery (MMS) for cutaneous melanoma is becoming more prevalent, but surgical technique varies. OBJECTIVE To define variations in published techniques for MMS for melanoma. METHODS AND MATERIALS A systematic review was performed of PubMed, EMBASE, and Scopus databases to identify all articles describing surgical techniques for MMS for melanoma. Technical details were recorded for the preoperative, intraoperative, and postoperative phases of MMS. RESULTS Twenty-four articles were included. Mohs surgeons vary in how they assess clinical margins, how wide a margin they excise on the first MMS layer, and how they process tissue to determine tumor stage and margin clearance during MMS for melanoma. CONCLUSION Mohs micrographic surgery for melanoma is performed with varied surgical techniques. To establish best practices, additional research is necessary to determine how different techniques affect outcomes.

Patient satisfaction is an important consideration when determining the optimal treatment for non-melanoma skin cancer (NMSC). One critical aspect of patient satisfaction is post-procedural wound care quality of life (QOL), especially as the elderly population grows. This study aimed to evaluate post-procedural wound care QOL in elderly patients undergoing electrodessication and curettage (ED&C) for NMSC in difficult-to-reach areas, namely the posterior shoulder and back. To do so, patient demographics, functionality, co-morbidities, and post-procedural wound care QOL were assessed in twenty elderly patients (age > 65) who underwent ED&C for NMSC at a single academic dermatologic surgery clinic. Independent t-tests were used to evaluate how QOL related to patient age, gender, living situation, relationship status, co-morbidities, and functionality. Patients who lived alone had better-wound care QOL compared to patients who did not live alone (p = 0.04). Patients reported concerns about knocking the wound and did not feel they could care for the wound independently. Patients who were married, female, or had a lower comorbidity score reported poorer QOL, although this finding was not statistically significant. This study indicates that patients’ QOL can be negatively affected by post-procedural wounds located in difficult-to-reach areas. As dermatologists strive to improve patient satisfaction, wound care quality of life should be considered when choosing treatment for NMSC.

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.

The prognostic significance of auricular location in cutaneous squamous cell carcinoma (cSCC) is controversial. We aimed to characterize risk factors for, and evaluate the cumulative incidence of, locoregional recurrence in a cohort of patients with primary auricular cSCC. The study design was a single-institution retrospective cohort review from 1/2007 to 12/2016. Among 851 potentially eligible individuals, 178 patients with primary auricular cSCC met strict criteria for inclusion. Median follow-up was 32 months, 93% were AJCC 8th edition (AJCC8) stage I and 6% were AJCC8 stage II. Most underwent Mohs micrographic surgery (MMS; 97%) and the remainder underwent wide local excision ± parotidectomy ± neck dissection ± adjuvant therapy (3%). Recurrences occurred in seven patients (4%): six were local and one was regional. The 3-year cumulative incidence of local and regional recurrence for AJCC8 stage I–II tumors were 1% (95% CI 0–5%) and 0%, respectively. Among ten patients upstaged to pT3 disease who underwent MMS alone, none recurred locoregionally. Compared to their respective counterparts, advanced stage, PNI, and LVI associated with a significantly increased risk of locoregional recurrence. Our findings suggest that auricular location may not be a significant risk factor for cSCC staging systems. In the absence of other risk factors, unimodal therapy appears adequate for patients with primary, stage I–II auricular cSCC. The prognostic significance of pT3 auricular cSCC stage due to depth of invasion alone should be evaluated further.

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

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As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint.

Renal cell carcinoma (RCC) is the most lethal urological tumor, often because it is widely metastasized at the time of diagnosis. There are reports of cutaneous metastases, most commonly to the head and neck, presenting late after RCC is diagnosed. This case presentation explores a 45-year old female patient with a growing skin lesion on her chin, previously treated as an epidermoid cyst before presenting to dermatology clinic. We present a case of cutaneous metastatic clear cell renal cell carcinoma presenting 7 years after initial diagnosis.

Background Prescription opioids play a large role in the opioid epidemic. Even short-term prescriptions provided postoperatively can lead to dependence. Objective To provide opioid prescription recommendations after Mohs micrographic surgery (MMS) and reconstruction. Methods 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. Results 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. Conclusion 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.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Dermatologic surgery in pregnant/postpartum patients requires deliberate consideration. Although surgery can be safely performed during any trimester, the second trimester and immediate postpartum period is optimal. Surgery should not be delayed for melanoma/high-risk skin cancers. Perioperative positioning, analgesic, antiseptic, and antibiotic selection should be deliberate to avoid risk to the patient/fetus/infant. The left lateral tilt position reduces aortocaval compression syndrome. Lidocaine and epinephrine can be used safely. Alcohol and chlorhexidine are considered safe. Antibiotics commonly used in skin surgery are safe in pregnancy and lactation. Acetaminophen is first line for pain management. Nonsteroidal antiinflammatory drugs should be avoided.

Overall, dermatologic surgery performed in the outpatient setting is very low risk to patients and safer than similar procedures performed under general anesthesia, and is also more cost-effective. There are several approaches to mitigating the risk of complications while optimizing patient outcomes. Strict oversight of the dermatology clinic helps to ensure team members all adhere to standards of care. Vial safety, strict hand hygiene, limiting the use of topical antibiotics, generally continuing all blood thinners perioperatively, and prebiopsy photographs are all examples of approaches to help maximize patient safety.

JAK (janus kinase) inhibitors are becoming increasingly prescribed for various conditions from dermatologic diseases to graft versus host disease in bone marrow transplant recipients. This class of drugs has been found to be truly life-changing for many, though they are not without potential adverse effects. While JAK inhibitors have not been shown to significantly increase the risk of non-melanoma skin cancer (NMSC) in large scale clinical trials, NMSC is one of the most concerning possible adverse events, and there have been several reported cases of aggressive squamous cell carcinomas, especially in our already immunosuppressed patient populations. In these patients, it is incredibly important that patients are on the lowest possible dosage of the JAK inhibitor. In addition, these patients must be routinely screened by a dermatologist with a comprehensive skin exam to ensure early detection if skin cancer was to develop. For those patients diagnosed with skin cancer, early intervention is key to optimize outcomes, and at times, multi-disciplinary care coordination is needed. In the future, large-scale studies with longer follow-up of patients would help determine whether JAK inhibitors significantly increase the risk of NMSC.

Basal cell carcinoma (BCC) histopathology can differ between original biopsy and wide local excision or Mohs micrographic surgery (MMS). We aimed to analyze the rate of difference in BCC subtypes between the original biopsy and MMS frozen section to determine the rate of histopathological upgrading and also to identify risk factors for upgrading. A single institution, retrospective cohort study of patients with BCC treated with MMS was performed at the University of Texas Southwestern. Screening criteria identified 3235 BCCs. Of these, 1289 tumors were identified as having lower-grade pathology on initial biopsy. 291 (22.6%) of the lower-grade pathology tumors were upgraded to a higher-grade pathology. Tumors with an upgraded pathology had significantly greater number of stages performed [mean of 2.5 vs 2.3, p

Given the rapidly evolving nature of the field, the current state of “high-risk” head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized. Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC. Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as “high risk” and “advanced” are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents. Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

Background There is limited literature on the long-term outcomes and prognostic factors of high-risk cutaneous squamous cell carcinomas (hrSCC) treated with Mohs micrographic surgery (MMS). Objective To determine the rates of local recurrence, metastatic disease, and disease-specific death in hrSCCs treated with MMS and patient or tumor factors associated with poor outcomes. Methods Single-institution, retrospective cohort analysis of hrSCC treated with MMS alone and MMS with adjuvant therapy. Results A total of 882 cases of hrSCC treated with MMS were identified, of which 842 were treated with MMS alone, with a median follow-up time of 2.4 years. The rate of local recurrence was 2.5%, of metastatic disease was 1.9%, and of disease-specific death was 0.57%. Perineural invasion, poor differentiation, and immunosuppression were significantly associated with poor outcomes. In propensity score–matched case patients treated with adjuvant therapy and control patients treated with Mohs alone, there was no significant difference in progression-free survival, but matching was imperfect. Limitations Single-institution, retrospective review. Conclusions MMS remains an effective treatment for hrSCC. Current SCC staging systems may be limited by inconsistent inclusion of poor differentiation. Immunosuppression, especially transplant, should be considered a high-risk clinical feature. Further study is needed on the effect of adjuvant treatment.

Background Mohs micrographic surgery (MMS) is under used in the treatment of nail unit melanoma in situ (MIS), with limited studies in the literature. Objective Report clinical outcomes for nail unit MIS using MMS with melanoma antigen recognized by T cells-1 (MART-1) immunostaining. Methods A retrospective observational study at a single academic institution of patients with a diagnosis of nail unit MIS treated with MMS with MART-1 immunostaining from January 1, 2006, to December 30, 2016. The primary outcome measure was the recurrence rate after MMS. Results Fourteen patients were identified. With an average follow-up of 6.0 years (71.6 months; range = 5-139 months), 1 patient developed recurrence 6.6 years after undergoing initial MMS, requiring amputation with no further treatment or recurrence thereafter. Conclusion Mohs micrographic surgery for nail unit MIS offers a high cure rate similar to other surgical modalities and can reduce the need for digital amputation. The evolution of the Mohs technique over time, namely, using MART-1 immunostaining, has led to improvement in treatment outcomes. Performing complete nail unit excision with nail plate remaining intact attached to the nail bed may also contribute to improved outcomes. Further refinement in technique and more data are necessary to continue to advance this treatment.

Although basal cell carcinoma is the most common malignancy in humans, intravascular basal cell carcinoma is rarely reported in the literature. A 78-year-old male presented for Mohs Micrographic surgery of a 1.5 by 1.5 cm2 nodular and focally infiltrative basal cell carcinoma on the left parietal scalp. In the fifth stage, intravascular tumor cells were noted, and the patient was still positive in five out of six specimens with a defect measuring 6.5 × 7.0 cm2. Mohs surgery was stopped due to concern of widespread disease. A positron emission tomography/computed tomography scan was ordered that demonstrated diffuse prominent activity in the cervical level IIa nodes, right sacrum, right scapula, and the third left rib, concerning for metastatic disease. This case emphasizes the importance of vigilance to examine high-risk basal cell carcinoma pathology for intravascular invasion in addition to perineural invasion, especially in the setting of high risk factors for metastatic basal cell carcinoma.

Mohs micrographic surgery (MMS) is a specialized technique for treating skin malignancies that offers the highest cure rate by allowing histological evaluation of the entire peripheral and deep margins. MMS also maximally preserves as much uninvolved, normal adjacent tissue as possible, allowing for the best cosmetic and functional outcomes. When used for appropriate indications, this technique is also more cost-effective than other treatment modalities. In this article, the authors will discuss the development of MMS, the steps involved in this procedure, and the indications for this technique. They will also review the use of MMS for basal cell carcinoma, squamous cell carcinoma, melanoma in situ, and some less common skin malignancies.