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The capacity for wonder (CfW) is a personal disposition related to lifelong learning and moral character development, two highly valued characteristics of health professionals. We previously developed and validated a CfW measure among college students. Here we describe how the scale performs among medical students.We invited all students at a top-tier U.S. medical school (276 students completed the survey for an overall response rate of 58%. Factor analysis resulted in a 10-item scale with an alpha of 0.79 and an eigen value of 3.57. Factor loadings ranged from 0.43 to 0.77. The mean total score was 39.3 (SD = 8.9) out of a possible high score of 60. Total scores varied by year in school with significantly lower scores among 2nd year students (32.9 vs. 41.5;We confirmed the reliability of a 10-item CfW scale in 4 cohorts of medical students. Results suggest that the 2nd year of medical school poses the greatest risk to students' capacity for wonder. Efforts should be made to understand this phenomenon and develop interventions to mitigate it. Future research should explore the validity of the CfW scale, its utility in evaluating interventions designed to cultivate the capacity for wonder, its applicability to other groups of health professionals, and its association with ethical decision-making and practice.

BACKGROUND: Reflective writing is used throughout medical education to help students navigate their transformation into medical professionals. Assessment of reflective writing, however, is challenging; each available methodology of assessment has distinct advantages and disadvantages. We tested if combining two independent assessment mechanisms—a faculty-designed rubric and Academic Writing Analytics (AWA), an automated technique—could be used together to form a more robust form of evaluation. METHODS: We obtained reflective essays written by first year medical students as part of a clinical skills course. Faculty scored essays using a rubric designed to evaluate Integration, Depth, and Writing. The same essays were subjected to AWA analysis, which counted the number of reflective phrases indicative of Context, Challenge, or Change. RESULTS: Faculty scored the essays uniformly high, indicating that most students met the standard for reflection as described by the rubric. AWA identified over 1400 instances of reflective behavior within the essays, and there was significant variability in how often different types of reflective phrases were used by individual students. CONCLUSIONS: While data from faculty assessment or AWA alone is sufficient to evaluate reflective essays, combining these methods offer a richer and more valuable understanding of the student’s reflection. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40670-020-01132-7) contains supplementary material, which is available to authorized users.

Experiences of wonder should be valued, protected, and promoted in academic settings. Identification of learning environments and interventions that cultivate students’ capacity for wonder (CfW) first requires a means to measure it. We used a mixed-methods approach to develop and validate a measure of CfW. In the qualitative component (Studies 1–3), we content analyzed open-ended descriptions of wonder (Study 1), interviewed people whom others identified as exemplifying CfW (Study 2), and conducted focus groups to review, for quality and consistency, and to establish face validity of, potential inventory items that capture wonder (Study 3). These items were then subjected to standard psychometric analyses in the quantitative component of our methods (Studies 4–6). In Study 4, exploratory factor analysis (EFA) revealed CfW may contain two subscales representing “Perspective Shifting” and “Emotional Reawakening.” In Study 5, confirmatory factor analysis (CFA) corroborated this two-factor structure in an independent sample and longitudinally across 17 months, establishing a final 10-item CfW scale; In Study 6, we assessed the scale’s discriminant and convergent validity. CfW was weakly to moderately correlated with theoretically related constructs of curiosity, tolerance for ambiguity, humility, and empathy. We conclude with a discussion of future directions and potential applications.

Background Surgical reconstruction of the anterior surface of the ear (concha, antihelix, scapha, and triangular fossa) is complicated by the paucity of mobile local skin. Objective This is a retrospective study of the transcartilage island pedicle flap for reconstruction of surgical defects of the anterior ear. Methods and materials Two hundred thirty-two Mohs micrographic surgery defects were included in the study. The technique involves circumferential incision of the flap in the postauricular sulcus, transfer of the flap to the anterior ear through a surgically created cartilage slit, suturing of the flap on the anterior surface of the ear, and repair of the secondary postauricular defect. Preoperative, intraoperative, and postoperative details of each case were tabulated and analyzed. Results The mean defect size was 1.9 × 1.5 cm. Complications included flap edema (n = 6, 2.6%), postoperative bleeding (n = 4, 1.7%), partial thickness flap necrosis (n = 2, 0.9%), pinning back of the ear (n = 2, 0.9%), and central flap dimpling (n = 2, 0.9%). There was 1 acute staphylococcal abscess and 1 sterile abscess that developed 13 months postoperatively. All complications resolved with medical or surgical management. Conclusion Transcartilage island pedicle flaps may be considered for single-stage surgical reconstruction of defects involving the anterior ear.

BACKGROUND Lower eyelid margin defects can be a reconstructive challenge. A possible alternative is second intention healing of the lower eyelid margin. OBJECTIVE To determine the cosmetic outcomes and patient satisfaction of second intention healing of the lower eyelid margin after Mohs micrographic surgery (MMS). MATERIALS AND METHODS A retrospective chart review was performed on patients who underwent MMS of the lower eyelid margin. Patient information was gathered on age, sex, diagnosis, postoperative size, number of Mohs stages, thickness of defect, and clinical photographs. The preoperative and postoperative photographs were evaluated with a physician assessment scale and patients completed a satisfaction survey. RESULTS In all 17 patients (100%), the cosmetic results obtained were considered good to excellent. The objective outcomes were graded as excellent, very good, good, satisfactory, unsatisfactory, and poor. The patient satisfaction survey was divided into excellent, good, satisfied, and unsatisfied. Patient satisfaction ranged from satisfied to excellent. The incidence of complications was low with one report of trichiasis. CONCLUSION Second intention healing of the lower eyelid margin can produce good cosmetic results and patients are generally satisfied with their outcomes.

BACKGROUND: The Student Curriculum Review Team (SCRT) was founded at the Johns Hopkins University School of Medicine (JHUSOM) in 2012 to refine pre-clinical courses. Since then, SCRT has provided a voice for student feedback—offering forums for discussion through ‘Town Hall meetings’ and confidential avenues for peer-to-peer comments. Here, we assess the perceived efficacy and utility of SCRT among the student body and faculty course directors. METHODS: A cross-sectional analysis was conducted in 2019 using an anonymous survey distributed to second- (MS2) and third-year (MS3) medical students as well as faculty course directors at JHUSOM. RESULTS: A total of 113 student surveys and 13 faculty surveys were returned. The majority of students (97%) endorsed SCRT as effective in enabling them to express their concerns. Most faculty (69%) reported SCRT’s impact on their respective course as positive and found SCRT suggestions to be “realistic and actionable”. Students (84%) and faculty (62%) alike considered SCRT to meet needs not met by other curricular organizations at JHUSOM. CONCLUSION: Students and faculty find that SCRT satisfies an unfilled position in the landscape of curricular feedback at JHUSOM. This study may be beneficial for other academic institutions considering ways to better engage students in curricular reform.

Background A vasovagal reaction is a commonly encountered event in outpatient procedures. There is a paucity of discussion on vasovagal reactions (VVRs) in the dermatologic surgery literature. However, recent investigations in the physiology, evaluation, and treatment of VVRs have been reported in other specialties. Objective A comprehensive review of the physiology, evaluation, treatment, and prevention of VVRs. Materials and methods A search as performed using the PubMed/MEDLINE databases. Search terms included "vasovagal," "vasovagal reaction," "syncope," "reflex syncope," "neurocardiogenic syncope," and "fainting." Results Studies demonstrate greater understanding in the physiology of a vasovagal reaction. Although permanent sequelae are uncommon, it is important to respond in a prompt manner. A variety of treatment and prevention options are presented. Conclusion Vasovagal reactions should be carefully evaluated. Additional studies may provide greater data in understanding and managing vasovagal reactions.

BACKGROUND The patient consent process traditionally relies on conversations between the physician and the patient and rarely utilizes supplemental multimedia aids. OBJECTIVE To determine whether the addition of an educational video on Mohs micrographic surgery (MMS) can improve patient satisfaction with the consent process. MATERIALS AND METHODS This prospective observational quality improvement study compared the outcomes of traditional patient consent alone versus standard consent plus an educational video among patients undergoing their first MMS for a primary skin cancer. End points were patient satisfaction and preferences measured by postprocedure questionnaires. RESULTS The addition of a supplemental video to the consent process did not affect overall patient satisfaction, which was very high in both video and control groups. However, specific components of patient satisfaction were improved such as patient perception of the opportunity to ask questions and understand the procedure. CONCLUSION Multimedia aids can be effective tools in the patient consent process.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening drug-induced reaction. Though the most common clinical manifestations are eosinophilia, fever, rash, and lymphadenopathy, patients can also present with severe organ dysfunction. The pathogenesis of DRESS syndrome is only currently partially understood, though it is known that DRESS syndrome is commonly associated with infection or viral reactivation; specifically, human herpes viruses 6 and 7 and Epstein-Barr virus have been implicated in the pathogenesis. We present the first case of DRESS syndrome in the context of serology-proven influenza virus.

Background The apical triangle of the upper cutaneous lip, also known as the alar-facial sulcus, is an anatomical structure bound medially by the nasal ala, laterally by the medial cheek, and inferiorly by the remainder of the upper cutaneous lip. During reconstruction, retaining the central concavity and the convex lateral and medial outlines of this location is required to maintain midfacial symmetry. Objective This is a retrospective study of our use of the melolabial rotation flap for reconstruction of surgical defects of the apical triangle. Methods and materials Eighty-six surgical defects involving the apical triangle that were repaired with melolabial rotation flaps were included. All tumors were treated with Mohs micrographic surgery before reconstruction. Preoperative, intraoperative, and postoperative details of each case were analyzed. Results Of the 86 defects included in the study, 68 (79%) were evaluated postoperatively. The apical triangle was preserved in all cases. Clinical asymmetry was noted in 3 patients (3.4%). No major complications were noted, and no patient required surgical revision. Conclusion Melolabial rotation flaps may be considered for single-stage reconstruction of surgical defects involving the apical triangle.

Background Histologic examination of tissue is the foundation of Mohs micrographic surgery because determination of surgical margins influences whether additional tissue will be taken. Currently, there is no large focused study comparing toluidine blue (TB) and hematoxylin and eosin (H&E) stains in the evaluation of squamous cell carcinoma (SCC). Objective This study evaluates whether TB and H&E are comparable in assessing the presence of tumor in frozen sections of SCC. Materials and methods One hundred eighty-six randomized slides representing 93 tissue pieces from 36 tumors were examined by 3 Mohs surgeons (1 Accreditation Council for Graduate Medical Education fellow and 2 fellowship-trained surgeons) and compared using a template that documented the presence and location of tumor on the slides. Results The evaluation of SCC with H&E and TB stains was highly concordant, with concordant identification of SCC in 96%, 96%, and 94% of tissue layers among the 3 Mohs surgeons ARS, LHG, and AK-A, respectively. Conclusion Toluidine blue and H&E stains are statistically similar in their ability to detect SCC and guide Mohs surgical decision-making.

Background The incidence of basal cell carcinoma (BCC) in younger individuals has increased in recent decades. However, the characteristics of BCCs in this population, especially in Ibero-Latin American countries, have not been completely defined. Objective To describe the demographic, clinical, and histopathological characteristics of BCCs in patients younger than 40 treated with Mohs Micrographic Surgery (MMS). Materials and methods A multicenter, retrospective study conducted between January 2009 and December 2014, in five Ibero-American countries, included biopsy-proven BCCs in patients younger than 40 that were treated with MMS. Demographic, clinical, histopathological, and surgical characteristics were described. Results The study included 301 tumors in 241 patients, of whom 61% were female. The most common Fitzpatrick phototype was III. The most common histological subtypes were nodular (37.5%) and infiltrative (18.9%). Perineural invasion was encountered in 1.7%, and tumor clearance was achieved in 87.4% within two stages of MMS. Conclusions This is the first Ibero-Latin American transnational study describing the characteristics of BCCs in young patients treated with MMS. Despite darker skin phototypes in this population, BCCs can occur in early ages and may present with aggressive features. Therefore, MMS may be considered an appropriate first-line treatment option in this population.

Subungual amelanotic melanoma can masquerade as onychomycosis. Recently a man whose amelanotic nail bed melanoma presented as persistent onychodystrophy was reported in the Dermatology Online Journal. The patient had a persistent nail dystrophy; culture and biopsy of the nail demonstrated Candida and dermatophyte infection, respectively. However, he subsequently presented with a nodule that was biopsied and demonstrated melanoma. Similar to that patient, we recently described a 67-year-old woman with a four-year history of persistent nail dystrophy of the left fourth fingernail who had a periodic acid-Schiff staining of the nail plate demonstrating fungal hyphae. Her nail plate subsequently detached, demonstrating a friable nodule; a biopsy of the nodule demonstrated melanoma. In conclusion, in individuals with new morphologic changes to a dystrophic nail or with persistent nail dystrophy despite appropriate therapy, it is important for clinicians to consider performing additional evaluation and possible biopsy to exclude malignancy.

Student feedback is a valuable asset in curriculum evaluation and improvement, but many institutions have faced challenges implementing it in a meaningful way. In this article, we report the rationale, process and impact of the Student Curriculum Review Team (SCRT), a student-led and faculty-supported organization at the Johns Hopkins University School of Medicine. SCRT's evaluation of each pre-clinical course is composed of a comprehensive three-step process: a review of course evaluation data, a Town Hall Meeting and online survey to generate and assess potential solutions, and a thoughtful discussion with course directors. Over the past two years, SCRT has demonstrated the strength of its approach by playing a substantial role in improving medical education, as reported by students and faculty. Furthermore, SCRT's uniquely student-centered, collaborative model has strengthened relationships between students and faculty and is one that could be readily adapted to other medical schools or academic institutions.

The aim of this study was to compare the ease and accuracy of measuring the surface area of a severe burn through the use of a mobile software application (BurnMed) to the traditional method of assessment, the Lund and Browder chart. BurnMed calculates the surface area of a burn by enabling the user to first manipulate a three-dimensional model on a mobile device and then by touching the model at the locations representing the patient's injury. The surface area of the burn is calculated in real time. Using a cohort of 18 first-year medical students with no experience in burn care, the surface area of a simulated burn on a mannequin was made using BurnMed and compared to estimates derived from the Lund and Browder chart. At the completion of this study, students were asked to complete a questionnaire designed to assess the ease of use of BurnMed. Users were able to easily and accurately measure the surface area of a simulated burn using the BurnMed application. In addition, there was less variability in surface area measurements with the application compared to the results obtained using the Lund and Browder chart. Users also reported that BurnMed was easier to use than the Lund and Browder chart. A software application, BurnMed, has been developed for a mobile device that easily and accurately determines the surface area of a burn. This system uses a three-dimensional model that can be rotated, enlarged, and transposed by the health care provider to easily determine the extent of a burn. Results show that the variability of measurements using BurnMed is lower than the measurements obtained using the Lund and Browder chart. BurnMed is available at no charge in the Apple™ Store.

Background The population of people aged 90 years and older is expected to more than triple by 2050. The incidence of skin cancers is increasing. Objective We sought to determine whether treatment of patients aged 90 years and older with skin cancer by Mohs micrographic surgery (MMS) changed their survival. Methods A group of 214 patients aged 90 years and older who underwent MMS from July 1997 to May 2006 was identified. Patient gender, age, tumor type, size, site, defect size, number of MMS stages, and surgical repair were recorded. Comorbid medical conditions were assessed using the Charlson index. Actual survival was compared with expected length of survival using life tables. Data were analyzed by the Kaplan-Meier method with log rank significance tests. Results Average patient age was 92.3 years. All patients tolerated the procedures well with no deaths within 1 month after surgery. Median survival after surgery was 36.9 months. Tumor characteristics, defect size, number of surgical stages, and closure type did not affect survival. There was no significant difference in survival based on comorbidities according to Charlson scores. Instantaneous mortality hazard was highest 2 to 3 years after surgery. Limitations Specific causes of death were not accessible. Conclusion This growing section of the population may safely undergo MMS.

Background Patients may delay treatment for skin cancer for various reasons. Prior research on treatment delay has focused on melanoma rather than nonmelanoma skin cancer (NMSC), which is much more common. Objective We sought to clarify the reasons for delay in the presentation for diagnosis and treatment of NMSC. Methods This was a prospective cohort study in a Mohs micrographic surgery private practice in an urban setting. Eligible subjects were 982 consecutive patients presenting for Mohs micrographic surgery for NMSC between March and December 2005. No enrolled subjects were withdrawn for adverse effects. The survey was a 4-page written self-administered questionnaire, eliciting patient medical history, skin cancer history, demographic information, initial and subsequent lesion size, and reasons for delay in presentation for evaluation and management. Outcome analyses addressed the: (1) frequency of specific reasons for delayed presentation, as provided by self-report; (2) association between reasons for delay with demographic or other patient-specific factors; and (3) change in lesion diameter from the time of detection by the patient to the time of presentation to the doctor. Results Among the reasons for waiting, denial (including: thought it would go away, thought it wasn't important, too busy, thought they could self-treat, afraid it might be something dangerous) was the most frequent, accounting for 71% of cases; difficulty scheduling was associated with 10% of the instances of delay. Older patients (age >64 years) were more likely to wait to seek care than younger patients (odd ratio [OR] = 0.5; 95% confidence interval [CI] 0.4-0.7). Patients with a prior skin cancer were more likely to wait (OR = 1.4; 95% CI 1.1-2.0), as were patients with major life problems (OR = 2.6; 95% CI 1.6-4.3) and patients with a history of any cancer (OR = 1.8; 95% CI 1.3-2.4). Weighted kappa analysis comparing tumor size at the two time points yielded a kappa of 0.72 (SE = .02; 95% CI 0.68-0.77). When the data were separated into two groups, one including those tumors that had decreased in size or remained the same (698 patients), and those that had increased in size (120 patients), the median delay-to-presentation intervals associated with these two groups (2.5 vs 6.0 months, respectively) were found to be significantly different ( P Limitations This study may have limited generalizability to the extent that it reflects the characteristics only of the subpopulation of patients with skin cancer who eventually received treatment at a referral-based, urban, dermatology private practice. Overall, these patients may have been better insured and be more affluent than the general population. Conclusions Denial is the most common patient-specific factor accounting for delayed presentation for NMSC diagnosis and treatment. Patients younger than 65 years, with a skin cancer history, with major life problems, and with a history of any cancer were most likely to wait to see a doctor. There was a significant increase in tumor size from the time when tumors were noticed by patients to the time when patients presented to a physician. Increased delay was associated with increased tumor growth.

Actinic keratoses (AKs) are in situ epidermal tumors that may progress to invasive squamous cell carcinomas. Liquid nitrogen is used during cryotherapy to freeze the epidermis and upper dermis and is the standard treatment for individual AKs.To evaluate the efficacy of a cryosurgery device incorporating an infrared sensor to measure the temperature at the skin surface while spraying liquid nitrogen on the surface of the skin during the treatment of AKs.Thirty-six patients with 180 thin AKs were treated with liquid nitrogen spray to a temperature of -5°C using the sensor to control the temperature at the skin surface. Patients were evaluated for cure rate, side effects, and healing time.At the 1-week follow-up, 66.7% of the lesions were cleared. By the 6-week follow-up, there was a 100% cure rate. Side effects were limited to redness, blistering, crusting, oozing, and ulceration at the 1-week follow-up and were resolved by the 6-week follow-up. No recurrence of AK, scarring, or hypopigmentation was noted.Cryotherapy with an integrated sensor for temperature control is an effective, safe, and precise treatment, allowing for a 100% short-term cure rate of AKs.

Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities.To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method.Eight female patients (Fitzpatrick skin type II-IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3- to 8-week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8-10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow-up visit 7 to 36 months (mean 13.5 months) after the last treatment session.At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow-up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted.FP is a safe and effective treatment for refractory melasma, with long-term remission.

Hypertrophic scars and keloids are a therapeutic challenge because of the low response to treatment and recurrences after treatment. A variety of treatment regimens have been used with different degrees of success, with no universally accepted treatment protocol resulting in their complete and permanent resolution. We offer this case to demonstrate a combination approach for the treatment of hypertrophic scarring. A 75-year-old woman (with Fitzpatrick skin type II) presented with a 4-month history of scarring, which had developed following a phenol peel for perioral rhytides. The patient underwent 10 treatment sessions with the 595-nm long-pulsed dye laser followed immediately by the 1450-nm diode laser in combination with intralesional triamcinolone and 5-fluorouracil. After the fifth treatment session, about 90% improvement was noted; at the last treatment session, greater than 95% overall improvement was noted. Two and a half years after the last treatment session, the patient and treating physician noted no regression. A limitation of this therapy is that the combination approach makes it difficult to determine what individual contributions each treatment modality had on the final result. We have illustrated a successful multifaceted treatment regimen for hypertrophic scars and keloids using a combination approach.

Background Several specialties and textbooks continue to advocate that local anesthesia using epinephrine should not be used during surgery involving the digits. Objective We sought to assess the association between local anesthesia (buffered 0.5% lidocaine and 1:200,000 epinephrine) injected into digits, comorbid patient conditions, and postoperative complications including ischemia or necrosis. Methods A retrospective review of all patients presenting for Mohs micrographic surgery in a private practice ambulatory surgery center was performed between October 2002 and January 2009. Patient factors including amount of anesthesia injected; preoperative vitals; history of hypertension, stroke, or circulatory disorders; and presence of anticoagulation were assessed. Results Three Mohs surgeons' patients were included in the study. No digital blocks were performed; local anesthesia was infiltrated directly into the tumor site. Patients received buffered 0.5% lidocaine plus epinephrine 1:200,000. Of 63 patients presenting for surgery (59 fingers and 4 toes), there were no cases of digital ischemia or necrosis. Approximately one-third had a circulatory disorder or diabetes, and more than half had a diagnosis of hypertension or were taking anticoagulation. The average amount of anesthesia injected was 6.92 mL, with the greatest amount being 25 mL. Limitations This was a retrospective review with possible overestimation of adverse effects as a result of referral bias of complicated patients to an ambulatory surgery center for treatment. Conclusion There is no evidence that buffered 0.5% lidocaine with epinephrine 1:200,000 causes ischemia or necrosis when injected into digits. This is true despite a history of circulatory disorders, thrombosis, diabetes, smoking, anticoagulation, or significant preoperative hypertension.

BACKGROUND AND OBJECTIVES Acne scars affect the entire population, causing significant distress and concern. Previous treatments for acne scars have yielded varying degrees of success and associated side effects. Fractional photothermolysis has been shown to improve scars, including surgical scars, hypopigmented scars, and atrophic acne scars. The newest system has the option of increased fluences for greater depth of penetration and variable treatment coverage. Our aim was to determine the efficacy and safety of the second-generation erbium-doped 1,550-nm fractional photothermolysis laser (1,550nm Fraxel SR laser, Reliant Technologies Inc.) in the treatment of all types of acne scars and of all severities. STUDY DESIGN/MATERIALS AND METHODS Twenty-nine patients (20 females and 9 males, ages 15–65 years), Fitzpatrick Skin Types I to V, were treated with two to six treatments with the second-generation erbium-doped 1,550-nm fractional photothermolysis laser at 1-month intervals. Fluences ranged from 35 to 40mJ/microthermal zone. Treatment levels varied from 7 to 10 and ‘‘Advanced Level 1,’’ corresponding to treatment coverage of 20% to 35%. Patients were graded on a 4-point scale by three independent physicians using digital photography. RESULTS The majority of patients achieved a 50% to 75% improvement in facial and back acne scarring (18 of 29 patients). Five patients had an improvement of greater than 75% in acne scarring, 5 patients had a 25% to 50% improvement in acne scarring, and 1 patient had less than a 25% response to treatment. The patients’ degree of satisfaction paralleled the physicians’ assessment. Side effects were minimal and no posttreatment pigmentary changes were noted. CONCLUSION Fractional photothermolysis is a safe and efficacious treatment modality for the treatment of all types of acne scars of all severities. No adverse effects were noted, including in patients with Fitzpatrick Skin Types III to V. The authors have indicated no significant interest with commercial supporters.

Background A 15-year-old Caucasian male presented with 9-month history of a recurrent nodule on the nasal columella. The previous biopsy was reported as a neurofibroma. Methods Frozen sections revealed a spindle cell neoplasm. Permanent section immunohistochemistry sections stained positive for vimentin and smooth muscle actin and negative for S100 and CD34, confirming the diagnosis of leiomyosarcoma. Results The tumor was removed using Mohs micrographic surgery. Radiological work-up revealed no distant metastasis. There has been no local recurrence to date. Conclusions Leiomyosarcoma is a difficult diagnosis to make clinically and requires histological confirmation. Re-biopsy of a “benign” growth may be necessary if clinicopathological correlation does not match with the clinical behavior of the tumor in question. Finally, Mohs micrographic surgery is a useful treatment modality for leiomyosarcomas, particularly those located in cosmetically-sensitive regions of the body such as the nose.