Christine A. Liang

Musculoskeletal disorders and ergonomics in dermatologic surgery: a survey of Mohs surgeons in 2010.

BACKGROUND Dermatologic surgeons perform numerous procedures that put them at risk of developing work‐related musculoskeletal disorders. OBJECTIVE To study the prevalence of work‐related musculoskeletal disorders and role of ergonomics in dermatologic surgery. METHODS AND MATERIALS A survey study was sent to members of the American College of Mohs Surgery in 2010. The main outcome measures were survey responses relating to surgeon demographics, musculoskeletal symptoms, workstyle habits and attitudes, and ergonomic practices. RESULTS Ninety percent of respondents reported some type of musculoskeletal symptoms or injuries. The most common complaints were neck, lower back, shoulder, and upper back pain. Most respondents were not using ergonomic modifications in their practice. CONCLUSION Mohs surgeons have a high prevalence of musculoskeletal disorders. Symptoms present early and persist throughout the careers of Mohs surgeons. The nature of the occupation leaves the surgeon vulnerable to injury. Ergonomic modifications in behavior and workplace are recommended to reduce pain and injury to surgeons. The authors have indicated no significant interest with commercial supporters.

Perioperative Antibiotic Use of Dermatologic Surgeons in 2012

BACKGROUND Recommendations for antibiotic prophylaxis in dermatologic surgery have been established, but there is variability in perioperative antibiotic use of dermatologists. Authoritative guidelines have shifted away from routine use of antibiotic prophylaxis because there is no conclusive evidence that antibiotic use reduces risk of infective endocarditis or prosthetic joint infection. OBJECTIVE To determine current practices of perioperative antibiotic use of Mohs‐trained surgeons and to compare patterns of use with updated administration guidelines. METHODS AND MATERIALS A survey was sent to American College of Mohs Surgery members in 2012. The main outcome measures were survey responses relating to demographic characteristics, experience with postoperative infection, familiarity with antibiotic guidelines, perioperative antibiotic practices, attitudes regarding antibiotic use, and antibiotic selection. RESULTS Most survey respondents are familiar with the Antibiotic Prophylaxis in Dermatologic Surgery Advisory Statement 2008, but respondents give antibiotics for more indications than are recommended. Although not recommended, a high percentage reported giving antibiotics to patients at high risk of infective endocarditis or joint infection even when surgery does not breach oral mucosa or involve infected skin. CONCLUSION Dermatologic surgeons overuse perioperative antibiotics for prevention of surgical site infection, infective endocarditis, and prosthetic joint infection based on current recommendations.

Ablative Fractional Laser-Assisted Topical Fluorouracil for the Treatment of Superficial Basal Cell Carcinoma and Squamous Cell Carcinoma In Situ: A Follow-Up Study.

BACKGROUND The authors previously reported the safety and short-term efficacy of ablative fractional laser (AFXL)–assisted delivery of topical fluorouracil in the treatment of superficial basal cell carcinoma (sBCC) and squamous cell carcinoma in situ (SCCis). OBJECTIVE This follow-up study was conducted to assess whether tumor clearance was sustained in this cohort of patients at >9 months post-treatment. METHODS Thirty primary sBCC or SCCis <2 cm on the trunk or extremities were treated with AFXL and a single application of topical 5-fluorouracil 5% under occlusion for 7 days. Among the 26 patients who achieved tumor clearance at 4 to 8 weeks post-treatment, 20 patients presented for this follow-up study and underwent shave biopsy to confirm histologic clearance. Mean follow-up time was 15 months. RESULTS Considering those who had persistent tumor at 4 to 8 weeks post-treatment and those who presented for follow-up at >9 months post-treatment, overall treatment success was 79% (95% confidence interval: 67%–96%), with 92% (11/12) for SCCis and 67% (8/12) for sBCC. Neither the tumor location nor size significantly impacted treatment outcome (p = .96 and 0.87, respectively). CONCLUSION Ablative fractional laser–assisted topical fluorouracil is a reasonable noninvasive treatment option for primary SCCis and sBCC, especially for lesions located in areas where self-application is not possible, or when clinician-administered therapy is preferred.

Sequential Curettage, 5-Fluorouracil, and Photodynamic Therapy for Field Cancerization of the Scalp and Face in Solid Organ Transplant Recipients.

BACKGROUND Field cancerization with actinic keratoses and squamous cell carcinoma in situ (AK/SCCIS) represents a common therapeutic challenge in solid organ transplant recipients (SOTRs). These patients often show inadequate responses to methods traditionally used as monotherapy (e.g., topical chemotherapy). OBJECTIVE To describe the clinical outcomes and feasibility of a sequential approach to treatment of field cancerization in SOTRs. METHODS Four SOTRs with field cancerization of the scalp and/or face were treated using a sequential approach. Light curettage of hypertrophic lesions was followed by application of 5-fluorouracil 5% cream twice daily for 5 days and photodynamic therapy (PDT) with 1-hour incubation on day 6. Pain level during and after PDT was recorded. Photographs were obtained immediately before and after treatment and at follow-up appointments. RESULTS All 4 patients tolerated this approach well and demonstrated excellent responses to treatment with complete or near-complete clinical resolution of AK/SCCIS lesions. Patients remained free of AK/SCCIS based on clinical examination 1 to 6 months after treatment. CONCLUSION For SOTRs with field cancerization, sequential therapy represents a viable therapeutic regimen with good tolerability and durable clinical response. This approach warrants further investigation to determine which therapeutic combinations have optimal tolerability and efficacy.

Ablative fractional laser therapy for the treatment of actinic keratosis: A split-face study

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Microcystic adnexal carcinoma associated with multiple benign syringomatous proliferations: a report of two cases.

We report two cases of microcystic adnexal carcinoma (MAC) associated with multiple benign syringomatous proliferations. In both cases, surgical management was challenging. Overlapping histologic features between MAC and syringoma made it difficult on intra-operative Mohs frozen sections to separate the peripheral border of the MAC from the background of multiple benign lesions. To our knowledge, MAC associated with multiple subclinical benign syringomatous proliferations has not been previously reported.

Treatment Patterns, Outcomes, and Patient Satisfaction of Primary Epidermally Limited Nonmelanoma Skin Cancer

BACKGROUND Epidermally limited nonmelanoma skin cancer (ELNMSC) (superficial basal cell carcinoma [SBCC] and squamous cell carcinoma in situ [SCCIS]) is common. Data on outcomes and patient satisfaction are lacking. OBJECTIVE To examine treatment efficacy and satisfaction in ELNMSC patients. PATIENTS AND METHODS Retrospective cohort study of adults with primary SBCC or SCCIS. A 25% random subset completed a satisfaction questionnaire. RESULTS Five hundred and fifty patients with 227 SBCC and 451 SCCIS were included; 329 tumors (49%) were treated with Mohs micrographic surgery (MMS) and 349 (51%) with non-MMS (imiquimod [n = 26], 5% 5-fluorouracil [n = 234], ingenol mebutate [n = 32], or cryotherapy [n = 57]). Five-year recurrence-free survival was high in both groups, with MMS having a small but statistically significant advantage (99% vs 95%, p = .004). More MMS patients were willing to undergo treatment again (97% vs 86%, p = .024). Dissatisfaction was mostly due to prolonged treatment course and pain associated with non-MMS treatments. CONCLUSION Surgical and nonsurgical treatments for primary ELNMSC have low recurrence rates, though cure rate and patient satisfaction are higher with MMS. Treatment choice for epidermal NMSC may be guided through patient preferences regarding ability to comply with topical treatment, out-of-pocket costs, desire to treat surrounding field disease, and desire to avoid a surgical scar.

The Z-advancement flap for reconstruction of lateral nasal tip and medial alar defects.

BACKGROUND Reconstruction of lateral nasal tip and medial alar defects is challenging. Contour, symmetry, and skin texture of the nose, along with adequate nasal airway patency, should be preserved. The Z‐advancement flap is a novel reconstruction technique designed for optimal cosmesis and function. OBJECTIVE To evaluate the aesthetic and functional outcomes of Z‐advancement flap nasal reconstruction. MATERIALS AND METHODS Twenty‐nine consecutive patients with defects 1 cm or less in diameter on the lateral nasal tip or medial ala underwent Z‐advancement flap repair. Patients completed a survey assessing cosmesis and airway patency. Three physicians evaluated standardized photographs on visibility of scar lines, erythema and telangiectasia, and contour and symmetry of the ala and nostril opening. RESULTS Twenty‐eight (96%) patients completed survey questionnaires. All patients were satisfied with the look and feel of their reconstructed nose. Twenty‐four (86%) saw no visible scar or abnormality. Postoperative photographs were available for review in 19 (66%) patients. In 95% to 96% of physician ratings, scars were invisible or visible only on close inspection, and alar symmetry was unchanged or only slightly altered. In 88%, nostril opening symmetry was unchanged or slightly altered. CONCLUSIONS The Z‐advancement flap preserves aesthetic subunits of the nose to produce excellent cosmesis and patient satisfaction for defects of the lateral nasal tip or medial ala 1 cm or less in diameter.