David E. Kent

Improving Survival of the Paramedian Forehead Flap in Patients with Excessive Tobacco Use: The Vascular Delay

Vascular delay has been extensively reviewed in the plastic surgery literature but not as well discussed in dermatologic surgery. It is an intermediate-stage procedure performed before flap transfer to improve blood flow into transferred tissue using various mechanisms. We present a case in which a paramedian forehead flap using vascular delay was performed to repair a nasal defect in a four-pack-a-day smoker.

Mohs micrographic surgery histopathology concordance in fellowship-trained surgeons

To the Editor: We read with interest the excellent article by Mariwalla et al in the January 2009 issue of the Journal regarding the histopathology concordance between fellowship-trained Mohs micrographic surgeons and dermatopathologists in frozen section interpretation. The authors did mention that all of the participating Mohs surgeons were fellowship-trained and that a ‘‘well trained [Mohs micrographic surgeon] is capable of accurately interpreting tumors histologically in the therapeutic setting.’’ However, we believe that this deserves more emphasis. Accurate histologic examination of surgical margins is the foundation of Mohs micrographic surgery. This is best achieved by the experience of a 11 year structured fellowship. Extended time with both direct and indirect mentoring is essential in developing expertise in not only Mohs histopathology but also in wound care, anatomy, and reconstruction. Casey et al recently reported the standardization of fellowship-trained Mohs surgeons in a study of 50 Mohs surgery fellowship directors. Murphy et al examined the fellowship training process with respect to critical errors in Mohs histopathology. These studies reinforce the fact that experience coupled with immediate feedback is the optimal means to achieve Mohs histopathology excellence. Murphy et al showed that ‘‘proficiency in the interpretation of Mohs histopathology cannot be achieved in a matter of days, weeks, or months. Nor can it be achieved by looking at a few cases, tens of cases, or even a few hundred cases.’’ Mentored correction of errors in Mohs histopathology is essential to training. Technical and interpretive errors are the most important factors that affect the recurrence rate following Mohs micrographic surgery. This is directly related to thequality ofMohshistopathology,whichof course relates back to the quality of the Mohs surgeon.

Functionality of Patients 75 Years and Older Undergoing Mohs Micrographic Surgery: A Multicenter Study

BACKGROUND Mohs surgery is indisputably a highly effective treatment for nonmelanoma skin cancers. In the current health care environment, physicians are challenged to provide high quality, efficacious care in a manner that is mindful of the patients general health and well-being. We have used a functional assessment to evaluate older patients who present for Mohs surgery. OBJECTIVE The purpose of this study is to categorize the functional status, using the Karnofsky Performance Status (KPS) Scale, of patients 75 years and older undergoing Mohs surgery of a nonmelanoma skin cancer and to identify distinguishing characteristics of lower functioning patients. METHODS Patients 75 years and older undergoing Mohs surgery for nonmelanoma skin cancer at 8 separate geographically diverse sites were included. Patient and tumor characteristics were recorded. Physicians scored subjects on the KPS scale and administered a questionnaire to categorize the symptoms and impact of their skin cancer. RESULTS A total of 291 subjects completed the study. The average KPS score was 90.1. 93.1% of our subjects had a KPS score of ≥70. Subjects with a KPS score <70 were more likely to be older with larger symptomatic tumors. CONCLUSION The vast majority of patients 75 years and older undergoing Mohs surgery are highly functioning. Lower functioning patients are older with larger symptomatic tumors that negatively impact their lives.

Use of Mohs micrographic surgery to treat basal cell carcinoma arising in a nevus sebaceous in an African American patient.

To the Editor: Nevus sebaceous is a common congenital lesion that is found predominantly on the face and scalp. It is associated with a multitude of benign and malignant tumors. The most common benign neoplasms are syringocystadenoma papilliferum and trichoblastoma. The most common malignant neoplasm is basal cell carcinoma. A number of other associated lesions have been associated with nevus sebaceous, including squamous cell carcinoma, melanoma, verrucous carcinoma, sebaceous carcinoma, tricholemmal carcinoma, trichoadenoma, sebaceoma, and spiradenoma. It is unusual for more than three distinct tumors to arise simultaneously within a nevus sebaceous; however, this has been reported. The majority of nevus sebaceous lesions are diagnosed from childhood to early adulthood. We present a 55-year-old African American woman with a basal cell carcinoma arising in a nevus sebaceous who was successfully treated with Mohs micrographic surgery. A 55-year-old African American woman presented for treatment of a nevus sebaceous with concomitant basal cell carcinoma on the scalp (Figure 1A). Review of the original specimen revealed evidence of both nodular basal cell carcinoma and small foci of trichoblastoma (Figure 1B). The patient was otherwise healthy and had no significant