Hugh Morris Gloster

Comparison of the Prevalence of Surgical Site Infection with Use of Sterile Versus Nonsterile Gloves for Resection and Reconstruction During Mohs Surgery

BACKGROUND The prevalence of surgical site infection (SSI) is low with Mohs micrographic surgery (MMS). It has not been determined whether sterile gloves (SG) or nonsterile gloves (NSG) should be used for resection and reconstruction during MMS. OBJECTIVE To compare the SSI rate with the use of SG and NSG for MMS, including reconstruction, and to determine whether SG help prevent SSI. MATERIALS & METHODS Data were collected and recorded for Mohs cases in which SG or NSG were used. Infected cases and SSI rate for SG and NSG were also recorded. Chi‐square analysis was performed to compare SSI. RESULTS There were 1,004 tumors in 942 patients in the SG group and 1,021 tumors in 941 patients in the NSG group. The prevalence of infection was 0.50% in the SG group and 0.49% in the NSG group (p = .82). The cost of gloves was

Laboratory errors leading to nonmelanoma skin cancer recurrence after Mohs micrographic surgery.

5.66 for one SG case and

Surgical pearl: A unique surgical marker.

1.63 for one NSG case. CONCLUSION The prevalence of infection with SG and NSG was almost identical. The cost to use SG was 3.5 times as great as for NSG. The use of NSG for MMS and reconstruction is safe and cost effective.

Perioperative complications with new oral anticoagulants dabigatran, apixaban, and rivaroxaban in Mohs micrographic surgery: A retrospective study

BACKGROUND Compared with standard surgical excision, Mohs micrographic surgery (MMS) provides superior cure rates for nonmelanoma skin cancer (NMSC). Although cure rates of NMSC approach 99% with MMS, local recurrences occasionally occur. OBJECTIVE The authors sought to identify histological features during frozen section examination that were associated with local recurrence of NMSC after MMS. MATERIALS AND METHODS A retrospective chart review was performed of patients undergoing a second MMS procedure to treat locally recurrent NMSC over a 20-month period. Histological slides were reviewed to assess for possible causes of local recurrence. RESULTS Of 3,169 NMSCs treated, 22 were locally recurrent. Possible causes of recurrence identified after MMS included dense inflammation in the final margin at sites affected by tumor in prior slides (27%), visible remaining tumor (23%), missing epidermal or dermal tissue (23%), and actinic keratosis (4%). One recurrence was possibly explained by incorrect mapping. No abnormality could be detected in 18% of cases. Possible limitations include the small sample size, retrospective design, and the possibility that some patients may have been lost to follow-up. CONCLUSION Local recurrences after MMS are extremely rare. When recurrences do occur, they can be attributed to errors in histological interpretation or tumor mapping.

Large Elliptical Specimens and the Single Section Method

S kin marking pens play an important role in the routine activities of a dermatological surgeon. Because preoperative infiltration of local anesthetic may alter the topography of the skin, surgical pens are used to guide excisions and to help identify anatomic sites, such as the lacrimal punctum. 1 Historically, multiple unique markers have been repor ted , including ballpoint pens, 2 hypodermic needles, 3 a wooden stick or wooden penholder with a felt tip, 4 a stick with a cot ton swab, an artists brush, and an autoclavable, refillable steel pen with an adjustable sized tip.5 Mlarakhia and Thorn ton 6 described the use of a disposable preinked marking pad saturated with gentian violet. Many surgeons today use commercially available sterile ink marking pens. Stromberg 7 evaluated several commercially available marking pens and found significant differences among the instruments, including amount and ease of application. These instruments are only rarely associated with adverse reactions such as allergic contact dermatitis. 8 To delineate incisions, a nonsterile marker may be used before creating a sterile field. Under sterile conditions, however, curettage of the lesion to be excised sometimes will extend beyond the predrawn incisions. New incision lines may be drawn with a sterile pen, but this may not be available on the surgical tray and is an added cost to surgery. We describe a unique, cost-effective approach to mark new incision lines in a sterile manner during operations. A 41-year-old woman had an enlarging nodule, approximately 0.8 cm, on her left arm; the nodule

Prophylaxis for Wound Infections and Endocarditis

To the Editor: Mohs micrographic surgery (MMS) has been reported to be safe, with a low incidence of adverse effects both intraoperatively and postoperatively. Approximately 25% to 38% of patients who undergo cutaneous surgery are taking an antithrombotic agent that puts them at a slightly higher risk for bleeding. Novel oral anticoagulants (NOACs) are an increasing presence in the dermatologist’s office, as head-to-head clinical trials have shown them to have efficacy equal to superior that of warfarin. A retrospective chart reviewwas performed of all patients who underwent MMS at the University of Cincinnati between October 1, 2011, and September 15, 2016, while they were taking any of the NOACs dabigatran, apixaban, or rivaroxaban. Data regarding age, sex, dose of anticoagulant medication, indication, concurrent anticoagulation, surgical site, number of stages, repair type, and complications (Table I) were collected. All patients were contacted by the surgeon and queried regarding complications at the routine 48-hour follow-up call. This study protocol was approved by the University of Cincinnati Institutional Review Board. Fifty-one patients who were taking dabigatran, apixaban, or rivaroxaban underwent 76 MMS procedures, with only 1 mild bleeding complication in a patient who was taking rivaroxaban and 2 cases of infection in which both patients were taking dabigatran. The overall rate of complications (Table II) in patients taking NOACs was very low at 3.94% (3 of 76). The hemorrhagic complication rate was

Hemorrhagic Complications in Cutaneous Surgery

linkage. The dermis of the posterior area of the neck is a histological continuation of the dermis of the backand nape; consequently, it is thicker than in the anterior– lateral portions. Posterior subcutaneous fat is also thicker than in the anterior–lateral areas. Therefore, a high cross-linkage can be safely chosen because it will not be visible on the skin surface. Proceeding toward the front of the neck, the dermis thins, thus resulting in a preference for HAs with less cross-linkage and expanding the injection area to create a subtle layer that is not visible but is effective at increasing the volume. Injections in the lateral portion must be performed carefully because of the presence of the lateral danger zone. Anesthesia should not be performed in this area because patient collaboration is useful in changing the direction of the cannula should pain or other nervous reflexes occur. Further studies are needed to assess the technique, but this report of these preliminary results is important because it shows a new neck rejuvenation technique that addresses the aspect of the neck using circumferential filler injections. References

Atypical Mycobacterium furunculosis occurring after pedicures

There are three instances when prophylactic antibiotics are indicated: prophylaxis for prevention of a sugical site infection (SSI), prevention of endocarditis, and prevention of prosthesis infection. Postoperative SSI are a serious complication in cutaneous surgery, and although some limited guidelines exist, many physicians are unaware of the proper use of antibiotics.1, 2, 3 Furthermore, the emergence of resistant bacteria makes the prudent use of antibiotics crucial. A thorough understanding of the various factors related to SSI prophylaxis, the Centers for Disease Control and Prevention (CDC) guidelines pertaining to SSI prophylaxis, and proper antibiotic usage is vital to the practice of cutaneous surgery and will be discussed in this chapter. Treatment of definitive SSI is discussed in Chapter 5.

Habit-tic–like and median nail–like dystrophies treated with multivitamins

It is logical to assume that anyone who performs cutaneous surgery has had or will have some sort of hemorrhagic complication, an inevitable event even in the hands of the most careful and skilled surgeon. Therefore, it is important for cutaneous surgeons to not only take precautions to prevent bleeding complications before they occur, but also to be capable of diagnosing and managing these unfortunate events as they arise to provide a better service for patients. This article will focus on the prevention, diagnosis, and management of hemorrhagic complications in cutaneous surgery.