Shang I. Brian Jiang

Adverse Events Associated With Mohs Micrographic Surgery Multicenter Prospective Cohort Study of 20 821 Cases at 23 Centers

IMPORTANCE Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Management of Pilomatrix Carcinoma: A Case Report of Successful Treatment with Mohs Micrographic Surgery and Review of the Literature

Pilomatrix carcinoma is a rare malignant variant of pilomatrixoma, a cutaneous adnexal tumor that originates from hair matrix cells. Reports of similar lesions date as far back as 1927, but Lopansri and Mihm first defined the tumor in 1980 as an aggressive form of pilomatrixoma with a tendency toward recurrence. Pilomatrix carcinoma has also been referred to in the literature as pilomatrical carcinoma, malignant pilomatricoma, malignant pilomatrixoma, matrical carcinoma, and calcifying epitheliocarcinoma of Malherbe. Lesions occur most commonly on severely sun-damaged skin and may arise through transformation of a pilomatrixoma or as a solitary, newly formed entity. These tumors are most frequently located on the head, neck, and back, although occurrence on the anterior trunk and upper and lower extremities has also been reported. Pilomatrix carcinoma manifests clinically as an asymptomatic mass that may resemble basal cell carcinoma, epidermal cyst, trichilemmal cyst, or pilomatrixoma. Lesions may arise over a period of months to many years, with a propensity for aggressive local recurrence and metastasis. Given its rarity, an optimal treatment regimen for pilomatrix carcinoma has not been established. Recurrence rates of >50% have been found after simple excision, with follow-up time ranging from a few months to many years. Most publications advocate wide local excision, with recommended margins varying between 5 mm and 2 cm. Mohs micrographic surgery (MMS) has been shown to be the most effective therapy for a number of rare malignant cutaneous tumors, including rare adnexal tumors such as sebaceous carcinoma and microcystic adnexal carcinoma. In 2004, Sable and Snow first reported on the successful management of pilomatrix carcinoma using MMS, with no evidence of recurrence at follow-up 5 months later. Given the tendency for aggressive local recurrence of pilomatrix carcinoma and the superior margin control available with MMS, MMS may represent an ideal treatment modality for this rare condition. Here, we report on a second case of pilomatrix carcinoma treated with MMS and provide a comprehensive literature review of the epidemiology, pathogenesis, clinical presentation, histopathologic findings, prognosis, follow-up, and management options for pilomatrix carcinoma.

Association Between Number of Stages in Mohs Micrographic Surgery and Surgeon-, Patient-, and Tumor-Specific Features: A Cross-Sectional Study of Practice Patterns of 20 Early- and Mid-Career Mohs Surgeons

OBJECTIVE To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early‐ to mid‐career Mohs surgeons and to assess other factors affecting number of stages. METHODS Statistical analysis of MMS logs of 20 representative early‐ to mid‐career surgeons. RESULTS There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS Early‐ and mid‐career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. &NA; The authors have indicated no significant interest with commercial supporters.

Treatment of Surgical Scars Using a 595‐nm Pulsed Dye Laser Using Purpuric and Nonpurpuric Parameters: A Comparative Study

BACKGROUND Many studies have examined laser treatment of scars, but cosmetic results have been variable. Although no studies have examined the effect of purpura on scar improvement using the pulsed dye laser (PDL), many clinicians believe inducing purpura results in better and quicker improvement. OBJECTIVE To determine whether PDL treatment of fresh surgical scars with purpura‐inducing settings improves clinical appearance more than non‐purpura‐inducing settings or no treatment. METHODS Twenty‐six subjects with surgical scars enrolled in this prospective study. Scars were divided into three equal segments; treatment was randomized: 595‐nm PDL with purpuric (1.5 ms) or nonpurpuric (10 ms) settings or no treatment. Fluences were adjusted to Fitzpatrick skin type. Scars were treated three times, 1 month apart, beginning at suture removal. Outcome measures included Vancouver Scar Scale (VSS) and blind clinical ratings. RESULTS The nonpurpuric condition showed significant improvement on the VSS total score, vascularity, and pliability ratings. The purpuric condition demonstrated a trend for improvement on the VSS total. According to blind observer ratings, all conditions improved, without differences between groups. CONCLUSION Nonpurpuric settings on the PDL resulted in significant improvements in the appearance of fresh surgical scars for vascularity, pliability, and VSS total scores, although all scar segments improved over time.

Efficacy and Complication Rates of Full-Thickness Skin Graft Repair of Lower Extremity Wounds After Mohs Micrographic Surgery

Background Repair of below‐the‐knee lower extremity defects after Mohs micrographic surgery (MMS) that are not amenable to primary closure can be challenging given the high propensity for complications. No criterion standard exists for management of these wounds, but secondary‐intention healing, partial‐ and full‐thickness skin grafts (FTSGs), and various flaps are possible options to manage these wounds. Few data exist on the efficacy of FTSG repairs for lower extremity wounds. Objectives Assess the efficacy and complications rates of FTSG repairs for lower extremity wounds after MMS. Methods This was a retrospective review of 80 FTSG repairs performed after MMS. Data were derived from 45 cases at Beth Israel Deaconess Medical Center and 35 cases at University of California, San Diego (UCSD) Medical Center. Results Seventy‐two of 80 cases (90%) had full graft survival, six (7.5%) had partial failure, and two (2.5%) had complete failure. In the cases where grafts had failed, wounds healed by secondary intention without further complications. Other complications included infections in nine (11%) cases and hematoma formation in two (2.5%). Conclusion FTSG is a consistent and safe reconstructive option for the management of lower extremity wounds after MMS.

Surgical smoke in dermatologic surgery.

BACKGROUND Potential dangers associated with smoke generated during electrosurgery have been described. However, the use of smoke management in dermatology is unknown. There is no objective data showing the amount or the composition of the smoke generated in dermatologic surgeries. OBJECTIVE To assess the use of smoke management in dermatologic surgery and provide data on the amount and chemical composition of surgical smoke. METHODS A total of 997 surveys were sent to dermatologic surgeons across the United States to assess the use of smoke management. Amounts and concentrations of particulates and chemical composition were measured during electrosurgery using a particulate meter and the Environmental Protection Agency-standardized gas chromatography–mass spectrometry analysis. RESULTS Thirty-two percent of the surgeons responded to the survey, and 77% of the respondents indicated no use of smoke management at all. Only approximately 10% of surgeons reported consistent use of smoke management. Active electrosurgery produced significant amounts of particulates. In addition, surgical smoke contained high concentrations of known carcinogens, such as benzene, butadiene, and acetonitrile. CONCLUSION Surgical smoke contains toxic compounds and particulates. Most dermatologic surgeons do not use smoke management within their practices. Raising the awareness of the potential risks can help increase the use of smoke management.

Nonmelanoma Skin Cancer With Aggressive Subclinical Extension in Immunosuppressed Patients

IMPORTANCE Immunosuppression (IS), such as in solid-organ transplant recipients (SOTRs) and patients with human immunodeficiency virus (HIV) or hematologic malignant neoplasms, increases the risk of developing nonmelanoma skin cancers (NMSCs). However, it is unknown whether IS patients are at increased risk of developing NMSCs with aggressive subclinical extensions (NMSC-ASE), which may extend aggressively far beyond conventional surgical margins. OBJECTIVE To study clinical characteristics of NMSC-ASE among immunocompetent (IC) and various subgroups of IS patients and to suggest a predictive model for NMSC-ASE lesions. DESIGN, SETTING, AND PARTICIPANTS A 6-year retrospective review of 2998 NMSC cases between February 26, 2007, and February 17, 2012, at the Dermatologic and Mohs Micrographic Surgery Unit of the University of California, San Diego, Medical Center. Nonmelanoma skin cancers that required at least 3 Mohs micrographic surgery stages with final surgical margins of at least 10 mm were defined as ASE lesions. All cases were categorized into 1 of 2 groups, IS or IC. Immunosuppressed cases were further subcategorized into 3 subgroups: SOTRs and patients with HIV or hematologic malignant neoplasm. The data were analyzed in December 2012. MAIN OUTCOMES AND MEASURES We evaluated the odds ratio of having NMSC-ASE lesions in IS patients (SOTRs, HIV, hematologic malignant neoplasm) compared with IC patients. Other clinical characteristics and preoperative risks were analyzed and compared. RESULTS Of all 2998 cases, we identified 805 NMSC-ASE cases: 137 IS and 668 IC. Immunosuppressed patients had an odds ratio of 1.94 of having ASE lesions compared with IC patients (95% CI, 1.54-2.44; P < .001). Additionally, the SOTR subgroup was associated with a 2.74 odds of having NSMC-ASE compared with non-SOTRs (95% CI, 2.00-3.76; P < .001), and the presence of hematologic malignant neoplasm was associated with 1.74 times the odds compared with IC patients (95% CI, 1.04-2.90; P = .04). Multivariate analysis found older age (P < .001), lesion locations such as zone 1 (OR, 1.39 [95% CI, 1.04-1.85]; P = .02) or zone 2 (OR, 1.45 [95% CI, 1.08-1.94]; P = .01), and IS status (OR, 1.94 [95% CI, 1.54-2.44]; P < .001) to be significant predictors of ASE. CONCLUSIONS AND RELEVANCE The findings of this study suggest an increased risk for NMSC-ASE lesions in IS patients, especially in SOTRs and those with hematologic malignant neoplasm, but not patients with HIV. Statistically significant predictors of NMSC-ASE lesions such as age, location, and IS status can help physicians choose the most appropriate treatment modalities and optimize surgical planning.

Desmoplastic trichilemmoma--a report of successful treatment with Mohs micrographic surgery and a review and update of the literature.

Desmoplastic trichilemmoma (DT) is a rare benign histologic variant of trichilemmoma, a benign growth of the pilosebaceous follicle’s outer sheath. Headington and French first described trichilemmoma in 1962. The presence of irregular cords and epithelial cell nests in a prominent densely sclerotic collagenous stroma in its center differentiate DT, which Hunt and colleagues described in 1990, from trichilemmoma.

Knowledge, understanding, and use of preventive strategies against nonmelanoma skin cancer in healthy and immunosuppressed individuals undergoing Mohs surgery.

BACKGROUND Despite various national recommendations advising individuals to reduce their exposure to ultraviolet radiation, many people still do not use these skin cancer prevention strategies. OBJECTIVES To assess patient sources of medical information, knowledge of sun protection strategies, and barriers to implementing these strategies and to compare the overall rate of use of skin cancer prevention strategies of healthy and immunocompromised patients. MATERIALS AND METHODS Survey‐based study conducted on 140 individuals undergoing Mohs surgery. RESULTS Seventy‐three percent of healthy and 74% of immunosuppressed participants identified sunscreen use as a form of protective strategy, whereas 36% and 27%, respectively, used sunscreen daily. Participants cited physicians and the internet as equal sources of medical information. Knowing two or more strategies correlated to a higher self‐rating of daily use of any protective strategy. CONCLUSION General knowledge regarding sun protection strategies is limited, but awareness of multiple strategies correlated with greater sun protective behavior. Despite having a much higher incidence of skin cancers, the immunosuppressed group did not show more awareness of prevention strategies or higher use than healthy participants.