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The Australasian Journal of Dermatology May 2024For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this...
For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this technique, utilising careful dissection to identify inferior perforators of the superior alar artery. Basing this flap on a visualised vascular pedicle aims to prevent common complications of internal mucosal buckling and free margin notching, by allowing more extensive dissection without compromising the vascularity of the flap.
Topics: Humans; Surgical Flaps; Nose Neoplasms; Rhinoplasty; Nose; Male; Skin Neoplasms; Female; Carcinoma, Basal Cell
PubMed: 38757426
DOI: 10.1111/ajd.14265 -
JAAD International Sep 2024Mohs micrographic surgery with melanocytic immunohistochemistry (MMS-I) is increasingly utilized for special site melanoma treatment. Yet, frequency and risk factors...
BACKGROUND
Mohs micrographic surgery with melanocytic immunohistochemistry (MMS-I) is increasingly utilized for special site melanoma treatment. Yet, frequency and risk factors associated with upstaging of all-stage cutaneous melanomas treated with MMS-I remain undefined.
OBJECTIVE
Determine upstaging frequency and factors associated with tumor upstaging for all-stage melanomas treated with MMS-I.
METHODS
In this retrospective, single-center case series, all cases of invasive and in situ melanoma treated with MMS-I between 2008 and 2018 were reviewed. Patient and tumor characteristics were recorded and compared between tumors that were and were not upstaged from their initial T stage.
RESULTS
Of the 962 melanoma MMS-I cases identified, 44 (4.6%) were upstaged, including 5.6% of in situ and 2.5% of invasive tumors. Risk factors for upstaging included lack of excisional intent at the time of initial biopsy ( < .01), nonlentigo maligna subtype ( = .03), female sex ( = .02), and initial in situ diagnosis ( = .03). Nonstatistically significant characteristics evaluated included patient age ( = .97), initial Breslow depth ( = .18), and biopsy type ( = .24).
LIMITATIONS
Retrospective study design.
CONCLUSIONS
All-stage cutaneous melanomas treated with MMS-I are associated with low upstaging rates. Tumor upstaging is associated with lack of excisional intent, female sex, and in situ tumors.
PubMed: 38756446
DOI: 10.1016/j.jdin.2024.02.006 -
Dermatologic Surgery : Official... May 2024Exogenous artifacts can interfere with accurate histologic tissue evaluation on frozen sections during Mohs micrographic surgery (MMS). Mohs surgeons should be aware of...
BACKGROUND
Exogenous artifacts can interfere with accurate histologic tissue evaluation on frozen sections during Mohs micrographic surgery (MMS). Mohs surgeons should be aware of these anomalies to avoid potential misdiagnoses.
OBJECTIVE
To review exogenous artifacts encountered in frozen tissue pathology during MMS.
METHODS
A literature search was conducted in PubMed to identify studies reporting on exogenous artifacts encountered during MMS and a list of previously described exogenous artifacts was compiled. A retrospective examination of frozen histology slides from recent Mohs cases at the authors' institution was performed to obtain illustrative examples of these artifacts, supplemented by formalin-fixed paraffin-embedded samples when frozen examples could not be found.
RESULTS
Exogenous artifacts represent foreign bodies that have been externally introduced into the skin or artifacts resulting from other external factors. If frozen section evaluation is inaccurate, overdiagnosis can occur during MMS, resulting in unnecessary layers, larger margins, and more complex reconstructions. These exogenous tissue changes can mimic inflammatory processes and melanocytic or keratinocyte malignancies on histology.
CONCLUSION
Exogenous artifacts are common findings during margin assessment in Mohs micrographic surgery. The resulting histological findings can be confusing but correlating them with the clinical and surgical history often reassures surgeons. Recognizing these artifacts facilitates accurate diagnosis and promotes optimal patient care.
PubMed: 38754128
DOI: 10.1097/DSS.0000000000004233 -
Dermatologic Surgery : Official... May 2024Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their...
BACKGROUND AND OBJECTIVE
Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction.
METHODS
A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included.
RESULTS
Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures.
CONCLUSION
Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.
PubMed: 38754124
DOI: 10.1097/DSS.0000000000004209 -
International Journal of Dermatology May 2024The nose is a common site for the development of skin cancers. Mohs micrographic surgery (MMS) is a highly curative treatment for skin cancer of the nose. Reconstruction...
BACKGROUND
The nose is a common site for the development of skin cancers. Mohs micrographic surgery (MMS) is a highly curative treatment for skin cancer of the nose. Reconstruction of MMS defects on the nose, especially on the distal aspect, can be challenging given the proximity of multiple subunits and limited adjacent tissue reservoirs. Our goal was to describe our experience using a nasal tip rotation flap (NTRF) for MMS defects on the distal nose.
METHODS
A retrospective review of all MMS cases at multiple institutions between June 2018 and June 2022 was undertaken. Cases that used an NTRF to repair the MMS defect(s) were selected, and data were collected on patient demographics, tumor type, anatomical location of the tumor, preoperative and postoperative size, number of stages needed to clear the tumor, repair dimensions, and any postoperative complications.
RESULTS
A total of 66 cases that utilized an NTRF for reconstruction were included. The mean preoperative tumor size was 0.8 cm (range: 0.3-1.6 cm), and the mean defect size was 1.2 cm (range: 0.7-1.9 cm). The defects were most commonly on the nasal tip. There were no significant complications observed.
CONCLUSIONS
The nasal tip rotation flap is a reliable reconstruction option for MMS defects of the distal nose. This flap can be used for defects that involve the nasal tip, soft triangle, and/or portions of the ala, including the alar rim.
PubMed: 38745345
DOI: 10.1111/ijd.17155 -
Archives of Dermatological Research May 2024
Topics: Humans; Mohs Surgery; Surveys and Questionnaires; Surgeons; Female; Skin Neoplasms; Male; Middle Aged; Cohort Studies
PubMed: 38744757
DOI: 10.1007/s00403-024-02903-7 -
Archives of Craniofacial Surgery Apr 2024The rising incidence of dialysis-dependent end-stage renal disease (ESRD) has underscored the need for collaboration between plastic surgeons and nephrologists,...
BACKGROUND
The rising incidence of dialysis-dependent end-stage renal disease (ESRD) has underscored the need for collaboration between plastic surgeons and nephrologists, particularly concerning preoperative and postoperative management for facial reconstruction. This collaboration is essential due to a scarcity of comprehensive information in this domain.
METHODS
A study initiated in January 2015 involved 10 ESRD cases on dialysis undergoing Mohs micrographic surgery for facial skin cancer, followed by reconstructive surgery under general anesthesia. To ensure surgical safety, rigorous measures were enacted, encompassing laboratory testing, nephrology consultations, and preoperative dialysis admission. Throughout surgery, meticulous control was exercised over vital signs, electrolytes, bleeding risk, and pain management (excluding nonsteroidal anti-inflammatory drugs). Postoperative assessments included monitoring flap integrity, hematoma formation, infection, and cardiovascular risk through plasma creatinine levels.
RESULTS
Adherence to the proposed guidelines yielded a notable absence of postoperative wound complications. Postoperative plasma creatinine levels exhibited an average decrease of 1.10 mg/dL compared to preoperative levels, indicating improved renal function. Importantly, no cardiopulmonary complications or 30-day mortality were observed. In ESRD patients, creatinine levels decreased significantly postoperatively compared to the preoperative levels (p< 0.05), indicating favorable outcomes.
CONCLUSION
The consistent application of guidelines for admission, anesthesia, and surgery yielded robust and stable outcomes across all patients. In particular, the findings support the importance of adjusting dialysis schedules. Despite the limited sample size in this study, these findings underscore the effectiveness of a collaborative and meticulous approach for plastic surgeons performing surgery on dialysis-dependent patients, ensuring successful outcomes.
PubMed: 38742333
DOI: 10.7181/acfs.2024.00045 -
Otolaryngology--head and Neck Surgery :... May 2024Few studies have examined the impact of preoperative and surgical factors on the change in cosmetic survey scores after nasal Mohs reconstruction using a subset of the...
OBJECTIVE
Few studies have examined the impact of preoperative and surgical factors on the change in cosmetic survey scores after nasal Mohs reconstruction using a subset of the 10-item Standardized Cosmesis and Health Nasal Outcomes Survey-Cosmesis (SCHNOS-C). We aim to determine preoperative and surgical factors that impact cosmetic outcomes following Mohs nasal reconstruction.
STUDY DESIGN
Retrospective analysis.
SETTING
Nasal Mohs reconstruction patients at a tertiary medical center.
METHODS
All patients receiving Mohs reconstruction of any nasal subunit at a tertiary medical center were analyzed. Variables collected included demographic and Mohs defect/reconstruction characteristics. Primary outcomes were changes in cosmetic (SCHNOS-C) scores and revision rates. Multivariable analysis was used to identify independent predictors of cosmetic scores/revision.
RESULTS
We included 296 patients for analysis. On multivariable logistic regression, factors contributing to better final cosmetic scores were receiving a skin/composite graft (odds ratio [OR]: 0.22, 95% confidence interval: 0.06-0.68, P = .014) compared to a local flaps. Women were more likely to have worsening cosmetic scores (OR: 2.27, 1.06-4.99, P = .037). Only initial cosmetic scores independently predicted receiving any revision (OR: 1.11, 1.03-1.20, P = .006).
CONCLUSION
Average SCHNOS-C scores after nasal reconstruction of Mohs defects are low. Only worse patient reported SCHNOS-C scores predicted revision. It is important to understand preoperative and surgical factors that affect cosmetic outcomes to optimize patient counseling and reconstructive planning. Patient perception is a key factor in predicting revisions.
PubMed: 38738913
DOI: 10.1002/ohn.811 -
Clinical and Experimental Dermatology May 2024ChatGPT® (OpenAI; California, USA) is an open-access chatbot developed using artificial intelligence (AI) that generates human-like responses.
BACKGROUND
ChatGPT® (OpenAI; California, USA) is an open-access chatbot developed using artificial intelligence (AI) that generates human-like responses.
OBJECTIVE
To evaluate the ChatGPT-4's concordance with three dermatologic surgeons on reconstructions for dermatological surgical defects.
METHODS
A total of 70 cases of non-melanoma skin cancer treated with surgery were obtained from clinical records for analysis. A list of 30 reconstruction options was designed by the main authors which included primary closure, secondary skin closure, skin flaps and skin grafts. Three blinded dermatologic surgeons, along with ChatGPT-4, were asked to select two reconstruction options from the list.
RESULTS
Seventy responses were analyzed using Cohen's kappa looking for concordance between each dermatologist and ChatGPT. The level of agreement among dermatologic surgeons was higher compared to that between dermatologic surgeons and ChatGPT, highlighting differences in decision-making. In the best reconstruction technique, the results indicated a fair level of agreement among the dermatologists ranging between κ 0.268 and 0.331. However, the concordance with ChatGPT-4 and the dermatologists was slight with κ values from 0.107 to 0.121. In the analysis of the second-choice options, the dermatologists showed slight agreement. In contrast, the level of concordance between ChatGPT-4 and the dermatologists was below chance.
CONCLUSIONS
As anticipated, this study reveals variability in medical decisions between dermatologic surgeons and ChatGPT. Although these tools offer exciting possibilities for the future, it's vital to acknowledge the risk of inadvertently rely on non-certified AI for medical advice.
PubMed: 38738492
DOI: 10.1093/ced/llae184 -
The British Journal of Dermatology May 2024Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue...
BACKGROUND
Autofluorescence (AF) - Raman spectroscopy is a technology that can detect residual basal cell carcinoma (BCC) on the resection margin of fresh surgically excised tissue specimens. The technology does not require tissue fixation, staining, labelling, or sectioning, and provides quantitative diagnosis maps of the surgical margins in 30 minutes.
OBJECTIVES
To determine the accuracy of the AF-Raman instrument to detect incomplete excisions of BCC during Mohs micrographic surgery, using histology as reference standard.
METHODS
Skin layers from 130 patients undergoing Mohs surgery at the Nottingham University Hospitals NHS Trust (September 2022 to July 2023) were investigated with the AF-Raman instrument. The layers were measured fresh, immediately after excision. The AF-Raman results and the intra-operative assessment by Mohs surgeons were compared to a post-operative consensus-derived reference produced by three dermatopathologists. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated.
RESULTS
The AF-Raman analysis was successfully completed for 125 out of the 130 layers. The AF-Raman analysis covered 91% of the specimen surface area on average, with the lowest being 87% for eyelid and the highest being 94% for forehead specimens. The AF-Raman instrument identified positive margins in 24 out of 36 BCC-positive cases, resulting in a 67% sensitivity (95% confidence intervals (CI): 49%-82%) and negative margins in 65 out of 89 BCC-negative cases, resulting in a 73% specificity (95% CI 63%-82%). Only one out of the 12 false negative cases was caused by misclassification by the AF-Raman algorithm. The other 11 false negatives cases were produced because no valid Raman signal was recorded at the location of the residual BCC due to either occlusion by blood or poor contact between tissue and cassette window. The intra-operative diagnosis by Mohs surgeons identified positive margins in 31 out of 36 BCC-positive cases, 86% sensitivity (95% CI: 70%-95%), and negative margins in 79 out of 89 BCC-negative cases, 89% specificity (95% CI: 81%-95%).
CONCLUSIONS
This study shows that the AF-Raman instrument has potential for intra-operative microscopic assessment of surgical margins in surgery of BCC. Further improvements are required for tissue processing to ensure complete coverage of the surgical specimens. ClinicalTrials.gov ID NCT03482622.
PubMed: 38736216
DOI: 10.1093/bjd/ljae196