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2021 Journal Club Archive

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2021

December 2021

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  • Article 1 take home points:
    • Gap between practice in AAFPRS members (and I'm sure others) practice and RASCR guidelines
    • Maximization of non-opioid analgesia is preferred over Rx of opioids
    • Equally effective for acute pain
    • Rx of 4-6 days inconsistent with data showing pain scores for skin surgery ~0 by 48 hours
  • Article 2 take home points:
    • Most injection sites were in deep tissues not typically injected by dermatologic surgeons
      • However, injections in superficial locations on eyelid were culprit of 10% of cases
  • Article 3 take home points:
    • Flaps/grafts have more SSI than linear repairs or 2nd intent healing, even after adjusting for wound size
    • Prophylactic antibiotics may not be effective at reducing SSI rate
  • Article 4 take home points:
    • N/A
  • Article 5 take home points:
    • N/A

Dr. Ian Maher (University of Minnesota), Dr. West Mori (University of Minnesota Fellow), and Dr. Laurin Council (Washington University School of Medicine in St. Louis) present the best dermatologic surgery relevant literature from the December Journals.

November 2021

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  • Article 1 take home points:
    • N/A
  • Article 2 take home points:
    • N/A
  • Article 3 take home points:
    • Substantial changes in opioid prescribing habits for patients having MMS
      • Frequency, opioid type
    • 27.9% absolute decrease in frequency from 2011-2020
      • Geographic variability in prescribing habits
    • Study limitations
      • Cannot account for unfilled opioid prescriptions that would not have an associated insurance claim in database
      • Conclusions assume patients take all pills prescribed
  • Article 4 take home points:
    • "A swing is a sling by another name"
    • Prolonged post-op hospital stay does temper study's generalizability
    • The ideal surgical candidate can tolerate having one eye closed for a couple weeks
  • Article 5 take home points:
    • Consider MCC primary site as an additional prognostic factor
    • Effect on disease-specific death is modified by stage at initial diagnosis
      • For localized disease -> scalp/neck, trunk worse
      • For metastatic disease -> lip worse

Dr. Ian Maher (University of Minnesota) and Dr. West Mori (University of Minnesota Fellow), present the best dermatologic surgery relevant literature from the November Journals.

October 2021

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  • Article 1 take home points:
    • N/A
  • Article 2 take home points:
    • Demographic data consistent with previously existing literature for desmoplastic melanoma
    • No overall survival benefit for adjuvant RT, which holds true for higher risk subsets (ie. high T stage, + LNs, + margin)
    • National Comprehensive Cancer Network guidelines currently state adjuvant RT may be considered in select high risk cases, but this is based on research demonstrating local control benefit, NOT overall survival benefit
    • Limited prospective data available
    • Limitation of present study:
      • No inclusion of RT impact on local control (not available in database)
      • Retrospective
  • Article 3 take home points:
    • Number and proportion of total biopsy claims by PAs and NPs up significantly in all states and regions 2012 to 2018
    • Wide variation in proportion as well as growth of proportion of biopsies by non-physicians by state/region
      • For example, more growth in areas with physician shortages
    • Northeast demonstrated smaller increases in PA/NP biopsies compared to elsewhere
      • Dense urban population with slower growth to independent non-physician practice
      • ↑ Medicare beneficiaries →  ↑ non-physicians in order to close widening gaps in care
    • Limitations
      • Only investigates derms, NPs, PAs (ie. not other non-derm physician providers)
      • Physician numbers possibly overestimated (PA/NP biopsies billed under physician)
  • Article 4 take home points:
    • Gives some information on growth of BCCS
    • Short follow up times
    • On individual basis, hard to predict both life expectancy and growth rate
    • Close follow up may be burdensome/unrealistic for patients
    • Majority of patients (63%) eventually chose treatment
    • Longer term studies needed
  • Article 5 take home points:
    • N/A

Dr. Mariah Brown (University of Colorado Medicine), Dr. Robert Kantor (Fellow) and two former fellows — Dr. Franki Lambert Smith (University of Rochester) and Dr. Dominic Ricci (Baylor, Scott & White) — present the best dermatologic surgery relevant literature from the October Journals.

September 2021

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  • Article 1 take home points:
    • Significant proportion of cSCCs are upstaged intraoperatively by Mohs surgeon
    • Patient and tumor traits may predict when this may occur
    • Consider such traits when counseling patients and during surgical planning
    • Findings dependent on subjective interpretation of histopathologic specimens
  • Article 2 take home points:
    • Majority of respondents believe N₂O is effective for patient comfort, easy to use, and safe
  • Article 3 take home points:
    • No significant impact of pandemic deferral period on distribution of pT stage or proportion of tumors having high-risk or poor prognostic pathologic features for BCC, SCC, and melanoma
      • Perhaps no lasting negative impact on patients by delay of surgery
  • Article 4 take home points:
    • Patient cohort was overall highly satisfied with their skin cancer treatment
    • Patients were most satisfied with factors related to interpersonal manner and reported the least satisfaction with accessibility and financial aspects of their care
    • Predictors of increased patient satisfaction included: 1) patient-perceived current health status and general satisfaction and 2) increased quality of life related to mental health
    • Predictors of decreased patient satisfaction included: 1) smoking status and 2) anticoagulation
  • Article 5 take home points:
    • There is a lack of widely accepted criteria for creating distinctions between well, moderately and poorly differentiated cSCC
    • In this study, dermatopathologists had a greater concordance than Mohs surgeons for poorly differentiated tumors in both rounds (0.73 and 0.66 vs. 0.55 and 0.56), corresponding to moderate concordance among dermatopathologists and weak concordance among Mohs surgeons
    • Interrater reliability of moderately differentiated tumors was the lowest, suggesting that this category of cSCC is difficult to categorize for dermatopathologists and Mohs surgeons

Dr. Basia Michalski, MSDO fellow at Cleveland Clinic, and Dr. West Mori, MSDO fellow at University of Minnesota, present the best dermatologic surgery relevant literature from the September Journals.

August 2021

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  • Article 1 take home points:
    • Facial melanomas are often large
    • With ~1cm needed for clearance of MIS and T1 on the face, the defects are almost always large
    • Large defects on the face require tissue rearrangement for optimal cosmesis and functional outcome.
  • Article 2 take home points:
    • LTR < LHR particulate concentrations
    • Metals and VOCs < OELs
      • No clear requirement for smoke evacuators, masks, and protective patches
    • Aerosolized bacteria of unclear significance
    • Limitations
      • Viral or fungal particles not measured
      • Small sample size
  • Article 3 take home points:
    • Study supports generalizability of MIA nomogram
    • Replaces body site and Clark level with mitotic rate, melanoma subtype, and lymphovascular invasion status
    • C-statistic not worse than that of MSK nomogram
  • Article 4 take home points:
    • Mohs is appropriately used in immune compromised, at least at this one institution.
    • Note that "uncertain" does not meet inappropriate, and even inappropriate has exceptions.
  • Article 5 take home points:
    • "L-lift" provides some benefits of face lift, not by plicating muscle and removing skin, but by increasing volume and stimulating neocollagenesis.
    • Notably, the authors assert their technique works by creating structural support at key sites and not by volume increase.
    • It is unclear how durable these results may be.

Dr. Ian Maher, Dr. Westley Mori, and Dr. Murad Alam present the best dermatologic surgery relevant literature from the August Journals.

July 2021

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  • Article 1 take home points:
    • A lot of what makes good safe care isn't glamorous
    • These guidelines are an important 1st step in improving care.
    • As with any guideline there will be times when it is necessary to deviate from the guideline
    • It's important for dermatology to participate in these types of endeavors
  • Article 2 take home points:
    • HA fillers most commonly used
    • Tear trough abnormality most common target
    • Risk of malar edema: calcium hydroxyapatite and autologous fat > HA fillers
    • Autologous fat may be best in select patients
    • Complications are rare but are due respect
    • Limitations
      • No mention of whether touch-ups were employed; method of injection (traditional needle versus soft-tipped cannula)
  • Article 3 take home points:
    • Always good to have arrows in the quiver
    • Grafts and granulation can require extended wound care
    • Flaps generally heal faster
    • This is a "size limited" closure option
    • Small pull throughs are hard to do
    • Therefore I think I'll likely use this for small conchal bowl defects in patients who need accelerated healing.
  • Article 4 take home points:
    • The high-risk traits that seem to be associated with positive SNLB are the familiar ones
    • All tumors with positive SNLB were AJCC-8 stage T3 and BWH stage T2b
      • Supports SLNB in these tumors but not at earlier stages
    • Cytokeratin AE1/AE3 may add value versus H&E alone to avoid false-negatives
    • More studies needed to determine if SLN status impacts survival and has prognostic value
  • Article 5 take home points:
    • Small study
    • FTSG in periocular area are rapidly perfused
    • 45% vascularity of surrounding skin at 1 week
    • 75% at 4 weeks
    • Normal at 7 weeks
    • Expect speed of vascularization to change with location

Dr. Ian Maher (University of Minnesota) and Dr. Westley Mori (University of Minnesota Fellow), will present the best dermatologic surgery relevant literature from the July Journals.

June 2021

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  • Article 1 take home points:
    • 20% may not fill their opioid Rx
    • No easily identifiable factors to predict who will fall into this population
  • Article 2 take home points:
    • This study confirms that all three incidental PNI patterns (large caliber, extensive nature, and deep PNI) as well as tumor diameter are associated with poor outcomes.
    • In addition, PNI greater than or equal to 0.1mm was independently associated with lymphatic progression. This refutes the theory that all PNI is just a marker for other high-risk features and not independently predictive.
    • ***Extensive PNI problematic because of a lack of a consensus definition and limited evaluation of tumor in bread-loaf sections.
      • The authors recommend discontinuing the use of this term
    • Tumor diameter & large nerve involvement are most closely a/w poor prognosis, although prospective studies are needed.
  • Article 3 take home points:
    • Adverse effects are rare and not serious.
    • Efficacy reported is good, but selection bias and variable follow up duration may overestimate.
    • A full manuscript would be helpful to understand how applicable IL 5-FU is for your patients.
    • Don't be tempted by an easier treatment when high quality care is available.
  • Article 4 take home points:
    • N/A

Dr. Michael Pelster (University of Texas Health) and Dr. Addison Demer (Mayo Clinic) present the best dermatologic surgery relevant literature from the June Journals.

May 2021

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  • Article 1 take home points:
    • N/A
  • Article 2 take home points:
    • Margins > 1.0 (vs<1.0 cm) associated with significant improvement in overall survival
      • Independent of other clinical/pathologic characteristics (RT status, +/- margin)
      • Extending margins from >1.0 to >2.0 cm showed no significant survival benefit
    • Addition of RT associated with improvement in survival within each margin size subgroup
      • i.e. Margin <1.0 cm + RT had similar survival to >1.0 cm without RT group
    • Best survival with margins 1.1-2.0 cm with adjuvant RT
  • Article 3 take home points:
    • N/A
  • Article 4 take home points:
    • Both of these are useful tools
    • On average no difference
    • Not sure the billing argument holds water
    • NBIPF is slightly more challenging to execute
    • BLF/TLF slightly more challenging to plan
    • Flaps should tap tissue reservoirs
    • LEARN BOTH WELL
    • Need a head-to-head trial to see if there is/isn't a difference (we're working on that)
  • Article 5 take home points:
    • Chlorhexidine is antiseptic of choice off the face/scalp (Povidone-iodine preferred given keratitis/ototoxicity)
    • Preoperative decolonization of S. aureus carriers with intranasal mupirocin
    • Limited situations in which evidence supports Abx prophylaxis:
      • High risk cardiac conditions
        • prosthetic valve, h/o IE, congenital heart disease, cardiac transplants with valvuopathy
      • Prosthetic joint at high risk for hematogenous joint infection
      • Procedure that breaches oral mucosa
      • Extensive inflammatory disease
    • Lower cost operative settings and use of clean technique are safe for skin cancer procedures (and likely improve patient access and reduce costs)
    • Topical antibiotics do not appear to provide benefit in prevention of SSI
    • Moist environment with low sensitizing agent (Petrolatum preferred)

Dr. Dr. Laurin Council (WUSOMSTL), Dr. Daniel Knabel (Fellow, University of Minnesota), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals.

April 2021

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  • Article 1 take home points:
    • DCA is safe with expected side effects in low abdominal fat treatment
    • Significant reduction in fat thickness
    • Measurable effect vs. significant effect?
    • A lot of product and thus cost in this application
  • Article 2 take home points:
    • Patients were pretty happy with both repairs
    • PMFF used in bigger defects than BLF as appropriate
    • Use of local flap does cause reduction in some distances relative to BLF
    • 3-D imaging isn't quite there for being widely applicable to reconstruction but it's getting close
  • Article 3 take home points:
    • PNI likely more complex than simple "binary score" (present v absent)
    • Authors composite PNI score significantly correlates with adverse outcomes in multivariant regression
    • Limitations
      • Small, single center study
      • Follow up limited to 24 months
  • Article 4 take home points:
    • Narrow margins not associated with increased risk of local recurrence, any recurrence, death from MCC, death from any cause compared with wide margins (>1.0 cm)
    • Margin size not associated with difference in reconstructive procedure or time to treatment with radiotherapy
    • Limitations
      • Relatively small cohort
      • Retrospective nature

Dr. Ian Maher (University of Minnesota) and Dr. Daniel Knabel (Fellow, University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals.

March 2021

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  • Article 1 take home points:
    • NAFL may be equivalent in effectiveness and easier to tolerate for patients with less downtime than AFL for atrophic acne scars of mild to moderate severity
  • Article 2 take home points:
    • Small study
    • PRP and TI seem to be safe adjuncts to microneedling for acne scars in dark skin types
    • How much additive improvement to microneedling along?
    • Interesting window into global drug pricing that insulin considered a cheap alternative?
  • Article 3 take home points:
    • Early division of PMFF successful in all 12 patients
      • Partial thickness, not greater than 50% of defect base with cartilage graft and no prior trauma/scarring of donor site
      • Flap appeared clinical engrafted
      • Flaps were aggressively thinned at the first stage
      • No/minimal additional thinning at second stage
    • Limitations
      • Small, single center study
  • Article 4 take home points:
    • N/A
  • Article 5 take home points:
    • Salvage radiation therapy can be considered in unresectable cutaneous squamous cell carcinoma.
    • In cases of unresected higher risk tumors (BWH T2b/AJCC8 T3), the benefit of salvage radiation may be limited.

Dr. Murad Alam (Northwestern Medicine), Dr. Daniel Knabel, (Fellow University of Minnesota), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals.

February 2021

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  • Article 1 take home points:
    • Most helpful debulk analysis: SCC > 2cm
    • Consider it for moderate differentiation, male sex or organ transplant patients
    • Minimal increased time/effort to obtain debulk
    • May be a low number upstaged, but it matters for those individual patients
  • Article 2 take home points:
    • MMS may be equivalent (if not superior) for invasive melanomas on trunk/proximal extremities
    • Start MMS with standard margins
  • Article 3 take home points:
    • BNP-CPT showed the greatest amount of retention in tumor versus NNP-CPT or CPT alone
    • BNP-CPT showed delayed tumor growth in mice and reduced tumor weight over time
    • When combined with an adjuvant, BNP-CPT caused histologically confirmed tumor resolution in 17-20%
  • Article 4 take home points:
    • No significant differences in
      • COVID-19 symptoms postoperatively
      • COVID-19 tests performed
    • In both groups:
      • 0 positive COVID-19 tests
      • 0 COVID-19 deaths

Dr. Nicholas Golda (University of Missouri) presents the best dermatologic surgery relevant literature from the February Journals.

January 2021

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  • Article 1 take home points:
    • Mohs surgery with MART-1 results in smaller defect size, fewer stages, simpler reconstruction and less cost to the health care system compared to Mohs surgery with H&E alone.
    • Although Mohs surgery with MART-1 required more stages than Staged Excision, the latter resulted in larger defects and more complex reconstruction.
    • Limitations: small study at a single institution
  • Article 2 take home points:
    • Option for relatively small medial lower lid defects
    • Upsides
      • MUCH less undermined area than large lateral rotation flap
      • Maintenance of medial canthal attachment should help maintain concavity
      • Wide arc of rotation distributes secondary defect minimizing loss of depth in "cone"
    • Downsides
      • Need very mobile tissue
      • Need cheek-nose texture match
      • Beware flaps that move toward free margin
  • Article 3 take home points:
    • SIF performed by Mohs surgeons in outpatient setting under local anesthesia are
      • Well-tolerated with low pain/anxiety levels
      • Perceived with high satisfaction from patients
  • Article 4 take home points:
    • Non-surgical rhinoplasty is a growing procedure
    • In depth knowledge of nasal anatomy and limits of "liquid rhinoplasty" required
    • Low rate of AE in expert injector
    • Excellent informed consent key
    • Careful patient selection
  • Article 5 take home points:
    • There is a lack of widely accepted criteria for creating distinctions between well, moderately and poorly differentiated cSCC
    • In this study, dermatopathologists had a greater concordance than Mohs surgeons for poorly differentiated tumors in both rounds (0.73 and 0.66 vs. 0.55 and 0.56), corresponding to moderate concordance among dermatopathologists and weak concordance among Mohs surgeons
    • Interrater reliability of moderately differentiated tumors was the lowest, suggesting that this category of cSCC is difficult to categorize for dermatopathologists and Mohs surgeons

Dr. Ian Maher (University of Minnesota) and Dr. Daniel Knabel (University of Minnesota Fellow) present the best dermatologic surgery relevant literature from the January Journals.

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