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2004 ASDS-ACMMSCO Combined Annual Meeting:
Mohs and Joint Accepted Abstracts

Linear Closures for Nasal Defects Following Mohs Micrographic Surgery

Authors: Leonard Harry Goldberg, MD, Arash Kimyai-Asadi, MD, Sirunya Silapunt, MD, Paul M. Friedman, MD, Ming H. Jih, MD, PhD

Purpose: Nasal defects following Mohs micrographic surgery can be repaired using linear closures, a variety of flaps, and skin grafts, or can be allowed to granulate and epithelialize. We report our experience with the feasibility of linear closures on the nose.

Design: A retrospective study of 300 consecutive nasal defects following Mohs surgery was performed.

Summary: Overall, linear closures, flaps, and grafts were used in 47%, 24%, and 14% respectively, with 15% being allowed to granulate and epithelialize. Linear closures were used for tumors on the nasal bridge, nasal sidewall, nasal tip, and nasal ala in 82%, 70%, 44%, and 10% of cases, respectively. On the nasal bridge, the average size of tumors closed in a linear fashion was 1.08 +- 0.42 as compared to 1.83 +/- 0.64 (p<0.01) for those closed using a flap or graft. On the nasal sidewall, the average size of tumors closed in a linear fashion was 1.02 +/- 0.40 as compared to 2.28 +/- 0.22 (p<0.0001) for those closed using a flap or graft.

Conclusions: Linear closures are feasible for most small-medium sized defects on the nasal bridge and sidewall.

Session Name: Reconstruction Research Abstracts

Session Date: Thursday, September 30

Late-breaking: No


Two for One: Closure of Multiple Adjacent Defects

Authors: Tatyana R. Humphreys, MD

Purpose: Patients may present for Mohs micrographic surgery with multiple adjacent neoplasms. Simultaneous removal may be necessary due to patient preference or to prevent relocation of a second neoplasm during flap repair.

Design: Cases requiring closure of techniques multiple adjacent defects were reviewed.

Summary: The nose was the most common site for the occurrence of multiple adjacent neoplasms. Flap planning and aesthetic considerations including the use of single or multiple combined closures are discussed.

Conclusions: Adjacent defects may often be closed using one flap. If separate cosmetic units are involved , combined closure techniques may be required. Planning for optimal cosmesis will be discussed.

Session Name: Reconstruction Research Abstracts

Session Date: Thursday, September 30

Late-breaking: No


FTSG's: How to Optimise Graft Appearance and Viability

Authors: Deborah MacFarlane, MD

Purpose: The full thickness skin graft is the workhorse on those occasions where routine closures or flaps are not possible. When properly designed and performed it provides an excellent closure option. On occasions however, grafts may have a 'stuck on' appearance and graft take may be less than 100%. We present various techniques to optimise graft appearance and viability.

Design: Through video demonstration of patients, techniques to optimise FTSG appearance and viability will be illustrated.

Summary: FTSG appearance may be improved by taking care with skin color and texture matching. Use of original donor sites such as the posterior ear lobe and the abdomen can be considered. Hemostasis at the recipient site is paramount. Grafts need to be thoroughly thinned of fat and sutured to recipient sites under slight tension and with excellent apposition of skin edges. Sterile steri-strips are used to keep suture ties organised. Bolster sutures are not used and may result in a pin-cushion effect, instead bolsters are manufactured from iodoform gauze and tied in place. Daily antibiotic ointment application around the bolster serves to keep the graft moist until the bolster is taken down.

Conclusions: Use of various techniques as demonstrated by video will help optimize FTSG appearance and viabilty.

Session Name: Reconstruction Research Abstracts

Session Date: Thursday, September 30

Late-breaking: No


How I feel With my Interpolation Flap

Authors: Tri H. Nguyen, MD

Purpose: Having skin cancer surgery is stressful for most patients. This strain is aggravated with complex reconstructions. Interpolation flaps are complex techniques that require at least two stages of surgery, with an interval period of deformity. Its impact on patients and their lives is unclear to most dermatologic surgeons. It is our purpose to highlight the patient's perspective during the perioperative period for these complex closures.

Design: Personal diaries were kept by a series of patients undergoing paramedian forehead, Abbe, and cheek interpolation flaps. These patients' perspectives on their flaps' psychologic, physical, and lifestyle impact were then evaluated.

Summary: Patients undergoing two stage complex reconstructions display at least a bimodal reaction pattern. Lifestyle morbidity was individualized to the patients' prior activity level and type of reconstruction. Surprising thoughts and emotions were expressed by a number of patients.

Conclusions: Physicians practice the best medicine and surgery when they are empathetic to their patients' needs. Few of us, however, can truly empathize with patients undergoing interpolation flaps. By being cognizant, however, of the non-medical consequences of our reconstructions, we will be more compassionate, understanding, and effective dermatologic surgeons.

Session Name: Reconstruction Research Abstracts

>Session Date: Thursday, September 30

Late-breaking: No


Pop-Up Flap: A Novel Flap for Reconstruction Following Mohs Micrographic Surgery

Authors: Saadia Raza, MD, Roberta Sengelmann, MD

Purpose: Here we describe the Pop-Up flap, a novel myocutaneous pedicle flap for reconstruction of partial thickness skin defects following Mohs micrographic surgery. This floating flap, which relies upon movement of tissue in a vertical fashion, is essentially a modification of the island pedicle flap. The beauty of this flap is that it precludes incisions and suture lines outside the confines of the original defect, in comparison to a traditional island pedicle flap.

Design: The Pop-Up flap is designed by incising the partial thickness defect circumferentially. The base of the flap is undermined, taking care not to sever underlying neurovascular structures and muscular pedicle. Once released from its dermal and fascial connections, the flap is allowed to rise into the wound to fill the defect. It is then secured to adjacent tissue with simple sutures.

Summary: To date, several patients, all with partial thickness defects of the nasal bulb, have undergone reconstruction following Mohs micrographic surgery using this technique. All patients had uneventful post-operative courses and excellent aesthetic outcomes.

Conclusions: The Pop-Up flap is a viable option for repair of partial thickness defects, especially on the nose, following Mohs micrographic surgery and may allow superior functional and cosmetic outcomes in comparison to alternative techniques.

Session Name: Reconstruction Research Abstracts

Session Date: Thursday, September 30

Late-breaking: No


Periorbital Reconstruction with Adjacent-Tissue Skin Grafts

Authors: Andrew J. Kaufman, MD

Purpose: Periorbital reconstruction presents unique challenges to the dermatologic surgeon. These include an adjacent lower lid free margin with risk of ectropion especially in older patients and a relative paucity of lax skin available for reconstruction. We describe the use of a novel reconstructive technique to avoid some of the pitfalls in periorbital repair.

Design: Several patient examples will be presented that illustrate the utility and technique of adjacent-tissue skin grafts in periorbital reconstruction. The procedure is accomplished by closure of a portion of the defect by complex or flap repair. The remaining surgical defect nearest the lid margin is repaired using tissue harvested during partial closure.

Summary: Flap or complex repair of periorbital defects risk excessive lid tension or ectropion. Full-thickness skin grafts harvested from other sites are less optimal due to differences in color, texture and thickness. Repair using adjacent-tissue skin grafts close the defect within cosmetic units or subunits, avoid excess tension or risk of ectropion and repair with tissue of more similar skin characteristics to the periorbital skin.

Conclusions: Reconstruction with adjacent-tissue skin grafts is a useful alternative for repair of selected surgical defects around the eye.

Session Name: Advanced Regional Reconstruction

Session Date: Saturday, October 2

Late-breaking: No


The Aesthetic Significance of the Melolabial Folds

Authors: Jonathan L. Cook, MD

Purpose: Because of their visual prominence in the central face, the melolabial folds are important landmarks to consider when selecting facial reconstructive options. Unfortunately, nasal, cheek, and lip flap repairs can introduce significant deformities in the melolabial folds. The resulting asymmetry is often unappreciated by the cutaneous surgeon, and there are usually reconstructive options that present less threats to the integrity of the melolabial folds.

Design: The normal variants of the melolabial folds are reviewed. The topographic contributions by the melolabial folds to facial symmetry will be emphasized. The anatomic basis for the melolabial folds is explained, and multiple case examples will be provided to illustrate the influence of facial reconstructive surgical procedures on the location, depth, and quality of the melolabial folds. Surgical cases will also demonstrate strategies to aid in the preservation of the visually important folds.

Summary: Minor degrees of melolabial fold distortion create only minor aesthetic concerns. When larger wounds require significant reconstructive efforts, the likelihood of introducing concerning distortion of the melolabial folds increases.

Conclusions: The symmetry and quality of the melolabial folds, although not frequently emphasized in the reconstructive surgical literature, define much of the aesthetic balance of the central face. Options for reconstructing central facial wounds should therefore seek to minimize the manipulation of the folds when possible.

Session Name: Advanced Regional Reconstruction

Session Date: Saturday, October 2

Late-breaking: No


Hinged Flap for Full Thickness (Through and Through) Defects of the Ear and Nose

Authors: Ken Lee, MD, Khosrow Mehrany, MD, Neil A. Swanson, MD

Purpose: Full thickness (through and through) defects on the nose and ear can be difficult to repair. The following cases demonstrate a single stage technique used to repair full thickness defects on the ear, nasal ala, and alar rim.

Design:

Summary: The hinged flap is the designed on the skin adjacent to the defect. The flap is completely raised with the only attachment (hinge) on the edge of the defect. The flap is lifted and flipped such that the "anterior skin " now becomes the "posterior skin" of the through and through defect. The anterior portion of the defect can now be reconstructed using either a local flap or skin graft. A variation- hinged turnover flap- can be used when the defect encompasses the full thickness of alar rim. The flap is designed superiorly to the ala and made longer. The flap is lifted and flipped inferiorly leaving it attached at the superior most aspect of the defect. The distal aspect of the flap is flipped back on itself to recreate the anterior alar rim.

Conclusions: The hinged flap is a simple and useful single stage procedure for the reconstruction of full thickness (through and through) defects of the ear and nose.

Session Name: Advanced Regional Reconstruction

Session Date: Saturday, October 2

Late-breaking: No


A Fusiform Elliptical Burows Graft for Nasal Tip Reconstruction

Authors: Khosrow Mehrany, MD, Ken K. Lee, MD

Purpose: The correction of cutaneous nasal tip defects presents a common reconstruction challenge with desirous aesthetic outcomes dependent on appropriate flap or graft selection and execution.

Design: We describe the fusiform elliptical Burows graft for repair of moderately sized nasal tip defects. It has the advantage of being a one-stage procedure with incisions and undermining no different than a primary linear closure.

Summary: A Burows triangle serving as a full thickness skin graft is removed superior to the defect for best possible cosmetic match. Closing the donor site results in lessening of the defect size. A small Burows triangle removed inferiorly may further reduce the defect size and convert the defect into a fusiform elliptical shape for better nasal tip contour. The superior Burrows triangle subsequently serves as a graft for the remainder of the defect.

Conclusions: The fusiform elliptical Burows graft is a simple and easily reproducible technique for repair of nasal tip and dorsum defects.

Session Name: Advanced Regional Reconstruction

Session Date: Saturday, October 2

Late-breaking: No


Extending the Reach of Your Forehead Flap

Authors: Tri H. Nguyen, MD

Purpose: The paramedian forehead flap is a reliable technique for complex nasal reconstruction. Rarely, the flaps length may be insufficient for wound closure. Modifications to the forehead flap's design and mobilization, however, can extend its reach and facilitate closure. We present various techniques to lengthen the reach of the paramedian forehead flap.

>Design: Through a high-resolution digital video format, the above modifications will be illustrated with patients and fresh cadaver dissections.

Summary: The reach of the forehead flap may be extended with modifications to both design and mobilization. Design considerations include; 1) limiting the pedicle's base width 2) extending the flap template lateral from midline. Procedural considerations; 1) a subperiosteal incision and elevation past the supraorbital rim 2) scoring epidermal incision at the pedicle base 3) temporary anchoring sutures to move the distal defect more proximally.

Conclusions: The above designs and modification will extend a paramedian forehead flap often more than one-centimeter (without risk to vascularity), thereby achieving critical length extension for reconstruction. The high-resolution digital video format will clearly demonstrate nuances in technique and execution.

Session Name: Abstract Session: Reconstruction and Pearls

Session Date: Thursday, September 30

Late-breaking: No


Nasalis Flap

Authors: Paul J.M. Salmon, MD, Amy Stanway, MD

Purpose: Nasalis Flap and Graft repair provides reliable closure for denuded defects of the nose. Summary Background Skin cancer surgery involving the nasal tip and dorsum sometimes results in exposure of underlying bone or cartilage. We describe a simple method of providing a vascular bed for the defect using the superficial nasalis musculoaponeurotic system ( SNAS ) of the nose, which allows full-thickness skin graft reconstruction of the defect and an acceptable cosmetic outcome. Objective The utility of nasalis flaps to provide a vascular bed for grafting has not been specifically addressed in the dermatology literature. Our experience with 26 SNAS flaps is outlined to demonstate the utility of this closure in the appropriate situations. Methods A discussion of the relevant anatomy is followed by an outline of the surgical technique. Results SNAS flaps provide a reliable vascular bed and contour for defects of the bridge and distal nose. Complications have been few. Conclusions The SNAS flap and graft is simple to perform and provide a reliable alternative to interpolated nasolabial or forehead flaps when the defect exposes significant bare cartilage or bone.

Design:

Summary:

Conclusions:

Session Name: Abstract Session: Reconstruction and Pearls

Session Date: Thursday, September 30

Late-breaking: No


Early Division of the Paramedian Forehead Flap: Improving Patient Satisfaction Without Compromising the Outcome

Authors: Hayes Gladstone, MD

Purpose: The paramedian forehead flap provides effective coverage for large nasal defects. Traditionally, the pedicle has been divided at three weeks. However, because of its large trunk, it often significantly impairs patient function many of whom require glasses as well as severely compromising cosmesis.

Design: Fifteen consecutive patients who had a paramedian forehead flap performed. Eight of the patients also required cartilage grafts. Two patients were smokers. At one week the pedicle was divided. The patients returned at week three for contouring of the flap. Two patients required an additional revision.

Summary: All flaps appeared well vascularized at one week. For selected patients, tissue oximetry was performed. At week three, only one flap had mild epidermal slough. There were no failures. Patients were highly satisfied both with the early division and their results. An independent physician evaluated the aesthetic results as very good.

Conclusions: Based on this series, it appears that in many patients, early division of the paramedian flap at one week and contouring at three weeks post surgery improves patient satisfaction and function without compromising the flap or cartilage grafts. Though in this series, flaps in patients who smoked also survived, it would be prudent to divide the pedicle at three weeks.

Session Name: Abstract Session: Reconstruction and Pearls

Session Date: Thursday, September 30

Late-breaking: No


The Shark Island Pedicle Flap for Repair of Combined Nasal ALA-Perialar Defects

Authors: Joseph L. Cvancara, MD, J. Michael Wentzell, MD

Purpose: Background: The combined nasal ala-perialar defect involving the concave intersection of the lateral nasal ala, nasal sidewall, cheek and upper cutaneous lip is a problem for reconstructive surgery. During repair of combined cheek and nose defects, it is important not to blunt the alar facial sulcus. Defects involving these adjacent cosmetic units can be repaired by using combination procedures such as a flap/graft.

Design: Objective: Our purpose is to introduce, describe and illustrate a one-stage flap repair descriptively named the "shark" island pedicle flap (SIPF). The SIPF was developed for combined nasal ala-perialar defects. This reconstruction restores the natural contours, preserves cosmetic boundaries, and eliminates the need for pexing sutures and graft/flap combinations

Summary: Methods: The SIPF is an island pedicle flap with a superior arm that rotates 90 degrees into the wound. This arm repairs the alar portion of the defect. The advancing island pedicle flap repairs the sulcus. The 90 degree rotation of the superior arm forces the alar portion of the flap to tilt 90 degrees relative to the remaining body of the SIPF. A natural re-creation of the lateral alar sulcus results. Illustrative examples with descriptive technique are provided for the SIPF.

Conclusions: Results: A well-planned SIPF reconstruction can provide exceptional cosmetic and functional results. Conclusion: Cutaneous reconstructive surgeons will find the SIPF useful and reproducible in their armamentarium for single stage aesthetic and functional repairs of defects involving the lateral ala and adjacent perialar tissues.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


Peritumoral Fibrosis in Basal Cell and Squamous Cell Carcinoma Mimicking Perineural Invasion : A Potential Pitfall In Mohs Micrographic Surgery

Authors: Ashraf Hassanein, MD, PhD, Steven A. Proper, MD, Franklin P. Flowers, MD

Purpose: Perineural invasion is seen in approximately 1 % of all cases of basal cell carcinoma (BCC) and in 3% of all cases of squamous cell carcinoma (SCC). Approximately 8% to 20% of BCC were reported to be aggressive (sclerosing/infiltrating and morpheaform) in academic institutions. Perineural invasion was reported to occur in 3% of aggressive BCC, which is approximately the same incidence as in SCC. The histologic differential diagnosis of perineural invasion includes reactive neuroepithelial aggregates and peritumoral fibrosis (PF). The latter includes peritumoral fibrous tissue that can mimic nerve fibers in frozen sections. PF can resemble perineural and intraneural invasion and dermatologic surgeons should have a better understanding of this phenomenon.

Design: All cases of BCC and SCC that were treated by Mohs micrographic surgery at the University of Florida College of Medicine Dermatologic Surgery Division, and the Center for Dermatology and Skin surgery, Tampa in the period January 1, 2003 to February 1, 2004 were reviewed for the presence of perineural invasion and PF . The latter was defined as the presence of concentric layers of fibrous tissue surrounding tumor formations and mimicking perineural and intraneural invasion. A total of 606 Cases of BCC and 164 cases of SCC were surveyed. Suspicious slides were de-stained and immunohistochemical staining with antibodies against S-100 protein was performed. Review of the original H&E biopsy slides was correlated with the Mohs surgery frozen sections.

Summary: PF was noticed in 3.6% of SCC and 5.9% of BCC. The incidence of unequivocal perineural invasion was noted to be 2.4% in SCC and 1.6% in BCC.

Conclusions: We describe a specific pattern of fibrosis noted in BCC and SCC which we called peritumoral fibrosis. It shows concentric layers of fibrous tissue surrounding tumor formations and resembles carcinomatous perineural and intraneural invasion . Mohs micrographic surgeons should be aware of this phenomenon to avoid unnecessary stages and/or irradiation.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


Primary Sequential Neurectomy In The Treatment Of Cutaneous Malignancies With Perineural Invasion

Authors: Steven D. Antrobus, MD, Gary D. Monheit, MD

Purpose: Perineural invasion of cutaneous malignancies continues to be associated with increased recurrence rates despite the common use of Mohs micrographic surgery and the frequent use of adjuvant radiation therapy. We propose that performing primary sequential proximal neurectomy of affected infraorbital and supraorbital nerves provides the potential of improving cure rates while causing little additional morbidity to the patient.

Design: A review of the current literature pertaining to perineural invasion by cutaneous malignancies was performed. Two case studies of patients treated with primary neurectomy are also presented.

Summary: Perineural invasion by skin cancers has been shown to involve skip areasť and to be associated with perineural inflammation. Due to these characteristics many Mohs surgeons have modified the standard Mohs technique in dealing with such cancers and treat perineural inflammation as a positive margin and also take an additional Mohs layer beyond the last clear margin in order to minimize the chance of leaving residual tumor. We propose that involvement of visible branches of the infraorbital and supraorbital nerves, in contrast to microscopic terminal branches within the dermis, should be treated with additional proximal neurectomy following the final Mohs layer. This can be performed in the following sequence with each additional resection dependent upon tumor involvement of prior margins. First, resection of nerve to the first major branch. Second, resection of nerve to the infraorbital foramen or the supraorbital notch. Third, osteotomy and resection of the orbital segment of the nerve. Consideration of any further proximal resection must be individualized to the patient. Neurectomy performed in this sequence has the additional benefit of providing ample nerve tissue for multiple cross sectional analysis and avoids potential false negatives from positional artifacts. The first patient is a 53-year-old white male who presented with a recurrent SCC of the right forehead following Mohs surgery one-year prior. Repeat Mohs was performed and perineural invasion of the supraorbital nerve was seen. After obtaining a clear Mohs margin, an additional 3 cm of the supraorbital nerve was resected to the supraorbital notch. Multiple cross sections of the nerve showed no residual tumor. The second patient is a 67-year-old white female who presented with a sclerosing BCC of the left upper lip, cheek, and nose with clinical symptoms of perineural invasion. Mohs surgery was performed which demonstrated perineural invasion of the infraorbital nerve. The infraorbital nerve was sequentially resected to the infraorbital foramen where tumor was present. A partial maxillary osteotomy was performed allowing for resection of an additional 3 cm of infraorbital nerve. This proximal nerve end was free of tumor.

Conclusions: Primary sequential neurectomy of select sensory nerves in the treatment of perineural invasion by skin cancers offers the potential of reducing recurrence rates and provides ample nerve tissue for multiple cross sectional analysis while causing little additional morbidity to the patient.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


A Decade Review of Periorbital Skin Cancer Addressing Orbital Penetration

Authors: Betty A. Davis, MD, Gary D. Monheit, MD

Purpose: The purpose of this presentation is to identify and characterize aggressive periorbital tumors.

Design: A retrospective review of 289 patients with 289 periorbital malignancies treated with Mohs from 1986 to 1996 focusing on which tumors behave aggressively and why was conducted. Type of malignancy, histologic classification, location, and predisposing medical conditions was reviewed with respect to which malignancies were invasive, had perineural involvement, led to metastatic disease, required numerous Mohs layers to excise, recurred, and required exenteration. Additionally symptomatology and length of time the tumor was present until excision was reviewed subjectively. Demographics of all tumors in this study were also characterized.

Summary: Two hundred eighty-nine periorbital malignancies were identified in 289 patients. The majority of the lesions were basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), 83.7% (242) and 12.5% (36) respectively. The histologic breakdown of BCCs was 76.0% nodular and 24.0% sclerosing. Of the 26 SCCs, 31.6% were SCCs in situ, 61.1% were well-differentiated SCCs, and 8.3% were poorly differentiated SCCs. Of the periorbital tumors, 2.1% (6) were melanoma, 0.7% (2) were adenocarcinoma, 0.3% (1) were basosquamous, 0.3% were a collision tumor of BCC and SCC, and 0.3% were sebaceous cell carcinoma. Invasive lesions, consisting of malignancies that invaded the lacrimal system, the septum, or both were present in 35.3% of cases. 31% of all nodular BCCs were invasive, 55.2% of sclerosing BCCs, 18.2% of SCC in situ, 18.2% of well-differentiated SCCs, and 33.3% of poorly differentiated SCCs. One lesion was identified as basosquamous and one lesion as a collision between BCC and SCC. Both of these lesions exhibited invasion. Six malignant melanomas were identified with three being invasive and two adenocarcinomas were identified with one being invasive. The lower eyelid and medial canthal lesions were the locations most commonly identified with invasiveness occurring in 40.8% and 20.4% respectively. Noninvasive lesions occurred on the lower eyelid and medial canthus 54.3% and 14.0% respectively. Two recurrent lesions were treated in the study. One lesion, a sclerosing BCC of the lower lid was excised previously by the Mohs technique and recurred. Three Mohs layers were required to clear the tumor, which did have septal penetration, but no exenteration was needed. Another lesion, a nodular BCC of the lower lid, was excised by a non-Mohs technique and recurred. It required two Mohs layers for cure and did not have orbital penetration. Ten (3.5%) of the periorbital malignancies required exenteration: three nodular BCCs (1.6% of total nodular BCCs), three sclerosing BCCs (5.2% of total sclerosing BCCs), one malignant melanoma (16.7%), one BCC/SCC collision tumor (100%), one well differentiated SCC (4.5%), and one poorly differentiated SCC (3.3%). 30% of lesions requiring exenteration were located on the lower lid/outer canthus area while only 3.8% of noninvasive lesions were located in this area.Twenty percent requiring exenterations were located on both the lower lid and the upper lid/outer canthal area with 54.3% and 1.6% respectively of noninvasive lesions present in these locations. The size of the lesions requiring exenteration ranged from 0.6 to 7 cm. The average size was 2.8 cm, which is larger on the average than the noninvasive tumors. An average of 3.9 layers was required to clear tumor for those lesions requiring exenteration, 2.8 for those invasive but not requiring exenteration, and 2.5 for those that were noninvasive. Of the lesions requiring exenteration, 25% exhibited excessive lacrimation, 75% of the lesions were fixed to bone, 63% had abnormal extraocular range of motion, and 63% exhibited proptosis. 20% of patients reporting tearing did not have invasive lesions. 6.3% of lesions fixed to bone, 13% of patients with proptosis, and 8.3% of patients with non-intact extraocular movements did not have invasive lesions. Only one lesion had perineural involvement. This was a poorly differentiated SCC of the upper lid/medial canthal area that was 0.6 X 0.6 cm in size in a patient with no significant medical history. He reported having the lesions for only 3-6 months. The lesion required five Mohs layers and exenteration for complete resection and was metastatic to the neck. The lesion was fixed to the bone but asymptomatic. Two lesions presented with metastatic disease at the time of resection. One is mentioned above. The other is a well-differentiated SCC on the right lower lid present for an unknown duration without orbital penetration requiring three Mohs layers for clearance in a patient with no significant medical history but with metastatic disease to the neck. He did have a previous history of SCC of the facial area, which could have been the etiology of the metastases. Twelve patients had a medial condition predisposing them to skin cancer including one patient with xeroderma pigmentosa, four patients with Gorlins Disease, two patients with history of an organ transplant, and three patients with myeloproliferative disease. Five of the 12 patients had invasion with one patient requiring exenteration. Of these patients, seven had nodular BCC, two sclerosing BCC, and one a BCC/SCC collision tumor. The average number of Mohs layers required for resection was 3. Four tumors were invasive. All but one was cleared with Mohs alone. One patient on chemotherapy had a very aggressive BCC/SCC collision tumor of the medical canthus/lower lid requiring exenteration. This tumor was asymptomatic.

Conclusions: Knowing which lesions in the periorbital area are more likely to behave aggressively will allow better management of these tumors. While it has been reported that aggressive histologic subtypes of BCC and SCC can be invasive, it is important to remember that nodular BCCs and SCCs diagnosed as in situ disease or well-differentiated need to be taken seriously as well. A thorough history of predisposing medical conditions and review of symptoms should be done and patients should be examined thoroughly for fixation of tumor, extraocular range of motion, proptosis, and lymphadenopathy.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


Improved Detection of Melanocytes and Decrease in Frozen Section Artifact with Saturated Sucrose Solution: A Preliminary Study of Cryprotective Effect in Mohs Surgery.

Authors: Aleksandar L. Krunic MD, Aleksandar L. Krunic MD, Gloria Munoz HT (ASCP) University of Texas Southwestern Medical Center, Robert Anderson MD, University of Texas Southwestern Medical Center, Sarah Weitzul MD, University of Texas Southwestern Medical Center, R Stan Taylor MD, University of Texas Southwestern Medical Center

Purpose: Accuracy of margin evaluation for melanoma in Mohs surgery remains a controversial issue. The freezing artifacts render slides of lower quality as compared to slides prepared as permanent sections. Pretreatment with cryoprotectants has been advocated to preserve cellular details and minimize artifacts. We pretreated skin specimens with a saturated sucrose solution to determine if the quality of frozen sections and visualization of melanocytes in these sections could be improved

Design: Normal skin samples from standing cone repairs from fifteen different patients undergoing post Mohs reconstructive procedures were studied. Tissue was trisected and one specimen was treated with a sucrose solution prior to Mohs frozen tissue processing while the second was processed without sucrose pretreatment. The third specimen was processed as a permanent section with formalin fixation and paraffin embedding. The first two tissue groups were analyzed for the presence of: a) vacuolated cytoplasm of epidermal cells, b) compression artifacts and c) cellular distortion due to ice crystals. An 'artifact score' (AFS) was calculated for each slide. The quality of melanocyte morphology was determined by a 'melanocyte quality score' (MQS) which included measurements of: a) the number of melanocytes/mm2, b) cellular detail and c) nuclear to cytoplasmic ratio.

Summary: Our results show that freezing artefacts decreased significantly and the ease of visualizing melanocytes was improved, as well as melanocyte morphology when specimens were treated with sucrose prior to frozen tissue processing.

Conclusions: Despite the slight increase in tissue processing time, we found that pretreatment of tissue with sucrose, improved the quality of Mohs frozen sections and can be of benefit to those who utilize Mohs surgery in the treatment of melanoma.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


Microcystic Adnexal Carcinoma involving a large portion of the face; when is surgery not reasonable?

Authors: Dan Eisen, MD, Dan Eisen, MD, David Zloty, MD, University of British Columbia, Vanvcouver, Canada

Purpose: Microcystic Adnexal Carcinoma is a neoplasm that not uncommonly presents to the dermatologic surgeon for treatment. When small or located in noncritical locations surgical treatment is straight forward. We present a case of a very large tumor on the face that presents a treatment dilemma. We review the literature regarding therapy with wide margin excision, Mohs surgery, radiation and chemotherapy. Also, we review all the reported cases of metastases and the one reported death due to this disease. We conclude that when tumor extirpation is likely to cause severe morbidity, observation is a reasonable approach given the very low incidence of metastases and death.

Design: Caser Report and Review of the Literature.

Summary: We report a case of Microcystic Adnexal Carcinoma(MAC) involving a large portion of the face, the largest size of any MAC reported thus far in this area and review the literature regarding the nature of the tumor and available treatments. We also review all the reported cases of metastases as well as the possible role of radiation in the etiopathogenesis with this tumor and conclude that radiation therapy is not appropriate for the treatment of these tumors. We feel that Mohs surgery should be the first line therapy where possible. However, when extirpation of the tumor entails sufficiently large morbidity, given the low rate of reported metastases, observation is a reasonable alternative.

Conclusions: At the end of the talk the audience should be familiar with the nature of MAC, it's potential treatment options, the potential role of radiation in the etiopathogenesis of this tumor, and the rate of metastases and death.

Session Name: Abstract Session: Cutaneous Oncology Fellow's Forum

Session Date: Thursday, September 30

Late-breaking: No


In-Transit Metastasis from Primary Cutaneous Squamous Cell Carcinoma in Organ Transplant Recipients and Non-Immunosuppressed Patients- Clinical Characteristics, Management and Outcome

Authors: John A. Carucci, MD, PhD, Juan Carlos Martinez, MD; Nathalie C. Zeitouni, MD; Leslie Christenson, MD; Brett Coldiron, MD; Stuart Zweibel, MD, PhD; Clark C. Otley, MD

Purpose: In-transit metastases from cutaneous squamous cell carcinoma (SCC) may occur in organ transplant recipients and may indicate aggressive disease and poor prognosis. This series is presented in order to describe in-transit metastases from cutaneous SCC and to identify factors associated with this phenomenon in a series of 21 patients. We also attempted to evaluate outcome with respect to status as an organ transplant recipient or non-organ transplant recipient. A multicenter case series of patients was reviewed factors including clinical presentation, management, and outcome. Twenty-one patients, 15 organ transplant recipients and 6 non-transplant recipients, with in-transit metastases were reviewed. In-transit metastases presented most commonly as discrete, dermal papules distinct from but in the vicinity of the primary tumor site. Histologic differentiation was variable. At a mean follow up of 24 months, 33% the transplant patients had no evidence of disease compared with 80% of non-transplant patients. Thirty three percent were dead from disease and 33% were alive with nodal or distant metastases. In contrast, 80% of non-immunosuppressed patients had no evidence of disease and none had died at mean follow up of 24 months. In transit metastasis from cutaneous SCC is a unique presentation of metastatic SCC, more commonly described in organ transplant recipients, and is associated with poor prognosis in that group. This description represents the largest experience with in-transit metastases from cutaneous SCC in the literature.

Design:

Summary:

Conclusions:

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Normal Melanocyte Density in Sun-exposed Skin: An Immunohistochemical Study

Authors: Ali Hendi, MD, David G. Brodland, MD, John A. Zitelli, MD

Purpose: To report our findings with regards to the normal density of melanocytes in sun-exposed skin.

Design: One hundred patients with non-melanoma skin cancers of the head and neck were selected. After complete removal of the tumors using the Mohs technique, the adjacent skin was evaluated for any visible pigmented lesions. Only patients who did not have any such lesions in the skin of the proposed Burrows triangles to be excised during the reconstruction were included. Vertical frozen sections (3-4 microns thick) were prepared from the excised burrows triangles. The sections were stained with Mart-1 immunostains, and the density of melanocytes per high power field, confluence of melanocytes, and extension of melanocytes along follicular epithelium were noted.

Summary: Initial results suggest that sun-exposed skin of the head and neck have a high density of melanocytes. Areas with the highest density were found to have focal confluence of up to 4-6 melanocytes. In addition melanocytes were seen extending along the superficial portions of the follicle. There was no pagetoid spread or nesting of melanocytes.

Conclusions: It is not unusual to have focal confluence of melanocytes in chronically sun-exposed skin. In addition, melanocytes can be seen in the superficial portions of follicular epithelium in chronically sun-exposed skin, a finding that has traditionally been attributed to lentigo maligna or lentigo maligna melanoma.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


One Hour Incubation ALA PDT for Treatment of Actinic Keratoses in Immunocompetent and Immunosuppressed Patients

Authors: Jeffrey Lander, Bertha B. Lin, MD, Peter K. Lee, MD, PhD

Purpose: PURPOSE:To evaluate the safety and efficacy of photodynamic therapy (PDT) using one hour incubation with delta-aminolevulinic acid (d-ALA) for the treatment of actinic keratoses (AKs) in 1) immunocompetent patients with significant photodamage and 2) immunosupressed patients following solid organ transplantation.

Design: METHODS. 25 immunocompetent and 25 immunosuppressed patients, each with at least 4 AKs and diffuse actinic damage, were treated. Anatomic sites included head, neck, dorsal hands and forearms, lower legs and dorsal feet. Sites were pre-treated with topical acetone. No pretreatment oral pain medications or topical anaesthetics were used. 20 % d-ALA was applied topically for 1 hour and photoactivation was carried out with a blue light source. A fan was used to cool the skin. Cetaphil cream was applied after treatment, and patients applied petrolatum 2 to 4 times per week until followup evaluation at 2 months.

Summary: RESULTS.All patients completed the study. Phototoxic reactions were well tolerated with average pain ratings of 2 to 3 on a 10 unit scale. Post-treatment erythema was noted by all patients, mild desquamation by most patients, and focal crusting of lesions by a smaller subset. At 2 months, approximately 90 % and 75 % AK clearance was observed in immunnocompetent and immunosupressed patients, respectively. All patients would recommend treatment again if indicated.

Conclusions: CONCLUSIONS This novel method of ALA PDT treatment demonstrated excellent outcomes for the treatment of AKs in both immunocompetent and immunosuppressed patient groups. The method was well tolerated and no significant side effects were observed.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Efficacy of Radiotherapy After Surgical Excision of High-Risk Cutaneous Squamous Cell Carcinoma: A Meta-Analysis

Authors: Chrysalyne Schmults, MD, Kenneth A. Katz, MD

Purpose: Numerous studies have examined the effectiveness of adjuvant post-surgical radiotherapy in the treatment of high-risk squamous cell carcinoma (SCC). However, studies suffer from small sample sizes, retrospective designs, and short follow-up periods. A meta-analysis was undertaken to evaluate the available data and guide the design of a future prospective trial.

Design: The English literature was reviewed for reports of high-risk SCC treated by adjuvant radiotherapy after surgical excision (either Mohs or non-Mohs).High risk was defined as the presence of one or more of the following: histologic classification as moderate or poorly differentiated, desmoplastic or spindle-cell histologic type, perineural invasion, size greater then 2cm, depth greater than 4mm, or invasion past dermis. All studies with 5 or more patients and at least 3 months of follow-up were included in the analysis. Disease-free survival and overall survival were evaluated. An age-matched control group of patients with high-risk SCC treated with surgical excision alone was created from the available literature and used for comparison.

Summary: Results are currently under analysis. (A full meta-analysis including stratification of data by patient age, gender, tumor location, Mohs vs non-Mohs excision, presence or absence of immunosuppression, and high-risk tumor types will be presented at the meeting.) A preliminary analysis indicates that adjuvant radiotherapy results in an increased disease-free survival. An increase in overall survival is difficult to demonstrate due to a limited number of patients with long-term follow-up.

Conclusions: Adjuvant radiotherapy after surgical excision of high-risk SCC may improve disease-free and overall survival. A prospective controlled trial is needed. Particular attention to sample size including a power analysis will be important in the design of such a trial.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Use of Dynamic Telepathology for Intraoperative Consultations during Mohs Surgery

Authors: Kishwer S. Nehal, MD, Klaus J. Busam, MD

Purpose: The diagnostic accuracy of a dynamic telepathology system in the setting of Mohs surgery was first reported in a recent feasibility study and showed complete agreement between conventional light microscopy and telepathology diagnoses of nonmelanoma skin cancers. This study assesses the range of application and clinical impact of dynamic telepathology for intraoperative consultations on frozen sections during Mohs surgery.

Design: All intraoperative consultations at a single institution using dynamic telepathology obtained during Mohs surgery with a dermatopathologist at a remote site were recorded during a one-year period following the initial feasibility study. Reason for consultation, correlation between Mohs surgeon and dermatopathologist interpretations, and clinical outcome were assessed.

Summary: 60 consultations were obtained during a one-year period using dynamic telepathology representing 11% of the annual Mohs volume. The primary Mohs diagnosis was BCC in 38 cases (63%); SCC in 16 cases (27%); and a mixed basosquamous histology in 6 cases (10%). The most common reason for consultation was to determine if a basaloid proliferation represented a BCC or a benign structure. In nearly all cases, there was agreement between the Mohs surgeon and the dermatopathologist in the interpretation of frozen section findings.

Conclusions: Dynamic telepathology is a useful and convenient tool in Mohs surgery for intraoperative consultations of challenging cases providing ongoing quality assurance and enhancing quality of patient care.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Incidence of Non-melanoma Skin Cancer in New Brunswick, Canada, 1992 to 2001: A Population Registry-Based Study

Authors: Robert Hayes, Robert Hayes, Suzanne Leonfellner, Wilfred Pilgrim, Jian Liu, Douglas N. Keeling

Purpose: Recent, high-quality data on the incidence of non-melanoma skin cancer (NMSC) in North America is lacking. Few cancer registries in the world collect data on NMSC. We recently studied the incidence of NMSC in the province of New Brunswick, Canada, using a population-based cancer registry.

Design: A descriptive analysis of the incidence of basal cell carcinoma (BCC) and invasive squamous cell carcinoma (SCC) was performed, utilizing data from the New Brunswick Provincial Cancer Registry from 1992 to 2001.

Summary: When adjusted to the world standard population, the age-standardized incidence rates (ASIRs) for BCC were 87 per 100,000 person-years in men and 68 in women. For SCC, the ASIRs were 34 per 100,000 person-years in men and 16 in women. The incidence of both BCC and SCC increased over the ten-year study period. The overall ratio of BCC to SCC in the population was 2.8 to 1. The approximate lifetime probabilities of developing BCC and SCC were 10% and 3%, respectively. The head and neck was the most common anatomical location of both BCC and SCC.

Conclusions: There is a significant and increasing incidence of NMSC in New Brunswick, Canada.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Local Adjuvant Radiation Following Surgery for Merkel Cell Carcinoma: A Meta-analysis of 970 Patients.

Authors: Kevan Lewis, MD, Martin A. Weinstock, MD, PhD, Clark C. Otley, MD

Purpose: Background and Purpose: Merkel cell carcinoma (MCC) is an aggressive neoplasm with a predilection for local recurrence and metastasis. There is no consensus on the management of MCC vis-Ă -vis the role of local radiation (to the primary site) as an adjuvant therapy to surgery. The purpose of this study was to evaluate the efficacy of local adjuvant radiation following surgery for MCC.

Design: Methods: A MEDLINE literature search and review of publication reference lists were performed. All studies of primary merkel cell tumors (with >1 month follow-up) treated surgically with or without local adjuvant radiation (combination therapy) were included.

Summary: Results: Fifty-four publications representing 970 patients were included although none were prospective nor randomized. A preliminary analysis of data pooled from 42 studies that presented data on individual patients was performed. The time to recurrence was significantly longer in patients with Stage 1 disease treated with combination therapy (median, 8 months) compared to surgery alone (4 months, p0.001, log rank test). A higher proportion of all patients treated with surgery alone (36%) developed local recurrence compared to combination therapy (15%) although duration of follow-up varied greatly. Among patients with Stage 1 (local) disease, a higher proportion developed regional (nodal) metastasis after surgery (53%) compared to combination therapy (26%); a smaller difference was observed for distant metastasis (31% vs. 20%, respectively).

Conclusions: Conclusions: In our preliminary analysis, combination therapy for MCC appears to portend a better outcome (longer time to recurrence and smaller proportion of patients with local recurrence and regional metastasis) compared to surgery alone. Prospective studies and more rigorous statistical analyses are required to validate these preliminary conclusions.

Session Name: Abstract Session: Cutaneous Oncology and Pathology

Session Date: Saturday, October 2

Late-breaking: No


Blood Pressure Levels Decrease During Mohs Micrographic Surgery

Authors: Joseph Alcalay, MD, R.Alkalay, MD, E.Grossman, MD

Purpose: A common practice is not to operate patients with elevated blood pressure (BP) levels to avoid cardiovascular and cerebrovascular complications. This common practice is not based on double blind prospective studies. The Mohs micrographic surgery (MMS) is a prolonged procedure that is done under local anesthesia. We therefore designed a study to evaluate the effect of prolonged surgery under local anesthesia on BP levels, and to compare the outcome of patients with elevated BP (systolic BP > 160 mm Hg) to those with normal BP (systolic BP 160 mm Hg) in regard to surgical complications such as hemorrhage, wound dehiscence and flap graft necrosis.

Design: We studied 121 patients (65 males) with a mean age of 60 + 14 years (range 31-89) who were referred for MMS because of skin cancer during the months June and July 2003. Forty six patients had a history of hypertension and were treated with angiotensin converting enzyme inhibitors (25 patients), calcium antagonists (15 patients), beta blockers (14 patients) and diuretics (12 patients) either as monotherapy or in combination. Blood pressure was measure in all subjects in the supine position with an automated device (Propaq 120EL by Protocol Sys. Inc) 5 times during the surgery; when the patient was lying down on the operating table with the maximal expected anxiety (baseline), at the end of the local anesthetics injection (Time 1), at the end of the first stage of surgery when the patient was ready to leave to the room (Time 2), before the beginning of wound reconstruction (Time 3) and at the end of surgery before discharge from the operating room (Time 4).

Summary: Blood pressure decreased significantly during the surgery from 152± 2/85± 1 mm Hg at baseline to 136 ± 2/76 ± 1 on Time 2, and 139 ± 2/79 ±1 at the end of the surgery (p Forty two patients (34%) had elevated BP levels at baseline whereas only 18 patients had these levels on Time 2. Seventeen patients had systolic BP greater than 180 mm Hg at baseline whereas only 4 patients had these levels on Time 2. All patients recovered completely. There was no difference in surgery outcomes between those with elevated and those with normal BP levels at baseline.

Conclusions: Blood pressure levels decrease during MMS under local anesthesia and the outcome of patients with elevated BP is good. Thus, patients with elevated BP can safely undergo surgery under local anesthesia.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Great Auricular Nerve Anastomosis

Authors: Alysa R. Herman, MD, Richard G. Bennett, MD

Purpose: Severing of peripheral sensory nerves is a potential risk in cutaneous surgery yet the management of this complication is rarely addressed in the dermatologic literature. We present a case of a 75 year old woman whose great auricular nerve was severed during Mohs micrographic surgery. A reanastomosis of the transected nerve was performed using the fascicular suturing technique with subsequent return of sensation in the distribution of the affected nerve. The rationale for nerve repair as well as techniques of nerve anastomosis will be discussed. In addition, literature which supports current surgical repair methods will be reviewed.

Design:

Summary:

Conclusions:

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Management of Cutaneous Neoplasms Invading the Parotid Gland

Authors: Elena Maydan, MD, Yehuda D. Eliezri, MD

Purpose: Background: Nonmelanoma skin cancers of the head and neck occasionally involve the parotid gland by either direct invasion or metastases to the parotid lymph nodes. While multiple studies have focused on the parotid lymph node metastases, direct invasion of the parotid gland by cutaneous malignancies has been infrequently addressed. There have been even fewer papers discussing the use of Mohs micrographic surgery (MMS) for skin cancers infiltrating the parotid gland. While limiting surgical management of the parotid gland minimizes the risk of facial nerve damage, the aggressive nature of nonmelanoma skin cancers invading the parotid gland may warrant aggressive surgery to improve local control of the disease and patients outcomes. Objective: To highlight the aggressive nature of nonmelanoma skin cancers invading the parotid gland and to address the potential inadequacy of MMS as a solo modality in management of such tumors.

Design: Design: Two patients treated with MMS for recurrent nonmelanoma skin cancers directly invading the parotid gland are presented. The literature on direct parotid invasion by cutaneous neoplasms is reviewed. The difficulty of performing MMS within the parotid gland is addressed.

Summary: Results: Two patients with recurrent nonmelanoma skin cancers infiltrating the parotid gland were treated with MMS. Histologically clear margins were achieved within the parenchyma of the parotid gland. In both patients, tumors recurred and repeated management with MMS was attempted. During the subsequent MMS stages, tumor involvement of the parotid tissue was observed, at which point MMS was abandoned, and patients were referred for parotidectomy.

Conclusions: Conclusions: Adequate management of the parotid gland directly infiltrated by skin cancer is critical for local control of the disease. MMS is a highly effective tool for treatment of cutaneous malignancies based on its ability to trace microscopic extensions of the tumor. We suggest, however, that the tissue characteristics and the pattern of tumor spread within its parenchyma make the parotid gland a difficult medium for proper evaluation of MMS sections. Therefore, in cases of direct extension of skin cancer into the parotid gland, we advocate abandoning MMS in favor of parotidectomy. Although this approach involves more aggressive surgery, the existing technical ability to perform parotidectomy with facial nerve preservation minimizes the potential functional and cosmetic morbidity to the patients while potentially improving local control of the disease and patients outcomes.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Ergonomics in Mohs Surgery

Authors: Adam Esser, MD, James G. Koshy, PhD, Henry W. Randle, MD, PhD

Purpose: Over 60 percent of Mohs surgeons are less than 50 years old. As the population of Mohs surgeons ages, repetitive stress injuries may become more common unless precautions are taken.

Design: We surveyed all current Mayo Clinic Mohs surgeons and those who were trained at the Mayo Clinic since 1990. One hundred percent of those surveyed responded (17 Mohs surgeons) to questions regarding their age, experience, operating style (standing versus sitting), use of magnification, and work related injuries and their impact on job performance. The Mohs surgeons currently practicing at the Mayo Clinic were videotaped during regular operating days. An expert in ergonomics analyzed the videotapes and made recommendations.

Summary: The study population consisted of 12 men and 5 women. The average age of the respondents was 39.5 with an average of 7 years experience performing Mohs surgery. Those surveyed spent an average of 24 hours per week in surgery. 3 of the 17 surgeons surveyed operated primarily in the seated position. Ninety-four percent of respondents stated that they either had symptoms caused or made worse by practicing Mohs surgery. For those whose symptoms started while practicing Mohs surgery the average age of onset was 35 and the average number of years in practice prior to onset was 2.5 years. The most common complaints included headaches and musculoskeletal problems. Neck pain and stiffness were the most common, occurring in 70% of surgeons. Fifty-nine percent of respondents complained of pain or stiffness in the shoulders, 47% complained of low back pain and stiffness, and 47% experienced headaches. The videotapes revealed problems with forceful exertion, awkward posture, poor positioning, lighting, stress, and duration of procedures.

Conclusions: Analysis of the data revealed early onset of symptoms of repetitive stress injuries in Mohs surgeons. Proper training and early intervention may be necessary to minimize the risk of injury. Analysis of the videotapes revealed multiple areas for improvement of ergonomics in Mohs surgery. Modifications include footwear, flooring, table and counter height, operating position (including the angle of the neck and spine), and light positioning. Recommendations including illustrations for improvement of ergonomics in Mohs surgery are presented. Our findings may also have applications to other surgical specialties beyond Mohs surgery.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Is Mohs surgery a Cost-Effective Treatment for Facial Nonmelanoma Skin Cancer? A Decision Analysis

Authors: Tracy Bialy, MD, M.P.H, James Whalen MD, Carl V. Washington, MD, Herb Szeto; Kaiser Permanente, Suephy C. Chen

Purpose: This study investigated whether Mohs surgery (Mohs) is more cost-effective to treat facial nonmelanoma skin cancer (NMSC) than traditional standard excision (TSE). Since cost-effectiveness analyses (CEAs) incorporate efficacy and outcomes in addition to cost, CEAs can compare the overall value rather than just the costs of one therapeutic strategy over another.

Design: We used data from our prospective trial of 98 consecutive patients with primary facial NMSC for baseline costs (Connecticut Medicare 2002 reimbursements) and efficacy (margin analysis). We approached the CEA using a decision analysis model via Treeage Data 4.0 software. Our model also incorporated efficacy using 5-year recurrence rates from the literature, and outcomes (quality-adjusted-life-years (QALYs)) using data from a focus group of patients. We performed a sensitivity analysis to determine the influence of key elements in the model.

Summary: Our baseline CEA demonstrated Mohs to be less costly and more effective than TSE ($956.60 vs. $1248.10, and 0.6 QALY gain). The sensitivity analysis showed that varying values for QALYs, recurrence rates, and percentage of frozen and permanent section margin analysis did not change the results of our CEA. Our model was sensitive to the proportion of defect repairs (granulation, primary closure, flaps, grafts) following the two procedure strategies.

Conclusions: Therefore, before the most cost-effective treatment for facial NMSC can be definitively established, further research into actual practice patterns of defect repair selection for both procedures must be examined.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Evaluation of Mohs Margins by Permanent Histopathological Evaluation

Authors: Ross Campbell, MD, Raymond G. Dufresne, Jr, MD

Purpose: This purpose of this study is to confirm the effectiveness of Mohs excision of skin cancers on the face by taking an additional specimen for permanent histopathological evaluation. This is the first report of post-Mohs margin evaluation by permanent section analysis in the literature.

Design: A retrospective analysis of our university's surgical logbooks identified 300 Mohs cases which after excision, were sent to plastic surgery for reconstruction. A plastic surgeon at our university takes an additional layer and sends for permanent histopathological analysis at the time of reconstruction by an independent dermatopathologist. A review of the pathology reports on these patients provides valuable data on tumor margins, tumor subtype, and histopathologic mimickers of skin cancer.

Summary: 300 cases were identified, mostly basal cell cancer, nodular subtype, from which 2 cases were determined by the dermatopathologist to have positive tumor involvement. Both cases were of nodular basal cell cancer and were located on the nasal tip and the nasolabial fold. On additional review, one specimen was determined to be consistent with follicular epithelium rather than a focus of basal cell carcinoma, and the second was determined to be a focus of nodular basal cell cancer.

Conclusions: This data supports the high reliability of Mohs surgery for margin control. Additionally it suggests that most nonmelanoma skin cancers spread in a contiguous manner.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Mohs Micrographic Surgery for Malignant Fibrohistiocytic Tumors

Authors: Sachin Bhardwaj, MD, Joseph J. Shaffer, MD, Whitney D. Tope, MPhil, MD

Purpose: Background: Malignant cutaneous fibrohistiocytic neoplasms manifest high rates of local recurrence following routine surgical excision. Mohs micrographic surgery (MMS) appears to offer a higher cure rate. We present a retrospective review of our experience treating these tumors in a tertiary care setting. Objective: To compare our cure rates for MMS of dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and malignant fibrous histiocytoma (MFH) with the reported rates in the literature.

Design: Methods: Retrospective chart review of all malignant fibrohistiocytic neoplasms treated with MMS at the University of Minnesota from August 1996 through June 2002. Patients and/or referring physicians were contacted to evaluate for recurrence.

Summary: Results: Twenty-three tumors were treated (mean follow up: 22 months), including seven DFSP (mean F/U: 22 months), 5 MFH (mean F/U: 30 months), and 11 AFX (mean F/U: 20 months). None of the 23 tumors manifested local recurrence. One patient with AFX with intravascular tumor developed an in-transit dermal metastasis.

Conclusions: Conclusion: Our recurrence rates after MMS are similar to those of published reports for DFSP and AFX, and superior for MFH. These results support MMS as the most effective treatment for malignant fibrohistiocytic tumors of the skin.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No


Minimizing Error in Mohs Surgery

Authors: Mark F. Baucom, MD

Purpose: This presentation will provide an overview of potential causes of error in Mohs surgery from having the correct patient and chart to technical aspects of slide interpretation and specimen management. A step-wise approach with an emphasis on efficiency and common sense will be used. Suggestions will be given for special situations such as multiple tumor sites or large specimens. The goal is for the Mohs surgeon to evaluate the entire patient encounter to minimize the risk of errors.

Design:

Summary: Potential sources of error: I. Wrong patient/tumor: A. Incorrect patient or site referral B. Patient or MD confuses site of biopsy C. Patient/chart mismatch D. Wrong slide attributed to patient E. Multiple sites/patients confused-use different ink combinations! II. Lab error A. Slide(s) mislabeled B. Slides/maps mismatched with charts C. Mapping errors 1. Surgeon/tech communication error-MD can (should?) ink and map 2. Map not correct 3. Rotational errors-surgical and mapping-have a standard way and note deviations on chart D. Interpretation pitfalls 1. False positives- "floaters", deep cuts/new tech 2. False negatives-"dropout", missing edge, etc... 3. Difficult tumors

Conclusions: Some straightforward aproaches may help minimize the risk of preventable errors in Mohs surgery.

Session Name: Abstract Session: Mohs Surgery

Session Date: Sunday, October 3

Late-breaking: No