2006 ACMMSCO Annual Meeting:
Accepted Abstracts and Posters

Friday, April 28, 2006
Tromovitch Award Abstracts
9:25am - 9:31am


PRESENTER: Anna Alexandra Bar, MD

TITLE: Two Cases of Reconstruction of Full Thickness Columella Loss Utilizing Four Parallel Auricular Cartilage Grafts and a Paramedian Forehead Flap

AUTHORS: Anna A. Bar, MD; Greg S. Morganroth, MD

Purpose:
Full thickness loss of the nasal columella is rare and is one of the most challenging facial reconstructions. Restoration of function and cosmesis requires a durable cartilaginous framework to support the overlying skin and nasal tip. Because of the high level of difficulty for repair, these defects are often referred to other specialists for reconstruction under general anesthesia. This report presents an effective and reproducible technique for harvesting four, ear-cartilage grafts to create a durable cartilaginous framework for total columella reconstruction under local anesthesia.

Design:
Two cases of full thickness columella loss following Mohs Micrographic Surgery for infiltrative basal cell carcinoma and the step-by-step reconstruction are presented. The defects consisted of complete loss of the columella and its cartilaginous and soft tissue framework extending from the central upper lip to the nasal infratip with complete exposure of the nasal septum. The two-stage reconstruction is performed completely under local anesthesia. Stage one consists of the recreation of the columella and nasal tip cartilaginous framework utilizing four parallel auricular cartilage grafts followed by a paramedian forehead flap for skin coverage. Three weeks later, stage two consists of division of the pedicle, thinning and inset of the distal flap into the nasal tip.

Summary:
The four parallel cartilage struts created a reproducible and durable framework for total columella reconstruction. At three month's follow-up, complete restoration of the columella, upper lip, and nasal tip to the patients baseline anatomy was achieved. At over three years follow-up, there are no changes in nasal contours.

Conclusions:
These two cases present an effective and reproducible technique for recreating the nasal columella and restoring function and cosmesis under local anesthesia. Patients with total columella loss can be effectively managed immediately following Mohs Micrographic Surgery instead of referring outside for general anesthesia reconstruction.

Friday, April 28, 2006
Tromovitch Award Abstracts
9:31am - 9:37am


PRESENTER: James Barlow, MD

TITLE: The Density and Distribution of Melanocytes in Chronically Sun Damaged Skin

AUTHORS: James Barlow, MD; Pearon G. Lang, MD; John Maize, Sr., MD

Purpose:
To determine the density and distribution patterns of melanocytes in chronically sun damaged skin from patients with melanoma and non-melanoma skin cancers using hematoxylin and eosin (H&E) and immunostained paraffin sections.

Design:
One hundred eighty (180) skin specimens obtained during routine repair of defects resulting from the removal of melanoma and non-melanoma skin cancers were analyzed using H&E and immunostains on paraffin sections to determine the presence, quantity, and distribution of epidermal melanocytes.

Summary:
The average melanocyte density was 7.97 melanocytes per 1 mm of epidermis (SD± 6.7). Contiguous melanocytes were found in 30 (16.7%), atypical melanocytes in 8 (4.4%), and extension of melanocytes into follicles was observed in 11 (6.1%) of the specimens. Contiguous melanocytes, atypical melanocytes, and follicular melanocytes were significantly associated with higher melanocyte densities (p<.001). These features were most commonly associated with specimens taken from patients with melanoma. However, these same features were also noted, although less frequently, in specimens taken from patients with basal cell and squamous cell carcinomas.

Conclusions:
There is significant variability of melanocyte densities seen in sun-damaged skin. Focal short runs of contiguous melanocytes, atypical melanocytes, and follicular melanocytes can be seen in the sun damaged skin surrounding both melanoma and non-melanoma skin cancers. However, this is more common in patients with melanoma. This observation should be taken into account when assessing the margins for melanoma arising on chronically sun damaged skin during Mohs surgery.

Friday, April 28, 2006
Tromovitch Award Abstracts
9:37am - 9:43am


PRESENTER: Sherry Henderson Maragh, MD

TITLE: Prospective Evaluation of Infection Rate in Patients Undergoing Mohs Micrographic Surgery Without the Use of Prophylactic Antibiotics

AUTHORS: Sherry H. Maragh, MD; Marc D. Brown, MD

Purpose:
To evaluate the rate of infection in patients undergoing Mohs micrographic surgery who have not received prophylactic antibiotics.

Design:
Prospective evaluation of 1,000 patients undergoing Mohs micrographic surgery without the use of prophylactic antibiotics. Patients were evaluated at the time of suture removal and/or follow-up (one to four weeks post-operatively) for signs or symptoms of infection, including erythema, edema, warmth, tenderness, pain, purulent or serosanguinous drainage. Those patients with an indication of infection were placed on appropriate antibiotic coverage according to culture results.

Summary:
Of 1000 patients prospectively evaluated, infections occurred in less than 1.0% of patients undergoing Mohs micrographic surgery.

Conclusions:
This prospective evaluation favors against the indiscriminate use of antibiotic prophylaxis in patients undergoing Mohs micrographic surgery. The decision to use antibiotic prophylaxis should be based on individual patient factors and the clinical judgment of the surgeon.

Friday, April 28, 2006
Tromovitch Award Abstracts
9:43am - 9:49am


PRESENTER: Hobart W, Walling, MD, PhD

TITLE: Staged Excision vs Mohs Micrographic Surgery for Lentigo Maligna

AUTHORS: Hobart W. Walling, MD, PhD; Andrew K. Bean, MD; Roger I. Ceilley, MD

Purpose:
Lentigo maligna (LM) is a relatively common tumor with increasing prevalence and substantial morbidity. A variety of surgical and medical treatment modalities are available for this tumor, though surgical techniques offering margin control offer the highest cure rate. A recent survey of dermatologic surgeons indicated that Mohs surgery is commonly employed, though preferences for frozen versus permanent paraffin sections varied. We were interested in comparing outcomes of Mohs surgery versus mapped staged excision with rush permanent sections (SE) for treating LM and lentigo maligna melanoma (LMM).

Design:
Retrospective chart review from our private practice of patients with LM and LMM diagnosed and treated between 1985 and 2001, with at least four years of clinical follow-up.

Summary:
We identified 52 patients (29 male, 33 female) treated in our office for LM or LMM. The mean follow-up duration was 72.9 months (range: 48-157 months). The mean age at diagnosis was 69.8 years (range: 49-93 years). The data set included 41 cases of LM and 11 cases of LMM; 36 tumors were located on the face, 9 on the extremities, 5 on the trunk, and 2 on the scalp. Thirty-nine (39) patients were treated with SE and 13 were treated with Mohs surgery. Demographics, tumor sites, and follow-up duration were similar between the cohorts. The mean size of the clinical lesion pre-operatively did not vary between the SE and Mohs cohorts (1.9 ± 0.3 cm2 for SE; 1.8 ± 0.7 cm2 for Mohs), nor did the mean size of post-operative defects (9.4 ± 1.1 cm2 for SE; 10.4 ± 2.9 cm2 for Mohs). Similarly, the ratio of post-operative defect to pre-operative lesion size did not vary between the modalities (9.3-fold increase for SE, 12.3-fold increase for Mohs). An average of 1.9 stages (range 1-6) were required for SE, and an average of 2.4 stages (range 1-7) were required for Mohs; clear margins were obtained in one or two stages in 77% of cases for SE and in 69% for Mohs. No recurrences (0/39) were noted in the SE group, while 2 recurrences (2/13) were seen in the Mohs group (p<0.025).

Conclusions:
Compared to Mohs micrographic surgery, mapped staged excision with rush permanent sections of LM and LMM is associated with a significantly lower recurrence rate with no difference in surgical defect size.

Friday, April 28, 2006
Tromovitch Award Abstracts
9:49am - 9:55am


PRESENTER: Bradley Kent Draper, MD, PhD

TITLE: The "Drum-Head" Graft Repair of Deep Nasal Alar Defects

AUTHORS: Bradley K. Draper, MD, PhD; J. Michael Wentzell, MD

Purpose:
Extirpation of tumors on the nasal alae using Mohs micrographic surgery often results in deep surgical defects. The nares and internal nasal valves are supported not just by alar cartilage, but also by the suspension effect of the overlying skin and subcutaneous tissue. Surgical loss of tissue may result in inward collapse of the nasal vestibule with resultant difficulty in breathing. Reconstruction options include local pattern flaps, 2nd intention healing and full-thickness skin grafts. Many flaps and 2nd intention healing frequently cause undesirable distortion of the alar rim. The use of full-thickness skin grafts on deep alar defects commonly results in a sunken or depressed graft that is functionally and cosmetically unacceptable. We describe a novel technique using an overlying plastic suspension strut to prevent undesirable collapse and depression of a full-thickness skin graft in the repair of deep nasal alar surgical defects.

Design:
We describe the use of a rigid plastic strut to suspend full-thickness grafts in the repair of deep alar defects. The defects measured 1.8 x 1.8 x 1.0 cm and 1.4 x 1.4 x 0.8 cm, respectively. Postauricular donor sites were selected in an effort to provide optimal color and texture match. The grafts were intentionally slightly undersized to create a taut "drum head" effect when sutured into place with 5-0, fast-absorbing gut. Plastic suture packaging material was cut to fashion a strut that was placed over the surface of the graft and extended approximately 5 mm beyond the graft on both ends. The strut achieved its suspensory function when secured in place by tacking a 4-0 polypropylene suture through the graft, graft bed and nasal vestibular sidewall. Intranasally, a Xeroform gauze bolster cushions the nasal valve as the suture reverses direction, passing around the bolster and back out through the graft and over the strut. The strut was tied into place with enough tension to lift the underlying bolster and elevate the graft bed to contact the "drum head," thereby completing the suspension effect. The strut and intranasal bolster were removed 7-10 days later.

Summary:
Patients were seen at one week and four weeks post-operatively. At each time point, there was no evidence of graft depression or nasal vestibular collapse. All patients had excellent functional and cosmetic outcomes. No adverse effects were noted.

Conclusions:
The "drum head" graft is a novel technique which enables the use of full-thickness skin grafts for deep alar defects by inhibiting undesirable depression of the graft and preventing collapse of the nasal vestibule.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:00pm - 3:06pm


PRESENTER: Ravi Krishnan, MD

TITLE: Tunnelled Transposition Flap for Reconstruction of Defects of the Nasal Ala

AUTHORS: Ravi Krishnan, MD; Heidi Donnelly, MD

Purpose:
We will describe the indications, advantages, design, and execution of a unique tunnelled transposition flap to reconstruct alar defects. To our knowledge, this useful flap has not been described for reconstruction of the nasal ala.

Design:
This is a pilot study involving 10 patients with defects of the nasal ala created by extirpation of non-melanoma skin cancers by Mohs surgery.

Summary:
The tunnelled transposition flap is an excellent flap for reconstruction of nasal alar defects which are too deep for a skin graft. This flap offers several distinct advantages over alternative reconstruction techniques. Unlike a melolabial interpolation flap, the patient does not require an external pedicle which must be separated. Furthermore, unlike the previously described transposition island pedicle flap, our tunnelled transposition flap leaves the junction of the cheek and nose at the melolabial fold completely intact. This is critical since the natural contours of this region are extremely difficult to re-create. Finally, unlike other nasally based flaps, the tunnelled transposition flap will leave the alar crease completely intact.

Conclusions:
The tunnelled transposition flap is a relatively simple flap which is extremely useful in the reconstruction of alar defects. It has several distinct advantages over alternative reconstruction techniques.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:06pm - 3:12pm


PRESENTER: Steven Chow, MD

TITLE: Correction of Nasal Alar Rim Notching Using an Inverted V to Y Closure

AUTHORS: Steven Chow, MD; Allison Hoffman, MD; Peter K. Lee, MD, PhD

Purpose:
An alternative technique for restoration of a notched nasal alar rim using an inverted V to Y closure is proposed.

Design:
Patients presented to the University of Minnesota Dermatologic Surgery Clinic with nasal alar rim notching as a complication from prior surgical procedures. The region was prepped and anesthetized using proper surgical techniques. An inverted V-shaped incision was made around the notched scar. The notched portion was then undermined at the submuscular level with preservation of the inferior-most connection. Minimal undermining was performed superior to the incision prior to its inferior advancement and closure in an inverted Y configuration. Patients returned to clinic one week following the procedure for suture removal and then at eight weeks to assess appearance and function.

Summary:
Repairs along the nasal surface present a unique surgical challenge due to the free margin of the nasal alar rim. Notching of the nasal alar rim commonly occurs as a complication of graft placement, flap repair or wound contracture. Standard techniques for correction of alar notching include delayed cartilage grafting, the use of a single-stage turnover flap proposed by Zitelli in 1994, or a Z-plasty. The application of an inverted V to Y closure is another technique that can correct alar rim deformities. In addition to restoring symmetry of the nose, this technique served to match the color, texture and sebaceous quality of the nasal alar surface. Preservation of nasal vault stability and airway patency also resulted from this procedure. All patients were satisfied with their outcomes and no postoperative complications occurred.

Conclusions:
An inverted V to Y closure for the repair of a notched nasal alar rim deformity results in favorable aesthetic and functional outcomes.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:12pm - 3:18pm


PRESENTER: David Charles Carlisle, MD

TITLE: Reconstruction of Mohs Defects of the Hand, Which Results in Partial to Complete Tendon Loss.

AUTHORS: David C. Carlisle, MD; Heidi Donnelly, MD.

Purpose:
Mohs excisions of locally invasive tumors of the hand can result in partial to complete resection of tendons. The repair of these defects can be extremely challenging for the Mohs surgeon since suboptimal repairs may result in a decrease in mobility and a loss of function. Maintaining complete mobility and function of the hands is of paramount importance as even minor deficits may significantly impact a patient's quality of life. In this study we will discuss the various reconstructive options available to the Mohs surgeon confronted with a defect of the hand that results in partial to complete tendon loss.

Design:
We describe various repair options including splinting, suturing, and grafting. We will also describe scenarios in which tendon repair is not required to maintain function. Furthemore, we will discuss the anatomic and technical considerations underlying the various reconstructive options.

Summary:
In some locations, approximately 50% of the tendon may be lost and patients will recover full function without tendon repair. For more significant defects splinting, directly suturing the tendon, or grafting may be required to restore function.

Conclusions:
Defects of the hands which result in partial to complete tendon loss can be challenging for the Mohs surgeon. Familiarity with the different techniques that may be used for tendon reconstruction and the scenarios in which these techniques are appropriate, will allow the surgeon to provide patients with superior functional outcomes.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:18pm - 3:24pm


PRESENTER: Arash Kimyai-Asadi, MD

TITLE: Repair of Alar-Facial Sulcus Defects Using a Melolabial Fold Rotation Flap

AUTHORS: Arash Kimyai-Asadi, MD

Purpose:
Defects of the alar-facial sulcus are typically repaired using the island pedicle flap. These repairs usually result in scarlines that are not camouflaged by normal skin folds and creases and the flaps are prone to post-operative swelling that can last months or even be permanent. Conversely, vertical linear repairs tend to obliterate the triangular space that creates the alar-facial sulcus, resulting in significant mid-facial asymmetry. Cheek-based repairs distort or obliterate the melolabial fold and are generally undesirable for this location. The purpose of this study is to describe my experience with the melolabial fold rotation flap to repair defects of the alar-facial sulcus.

Design:
Seventeen (17) patients underwent this repair. An inferolateral incision is made in the melolabial fold from the inferolateral edge of the defect. The skin is undermined in a superficial subcutaneous plane and is rotated onto the defect. A dog-ear is removed either horizontally beneath the nasal sill or inferiorly in a vertical fashion in the cutaneous lip.

Summary:
The average defect repaired using this flap was 1.4 x 1.0 cm (range 0.9 x 0.5 cm - 2.6 x 1.9 cm). Necrosis of the flap was not seen in any patient. No patient needed any subsequent surgical revision. Persistent distortion of the lip was not seen in any patient. The incisions in the melolabial fold and beneath the nasal sill were typically difficult to detect postoperatively.

Conclusions:
The melolabial rotation flap provides an optimal first-line repair choice for defects of the alar-facial sulcus. It has clear advantages over linear repairs, island pedicle flaps, and cheek-based repairs.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:24pm - 3:30pm


PRESENTER: Arash Kimyai-Asadi, MD

TITLE: Single-Staged Transcartilage Tubed Pedicle Flap for Repair of Anterior Ear Defects

AUTHORS: Arash Kimyai-Asadi, MD; Ming H. Jih, MD; Leonard H. Goldberg, MD

Purpose:
Significant defects of the anterior ear are often difficult to repair due to the paucity of donor skin in that anatomic area. Defects are often allowed to heal by secondary intention, but for larger defects this creates the risk of slow healing, prolonged postoperative pain, and chondritis. Moreover, wound contracture can cause anatomic distortion of the anterior ear and blunt some of the anatomic features of this area. Skin grafts can be used, but especially when the perichondrium has been removed, grafts are subject to an unreliable blood supply. Two-staged flaps can also be used but are inconvenient for patients. We report our experience with the transcartilage tubed pedicle flap for repair of anterior ear defects.

Design:
Eighteen (18) patients underwent this repair. A template was made from the defect and an equal-sized portion of skin was incised in the postauricular skin, starting in a spot that corresponds to the posterior portion of the defect. The pedicle is undermined except for a small central pedicle. An incision was made through the cartilage and the pedicle flap was tubed to the anterior ear. The flap was sewn onto the defect. The postauricular donor site was usually repaired primarily.

Summary:
The defects repaired using this flap were of the antihelix (7), concha (7), triangular fossa (3) and scapha (1). The average defect measured 2.1 x 1.7 cm (range 1 x 1 cm to 3.2 x 3 cm). One patient developed partial necrosis of the flap due to smoking three packs per day; a hematoma also developed, due to trauma. One patient developed postoperative flap swelling but refused any revision. Chondritis was not seen in any patient. No patients experienced severe or prolonged post-operative pain.

Conclusions:
The transcartilage tubed pedicle flap provides an alternative to second intention healing, skin grafts and two-staged interpolation flaps for repairing significant anterior ear defects. Although the surgical technique is not intuitive, it is a repair that is relatively simple to master and reproducible.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:30pm - 3:36pm


PRESENTER: Joel Cook, MD

TITLE: The Utility of Fold-Over Flaps in Facial Reconstruction.

AUTHORS: Joel Cook, MD

Purpose:
The reconstruction of surgical wounds following Mohs surgery may prove challenging. There are many repair choices for an individual defect. The repair which best preserves or restores function in an aesthetic manner proves superior. Larger defects, deeper defects, or defects occupying more than one cosmetic unit frequently require more involved reconstructive techniques. Such defects may require multiple flaps or staged repairs. Fold-over flaps are robust, random-pattern flaps used in head and neck reconstruction. These flaps may yield excellent postoperative results in fewer and less morbid prodecures. The use of the flap will be reviewed.

Design:
Selected surgical wounds following Mohs surgery by a single Mohs surgeon for skin cancer are reviewed. Repairs, including a fold over flap as a portion of the closure, are presented. The aesthetic and functional outcomes will be detailed. The utility of the flap will be explored. The surgical technique will be reviewed.

Summary:
Surgical defects of the central face can often be repaired with a single-staged procedure using a fold-over flap. These flaps are robust flaps that, once created, provide an excellent platform upon which to place another flap or skin graft. The flap may be subcutaneous tissue or muscle in character. The flap's donor site rarely shows any significant contour problems secondary to the flap's harvest.

Conclusions:
The fold-over flap is a useful technique in dermatologic surgery. The flap affords the surgeon tissue for contour restoration of larger, deeper, or more complex surgical wounds. The flap may frequently reduce the number of required surgical procedures whilst providing excellent functional and cosmetic outcomes.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
3:36pm - 3:42pm


PRESENTER: Steven Marc Rotter, MD

TITLE: The Use of Immediate Cartilage Grafts with Delayed Skin Grafts for Nasal Reconstruction

AUTHORS: Steven M. Rotter, MD

Purpose:
To present a novel reconstruction option for alar defects.

Design:
Wounds that are too deep for immediate grafting, and that would cause contracture deformity if left to heal by second intention, can be managed by immediate cartilage grafting and delayed skin grafting. Methods and patient examples will be shown.

Summary:
This is a useful option in patients who would prefer not to have two-staged flaps.

Conclusions:
Cartilage grafts survive beautifully without immediate soft tissue coverage and with delayed grafting can be a useful option for reconstructing defects on the nasal ala.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
Late-breaking Abstract
3:42pm - 3:48pm


PRESENTER: Ravi Krishnan, MD

TITLE: Management of Parotid Duct Injuries Resulting from Extirpation of Cutaneous Malignancies

AUTHORS: Ravi Krishnan, MD; Heidi Donnelly, MD

Purpose:
Large, aggressive skin cancers on the cheeks not uncommonly involve the parotid duct. In such cases, in order for the tumor to be successfully removed, at least part of the parotid duct must be excised as well. It behooves the Mohs surgeon to understand how to identify and manage parotid duct injuries so that the surgeon will be prepared for such situations.

Design:
We present a series of cases in which large, aggressive tumors on the cheek resulted in injury to the parotid duct. We will demonstrate the relevant anatomical considerations and discuss techniques for visualizing parotid duct injury including sialography and retrograde injections of methylene blue. We shall also describe several treatment modalities available to manage parotid duct injuries, including injections with botulinum toxin, ligation of the parotid duct, tympanic neurectomy, parotidectomy, vein micrografts, radiation therapy and conservative management.

Summary:
While there are a variety of aggressive modalities available for the management of parotid duct injuries, many such injuries can be managed by less invasive means. Conservative management with pressure bandages and antisialogogues, with or without adjunctive intraparotid injections of botulinum toxin, often yields excellent results.

Conclusions:
Parotid duct injuries may occur when removing large tumors from the cheek. A thorough knowlege of the relevant anatomy and histology of the parotid duct will allow easy diagnosis of insults to the parotid duct. Once a parotid duct injury has been diagnosed, relatively conservative measures may provide the patient with an excellent functional result. If these conservative measures fail, then there are a variety of more aggressive modalities which may be offered.

Friday, April 28, 2006
Reconstructive Surgery Abstracts
Late-breaking Abstract
3:48pm - 3:54pm


PRESENTER: Anthony Benedetto, DO

TITLE: Facial Palsies After Mohs Surgery Treated with Polypropylene Barbed Threads

AUTHORS: Anthony Benedetto, DO; Anthony Papadopoulos, MD; Ernest Benedetto, MD

Purpose:
To examine the utility of a minimally invasive 'threading' technique using polypropylene barbed threads to correct unilateral brow ptosis secondary to Mohs surgical extirpation of a large skin cancer.

Design:
Mohs surgical extirpation of extensive and deep skin cancers of the face can result in unilateral facial nerve paresis. Until recently, correction of such acquired and permanent nerve palsies of the face required invasive surgical reconstructive procedures. Recently, barbed polypropylene threads have been introduced for the cosmetic use of lifting ptotic, aged skin of the face obviating the usual postoperative morbidity associated with traditional interventive rhytidectomies. This pilot study examined the feasibility of using either conventional "floating" Aptos threads or the new, anchored ContourThreads to lift and support hemiparetic forehead skin and unilateral brow ptosis resulting from obligatory, deep Mohs surgical resection of skin cancer.

Summary:
Minimally invasive, polypropylene thread lifts may offer cosmetically acceptable correction of brow ptosis secondary to Mohs surgery with decreased morbidity as compared to invasive surgical procedures.

Conclusions:


Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:00am - 9:06am


PRESENTER: Gregory M Bricca, MD

TITLE: Cutaneous Head and Neck Melanoma Treated with Mohs Micrographic Surgery

AUTHORS: Gregory M. Bricca, MD; David G. Brodland, MD; Dianxu Ren, MS; John A. Zitelli, MD

Purpose:
Our purpose was to determine the safety and efficacy of Mohs micrographic surgery for the treatment of primary cutaneous melanoma of the head and neck.

Design:
A consecutive sample of 625 patients referred for treatment of primary cutaneous melanoma of the head and neck comprised the study group. Mean follow-up for the group was 58.0 months. All melanomas were excised using Mohs micrographic surgery and surgical margin examination was performed using frozen section tissue in all cases. After stratification using updated American Joint Commission for Cancer (AJCC) Breslow thickness criteria, the Kaplan-Meier method was used to calculate five-year local recurrence rates, metastasis rates, and disease specific survival rates. Tumors were then restratified by earlier Breslow thickness criteria for comparison to historical controls for local recurrence rates, metastasis rates, and disease specific survival rates. Recommendations for predetermined excision margins were proposed and were based on the surgical margin widths that achieved complete melanoma removal in 97% of the cases in this study.

Summary:
Mohs micrographic surgery for the treatment of head and neck melanoma achieved five-year local recurrence rates, metastasis rates, and disease-specific survival rates comparable to or better than historical controls after Breslow thickness stratification. The size of the surgical margin required for complete excision was significantly related to tumor thickness but not tumor size or specific location.

Conclusions:
Mohs micrographic surgery is an effective treatment modality for primary cutaneous melanoma, and may contribute to favorable outcomes especially on the head and neck where extensive sub-clinical spread is relatively common.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:06am - 9:12am


PRESENTER: Ross M Campbell, MD

TITLE: Characteristics of Mohs Practices in the United States

AUTHORS: Ross M. Campbell, MD; Clifford S. Perlis, MD; Mohsin Malik; Raymond G. Dufresne, MD

Purpose:
The practice of Mohs Micrographic Surgery has rapidly expanded over the last 30 years. The purpose of this study is to better characterize the typical Mohs practice in the United States and to generate data that may be useful in future practice models.

Design:
A survey was mailed in early 2004 to all 599 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology with United States addresses.

Summary:
Of 599 surveys sent, 303 responses were returned. Most respondents were part of a single specialty group (39%), in a suburban or urban setting (90%), performed between 501-1000 cases per year (43%), and had been in practice from 0-5 years (26%). The vast majority of Mohs excisions are for basal cell cancers and squamous cell cancers, 73% and 23 %, respectively, followed by melanoma (2%). Primary closure is the most common method of repair (46%), followed by the use of flaps (25%), second intention (13%), and full thickness skin grafts (10%). Only 6% of cases were referred to other specialties for closure. Many surgeons augment their practice with non-Mohs, cosmetic procedures. 235 respondents (77%) performed Botox, 147 (49%) used injectable fillers, 142 (47%) performed sclerotherapy, and 152 (50%) use laser treatment in their practices.

Conclusions:
The characteristics of current Mohs surgery practices in the United States provides useful data for training programs, potential trainees, workforce issues, statistical modeling systems, and Mohs surgeons in the evaluation of their own practices.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:12am - 9:18am


PRESENTER: Daniel Dapprich, MD

TITLE: Outcomes of Melanoma in Solid Organ Transplant Recipients

AUTHORS: Daniel Dapprich, MD; Amy L. Weaver, MS; Weenig H. Roger, MD, MPH; Katherine K. Lim Quan, MD; John S. Walsh, MD; James Keeling, MD; Leslie J. Christenson, MD

Purpose:
There is little known regarding malignant melanoma (MM) in immunosuppressed solid organ transplant recipients. Melanoma, known to be an immune responsive tumor, has been reported to have potentially worse outcomes in the immunosuppressed host versus the nonimmunosuppressed host. Prior reports however, lack or have limited crucial prognostic information of the MMs in these patients, limiting the applicability of these reports to transplant-patient care decisions. The primary objective of this study was to describe outcomes of MM in transplant recipients and compare with the general population matched for prognostic information (Breslow depth or AJCC staging criteria)

Design:
This study was approved by the Internal Review Board at the Mayo Clinic. The Surgical and Medical Index databases of the Mayo Clinic, Rochester, MN, were searched to identify all patients with the diagnoses of MM and solid organ transplantation between 1978 and 2004. Known cases from Mayo Clinic Scottsdale, AZ, and Jacksonville, FL, were also identified. Retrospective chart review was performed. Risk factor questionnaires were sent to all study-eligible patients or family members if the patient was deceased. Obtainable pathology slides were reviewed. Outcomes were compared with those reported in the general population.

Summary:
Thirty-five (35) MMs were identified in 33 transplant patients . Pathology slides were reviewed for 18 MMs. Twelve (12) MMs were diagnosed before the 1st solid organ transplant, 23 were diagnosed after the solid organ transplantation. 6, 7, 3 and 8 MMs were Clark s level I, II, III, and IV respectively. Median Breslow depth was 0.96mm, with the minimum Breslow depth of 0.32mm and a maximum of 2.90mm. The number of MMs with Breslow depths <=1mm, 1.01-2mm, 2.01-4mm and >4mm were as follows: 11, 8, 3, 0. Ulceration was not seen. Regression was seen in 1 MM, which was diagnosis after transplantation. Lymphocytic infiltrate was absent in 16 and nonbrisk in 5. MM was seen to arise in a preexisting nevus in 3 cases. Fifteen (15) MMs were superficial spreading, 3 were lentigo maligna, and 3 were nodular subtypes. Eleven (11) were stage IA, 7 were stage IB, 3 were stage IIA, 2 were stage IV, and 12 were of unknown stage. Sentinel lymph node biopsy (SLN) was performed for 4 MMs and all were negative. Elective lymph node dissection was performed for 1 MM and was negative. Twenty-two (22) MMs were treated with wide local excision, 2 with Mohs micrographic surgery, and 1 patient had removal of their renal allograft. There was no chart documentation of treatment in 10 cases. Four (4) patients experienced metastasis. Three (3 )of the metastasis occurred after transplantation. Two (2) of 3 cases with Breslow depths greater than 2 had metastasis. Median time from diagnosis of 1st MM to last follow up was 4.4 years. Those with MM prior to transplant had a median follow up of 9.4 years after the diagnosis of MM and those with MM after transplantation had a median follow up of 2.7 years after diagnosis of MM. At last follow up, 1 patient was deceased from MM, 11 were deceased with other or unknown causes, 1 patient was alive with evidence of MM, 19 were alive with no evidence of MM, and 1 was alive with unknown disease status. The one patient deceased due to MM had Breslow depth 2.90 and Clark IV, no lymph node evaluation other than palpation had been performed.

Conclusions:
According to this small retrospective case series, outcomes of MM in immunosuppressed transplant recipients appear similar to prognostically matched nonimmunosuppressed hosts. Concern does exist that immunosuppressed transplant recipients with a MM of greater than 2mm Breslow depth may have significant risk of metastasis, but the number of cases in this study is too low to even compare to the general population. Further study looking at larger patient populations is needed to attain statistically significant comparisons.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:18am - 9:26am


PRESENTER: David E Kent, MD

TITLE: Radiologic Imaging of the Patient with Perineural Tumor: What Every Mohs Surgeon Should Know

AUTHORS: David E. Kent, MD; Robert G. Goodrich, MD; Joshua E. Lane, MD

Purpose:
Discovering perineural tumor spread may have a devastating impact on patients with skin cancer. Tumor cells may spread considerable distances from the primary site and make surgical cure difficult. Recognition of perineural tumor with radiologic imaging may change treatment goals from cure to palliation and can therefore significantly affect patient care.

Design:
The majority of perineural skin cancer spread involves the head and neck and predominately the trigeminal and facial nerves. Having a clear understanding of neuroanatomy and which radiologic test to order for imaging both extracranial and potential retrograde extension intracranially is central to managing patients.

Summary:
This presentation will highlight the neuroanatomy relevant to perineural tumor spread that Mohs surgeons may encounter in the head and neck. Additionally, an emphasis will be placed on deciding which radiologic imaging tests are sensitive and specific for imaging these anatomic areas and how to make sense of this information.

Conclusions:
A thorough understanding of radiologic imaging techniques is critical for the Mohs surgeon, especially with perineural tumors.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:26am-9:32am


PRESENTER: Heather L Anderson

TITLE: A Pilot Feasibility Study of a Rare Skin Tumor Database

AUTHORS: Heather L. Anderson; Aaron K. Joseph, MD

Purpose:
The purpose of this study is to demonstrate that a database of rare skin tumors removed by Mohs micrographic surgery can be accomplished by the sharing of data among Mohs surgeons. We believe that this project may serve as a model for a nationwide rare skin tumor database.

Design:
Mohs surgeons in the greater Houston, Texas, area were asked to participate in the database by allowing review of their Mohs surgery logs to collect information on patient demographics, tumor types and tumor locations. Basal cell carcinomas, Squamous cell carcinomas, and Melanomas were excluded. No identifying data (first or last name) is included in the database. Data from 1998 through 2004 was collected.

Summary:
Data from Mohs surgeons in the Houston area was pooled to examine the total number of rare tumors removed by Mohs surgery. In the review of four Mohs surgery practices in the Houston area, 37 types of non-BCC, non-SCC, non-melanoma tumors were identified. Over 150 rare tumors were treated. No single practice saw more than seven rare tumor types in a single year. Atypical Fibroxanthoma was the rare tumor most often treated by Mohs micrographic surgery.

Conclusions:
With cooperation among colleagues, a database of rare tumors removed by Mohs surgery has been compiled. A diverse range of tumors greater than that seen in any single practice is now available for a geographically based epidemiologic study. This should provide the impetus for a nationwide rare tumor database and future prospective studies of surgical outcomes.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:32am - 9:38am


PRESENTER: Clark Clothier Otley, MD

TITLE: Reduction of Immunosuppression for Transplant-Associated Skin Cancer: Survey of Transplant Physicians

AUTHORS: Clark C. Otley, MD; Matthew D. Griffin, MD; Michael R. Charlton, MD; Brooks S. Edwards, MD; Marcy Neuburg, MD; Thomas Stasko, MD

Purpose:
Reduction of immunosuppression is considered a reasonable adjuvant therapeutic strategy for solid organ transplant recipients who experience severe skin cancer, and there are multiple lines of evidence to suggest potential efficacy. However, the clinical thresholds for initiating reduction of immunosuppression remain undefined. Additionally, the potential risks of rejection associated with varying levels of reduction of immunosuppression are poorly defined. Our objective was to survey expert transplant physicians regarding appropriate thresholds for consideration of reduction of immunosuppression and the likelihood of rejection and allograft compromise associated with varying levels of reduction of immunosuppression.

Design:
A survey was distributed by members of the International Transplant-Skin Cancer Collaborative's Reduction of Immunosuppression Task Force to collaborating transplant physicians. Fifty-two transplant physicians provided their opinions on 13 hypothetical patient scenarios with graduated morbidity and mortality risk regarding the degree of reduction of immunosuppression warranted and the risks associated with varying levels of reduction of immunosuppression.

Summary:
Renal, liver, and cardiac transplant physicians generally concurred on the appropriate level of reduction of immunosuppression which might be warranted by varying degrees of skin cancer. As morbidity and mortality from skin cancer increased, physicians were more likely to accept risk to allograft function from more aggressive reduction of immunosuppression. Interestingly, transplant physicians were more willing to consider a reduction of immunosuppression than dermatologists from a prior survey. Although physicians agreed that more aggressive reduction of immunosuppression was associated with increasing risks of allograft compromise, there was variability in the estimated degree of risk.

Conclusions:
Reduction of immunosuppression is considered a reasonable adjuvant strategy in solid organ transplant recipients experiencing significant morbidity and mortality risk from skin cancer. Physicians are willing to accept an increased risk of allograft compromise when confronted by severe or extensive skin cancer. Further research is needed to define the precise correlation between levels of reduction of immunosuppression, therapeutic efficacy, and concomitant risks.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:38am - 9:44am


PRESENTER: Aradhna Saxena, MD

TITLE: Basaloid Follicular Hamartoma: A Cautionary Tale

AUTHORS: Aradhna Saxena, MD; Michael Shapiro, MD; David A. Kasper, MBA; J. Ramsey Mellette, MD; James Fitzpatrick, MD

Purpose:
Basaloid follicular hamartoma (BFH), also referred to as benign follicular hamartoma, is a rare cutaneous follicular neoplasm that presents as small skin-colored papules on the face, scalp, and occasionally, the trunk. The histological pattern mimics infundibulocystic basal cell carcinoma (BCC), and as such, there has been much debate in the literature regarding the distinction between these two entities. Although BFH may be difficult to differentiate both clinically and histologically from BCC, it is important to recognize that the lesions are biologically very different entities; generally, BFH is considered benign and is not locally destructive.

Design:
A case report with review of the literature.

Summary:
We report a case of a 39-year-old white female with a recurrent BCC on the left alar crease. Mohs micrographic surgery was recommended for treatment. The initial stage was consistent with BCC; positive margins were noted and further stages were taken. By the third stage, foci of clefting and single-cell necrosis still suggested a diagnosis of BCC, however, a follicular appearance to the some of the tumor buds was noted. The process mapped cephalad along the nasal sidewall, towards the nasal root. In subsequent stages, the clinical appearance of the involved tissue was unremarkable except for an imperceptibly fine, tan stippling. By the 10th Mohs micrographic surgery stage, the process assumed an even more remarkably follicular appearance. After considerable review with a dermatopathologist, the histologic features were deemed consistent with a diagnosis of BFH. Despite positive margins, further tissue removal was deemed unnecessary. The final defect was repaired with a left post-auricular full thickness skin graft. After six months of follow-up, signs of tumor recurrence were not apparent by clinical examination. It is important to use reliable clinical and histopathological criteria to distinguish BFH from BCC in order to avoid inappropriate surgical procedures. Infundibulocystic BCC and BFH are both located on the face, and both may exhibit well-defined smooth margins. However, BFH lesions do not grow or ulcerate, in contrast to most lesions of BCC. Clinically, BFH presents in four different forms. It has been our experience that patients with any type of BFH have an increased risk of BCC, although the BCC lesions arise independently, not directly from BFH. As this is the case in our patient, the association of these two lesions may be underreported or underestimated. The histologic features of the two entities will be compared and contrasted. Additionally, the origin and development of these neoplasms will be addressed. Finally, helpful immunohistochemical staining features will be discussed.

Conclusions:
The present case illustrates the difficulty of differentiating these two processes and underscores the importance of doing so in a timely fashion. The differences between these two histologic entities have implications beyond the realm of academia, since BFH is stable over time and may be observed while BCC must be treated (topically, surgically, or by radiation) to prevent inexorable growth and tissue destruction. Clinicians must maintain a high index of suspicion for BFH in appropriate clinical contexts.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:44am - 9:52am


PRESENTER: Murad Alam, MD

TITLE: Surgical Management of Animal-Type Melanoma

AUTHORS: Murad Alam, MD; Ross Levy, MD; Simon S. Yoo, MD; Joan Guitart, MD

Purpose:
Animal-type melanoma (also known as pigmented epithelioid melanocytoma) in humans is a recently described and rare variant of melanoma that mimics a similar lesion in horses. Clinically, this lesion resembles a nodular melanoma, and histologic findings are consistent with a deeply invasive melanocytic lesion. Notably, there is disagreement in the limited literature regarding this tumor's degree of aggressiveness and the associated prognosis. The purpose of this review is to analyze the reported cases of animal-type melanoma to arrive at generalizations regarding diagnosis and management. Specifically, we aim to clarify how radical a surgical approach may be appropriate for extirpation of this tumor, which appears alarming both clinically and histologically. We also provide clinical and histologic images to aid in diagnosis of this entity.

Design:
Structured review of 49 published cases (MEDline, 1999-2005) of animal-type melanoma, as well as one additional previously unpublished case, presented for illustrative purposes. Assessment of typical sex/age of afflicted patients, anatomic sites of predilection, size at diagnosis, clinical appearance, histologic features, diagnostic testing and staging (including sentinel lymph node biopsy), method of surgical removal, risk of recurrence and metastasis, and final prognosis. Use of this summary data to generate guidelines for management of this tumor. Display of representative clinical and histologic photographs to aid in diagnosis.

Summary:
Animal-type melanoma, also recently referred to as pigmented epithelioid melanocytoma, is a heavily pigmented melanocytic tumor that occurs rarely in humans. Tumors clinically present as dark to violaceous nodules, some ulcerated, with median tumor thickness of 3-4 mm and peak thickness of 1 cm or greater with Clark's level IV or V. More lesions have been found on the trunk and extremities than on the head and neck, and while white patients are at greatest risk, over 1/3 of lesions have occurred in hispanic, black, and asian patients. Histologically, the tumors appear as heavily pigmented dermal melanocytic tumors with infiltrative borders. Composed of a mixture of epithelioid and spindled melanocytes, these lesions often extend into subcutaneous tissue. Prior to diagnosis as animal-type melanoma, these tumors may be missclassified (or imprecisely classified) as atypical blue/cellular blue nevus, deep penetrating nevus, congenital nevus, atypical melanocytic proliferation, or routine melanoma. Historically, surgical management has entailed wide local excision with 1-2 cm margins. In approximately half of cases, sentinel lymph node biopsy was performed, and among patients undergoing such biopsy, metastatic disease was detected in 40-50% of patients in various series. Widespread distant metastasis culminating in death has been reported in several cases.

Conclusions:
Surgical management of animal-type melanoma is challenging and uncertain, given the small number of cases as well as the difficulty in obtaining timely histologic diagnosis. One approach is to treat these lesions as routine, deeply invasive, nodular melanoma, and aggressively manage them with very wide local excision to fascia and sentinel lymph node biopsy, as well as adjuvant chemotherapy per protocol. The other approach is predicated on the expectation that these lesions are more indolent than routine nodular melanomas of comparable Breslow depth and Clark's level; in this vein, moderately wide surgical excision sparing vital structures may be sufficient, and detection of microscopic metastases in sentinel lymph nodes may not be as dire a prognostic indicator. Whatever the selected therapeutic approach, in-depth discussion with the patient is vital. The patient should be instructed carefully about the lack of firm knowledge about diagnosis, prognosis, and hence optimal therapy. Further, the patient should be encouraged to participate in the selection of therapy. Surgeons should not hesitate to consult colleagues in melanoma surgery, melanoma medicine, and dermatopathology to assist in the management of this troublesome and worrisome disease.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
9:52am - 9:58am


PRESENTER: Jerry Dewayne Brewer, MD

TITLE: The Effects of Sirolimus on Wound Healing in Dermatologic Surgery

AUTHORS: Jerry D. Brewer, MD; Clark C. Otley, MD; Leslie J. Christenson, MD; Pamela K. Phillips, MD; Randall K. Roenigk, MD

Purpose:
To determine the effect of sirolimus administration on wound healing in transplant patients undergoing dermatologic surgical procedures.

Design:
The medical and surgical index and medication list database at Mayo Clinic was queried to identify transplant patients on sirolimus who underwent dermatologic surgery procedures. Retrospective review of surgical reports and follow-up care was performed to quantify wound healing outcomes while on sirolimus compared to a group of matched control patients who were not taking sirolimus.

Summary:
Nineteen (19) transplant patients were identified who underwent dermatologic surgical procedures while on sirolimus. Comparing the sirolimus group to a control group of 17 patients, post-operative infections were identified in 26.3% (95% CI of 9.2% - 51.2%) compared to 6% (95% CI of 0.2% - 28.7%) of procedures respectively (p=0.182).* In addition, the incidence of wound dehiscence was elevated in the sirolimus group in 5.3% compared to 0% in the control group (p=1.00). 26.3% of the sirolimus group of patients reportedly felt like their wounds were slow to heal, while none of the control group reported this finding (p=0.047). * All p-values based on Fisher's exact test for statistical analysis

Conclusions:
This retrospective study raises concern that sirolimus may have adverse effects on wound healing in transplant patients undergoing dermatologic surgical procedures, based on elevated incidence of wound infections, dehiscence, and healing time. A prospective study is needed to clarify these findings and to more precisely elucidate the side effects of sirolimus in the setting of dermatologic surgery.

Saturday, April 29, 2006
Pathology and Oncology Abstracts
Late-breaking Abstract
9:58am - 10:04am


PRESENTER: Tina Wright, MD

TITLE: Treatment of Recurrent Dermatofibrosarcoma Protuberans with Imatinib Mesylate, Followed by Mohs Micrographic Surgery

AUTHORS: Jeffrey E. Petersen, MD; Tina Wright, MD

Purpose:
In the pre-surgical treatment of locally advanced and metastatic dermatofibrosarcoma protuberans (DFSP), imatinib mesylate (Gleevec or STI-571; Novartis, Basel, Switzerland) has been used with some success in six case reports and a clinical trial.1-7 This is our case report of a patient with DFSP, who after two previous resections with subsequent recurrence, was pre-surgically treated with imatinib mesylate, underwent a third resection, and is now tumor free for 16 months.


Design:
Patient with recurrent DFSP was treated with imatinib mesylate 400mg P.O. for five months prior to surgical resection.

Summary:
The standard of care for DFSP has been wide local resection; however, the rate of recurrence is as high as 60%.8-10 Fibrosarcomatous histopathology in the tumor is commonly associated with recurrence and increased risk of metastasis, most commonly to the lungs.11-12 A defining characteristic of DFSP is the aberrant constitutional over expression of platelet derived growth factor beta(PDGFB) which serves to activate platelet derived growth factor receptor beta (PDGFRB) and its tyrosine kinases through an autocrine mechanism that results in cell growth and proliferation. This over expression of PDGFB is the result of a fusion gene consisting of collagen type I-alpha1 gene and PDGFB-chain gene from the rearrangement of chromosomes 17 and 22, leading to a supranumery ring [r(17;22)] or reciprocal translocation [t(17;22)].13,14 Imatinib mesylate is FDA approved for the treatment of Chronic Myelogenous Leukemia (CML) and has also been used successfully against Gastrointestinal stromal tumors (GIST). Like DFSP, both have constitutional over stimulation of tyrosine kinase receptors, bcr-abl and c-kit respectively. It works as a protein tyrosine kinase inhibitor and thus disrupts this autocrine stimulation (Figure 1).15-17 With this knowledge, the use of imatinib mesylate in the treatment of DFSP has also been investigated and there are now six case reports and a clinical trial concerning its use as the sole treatment in metastatic, inoperable DFSP or pre-surgically in locally advanced DFSP. These publications demonstrate that patients with DFSP known to have the t(17;22) or r(17;22) rearrangement with subsequent PDGFB over expression obtain partial or complete response using imatinib mesylate, as shown clinically, as well as by radiologic and histologic evidence. Many of the patients had a clinical response within the first thirty days of treatment.1-7 In this case report we will discuss our findings and outcome treating a patient with recurrent DFSP using imatinib mesylate followed by resection.


Conclusions:
Imatinib mesylate should be given consideration in the treatment of DFSP, when the tumor is recurrent or in a surgically challenging location


POSTERS

100

PRESENTER: Murad Alam, MD

TITLE: Cost-Effectiveness of Optimal Skin Cancer Screening Intervals for Patients Following Solid-Organ Transplantation

AUTHORS: Murad Alam, MD; Simon S. Yoo, MD; Lucile E. White, MD; John Y. Kim, MD; Douglas Sidle, MD; Michael Abecassis, MD, MBA.

Purpose:
Patients who receive solid organ transplants have vastly elevated post-transplant risk of skin cancer, especially for cutaneous squamous cell carcinoma, which is a major cause of morbidity and mortality in this population. The purpose of this study was to determine the optimal interval between screening visits for patients with transplant-associated skin cancer. Unlike past recommendations, which have been based on physician consensus alone, we base ours on a quantitative decision analysis model that takes into account patient-specific factors.

Design:
A literature review of MEDLINE (1985-2005) was performed to elicit information regarding baseline likelihood of skin tumors in transplant recipients and likelihood of subsequent such tumors in patients who had previous post-transplant skin cancers. Decision rules were developed using this information. These decision rules were used to construct a decision tree using DATA software. Costs of treatments and quality of life data were entered into the model. The model was used to estimate optimal screening intervals for patients based on prior history of skin cancer. The cost of treatment per quality-adjusted life year was calculated.

Summary:
Based on prior incidence of skin cancer and patient-specific factors, the decision analysis model suggested that post-transplant patients can be assigned to one of 4 screening intervals for future skin cancers. Patients with no prior skin cancers can be screened every 12 months, those few post-transplant skin cancers (2 or fewer per year post-transplant) can be screened every 6 months, those with moderate transplant-associated carcinogenesis (3-8 tumors per year post-transplant) can be screened every 4 months, and patients with catastrophic carcinogenesis (9 or more tumors per year) can be screened every 2-3 months. At each screening visit, patients can be treated with definitive means (Mohs or wide local excision) for infiltrative, histologically aggressive, or large (> 2cm) tumors, local destruction (electrodessication and curettage) for smaller, lower risk tumors, and chemoprophylaxis (topical medications or liquid nitrogen) for incipient or in-situ tumors. This screening scheme is associated with a cost of less than $100,000 per quality-adjusted life year, and thus meets commonly accepted parameters for a cost-effective screening program.

Conclusions:
Skin cancer screening of transplant patients can reduce morbidity and mortality by ensuring timely treatment of new skin cancers. By assigning transplant patients to one of four screening groups based on their prior history of skin cancers, screening intervals can be individually tailored to maximize quality-adjusted life years (QALYS) saved while minimizing screening costs.

101

PRESENTER: Dafnis Carolina Carranza, MD

TITLE: The Use of Autologous Platelet Concentrate in Granulating Defects of the Lower Extremities Following Mohs Micrographic Surgery

AUTHORS: Dafnis C. Carranza, MD; Teresa Soriano, MD; Deborah Caswell

Purpose: Platelets are known to secrete growth factors and cytokines that promote tissue repair. Autologous platelets have been reported to aid in the healing of chronic wounds.
To describe the use of fresh autologous platelet concentrate in healing of full thickness leg wounds after Mohs micrographic surgery.

Design:
The patients had lower extremity wounds resulting from excision of non-melanoma skin cancer using Mohs micrographic surgery. The resulting surgical defects, which measured greater than two centimeters and extended to subcutaneous tissue, were left open to granulate. Postoperatively, autologous platelet rich plasma was placed on the wounds and the patients were followed at regular intervals until wounds were completely healed.

Summary:
Autologous platelet rich plasma promoted wound healing in acute wounds after Mohs micrographic surgery. No adverse reactions were noted.

Conclusions:
Autologous platelet concentrate is a novel technique that may be of benefit in treating difficult-to-heal wounds after Mohs micrographic surgery.

102

PRESENTER: Arianne Elizabeth Chavez-Frazier, MD

TITLE: A Combined Horizontal to Vertical Buried Suture to Close Curvilinear Surgical Defects

AUTHORS: Arianne E. Chavez-Frazier, MD; Tri Nguyen, MD; Michael R. Migden, MD.

Purpose:
To describe a new, interrupted subcutaneous suture combining the traditional horizontal and vertical buried sutures to approximate wounds with unequal edges. This alternative to "the rule of halves" better distributes tension along curvilinear defects and preempts standing cones.

Design:
Along the longer wound edge, a horizontal suture is placed in the deep dermis following the arc of the needle. The horizontal bite should not exceed approximately 10 mm in width to avoid excessive bunching of skin. The needle is then placed vertically along the shorter wound length in the same dermal plane. The vertical suture should be placed at the midpoint of the horizontal suture. A surgeon's knot is tied approximating the wound edges and results in a buried knot halfway between the deep dermis and the subcutis. The 10 mm horizontal to 1 mm vertical suture progressively narrows the longer edge in a 10:1 ratio.

Summary:
A new suture technique, which combines the traditional horizontal and vertical buried stitches to close a curvilinear surgical defect, is described. The advantages of this suture over the traditional subcutaneous sutures in such a defect are that it results in equalization of the wound-edge-length discrepancy and more evenly distributes tension throughout the length of the wound. Significant wound-length discrepancies that would otherwise require standing cone excision may be closed with this horizontal-to-vertical dermal suture.

Conclusions:
There are many suturing techniques described for repairing surgical defects. Furthermore, many modifications and combinations of the basic suturing techniques are used to optimize the final cosmetic outcome. Subcutaneous sutures are the most critical aspect of wound closure as they close dead space, redistribute wound tension, and approximate wound edges. Exact wound edge approximation throughout the length of a curvilinear defect can be a challenge and usually requires a standing cone excision. We present a new suture technique combining the traditional horizontal and vertical buried sutures to close the unequal wound edges of a curvilinear defect. The combined horizontal-to-vertical suture fulfills all the necessary requirements of an effective subcutaneous suture described above. In addition, it allows for a more even distribution of tension and a more precise wound-edge approximation along the entire length of a wound with unequal edges. It is simple to perform and takes no more time than the traditional subcutaneous sutures in our surgical armamentarium.

103

PRESENTER: Teris Minsue Chen, MD

TITLE: Electronic Leash: Hands-Free Headsets to Improve Mohs/Dermatology Surgery Clinic Flow and Reduce Patient Wait Time

AUTHORS: Teris M. Chen, MD; Tri Nguyen, MD.

Purpose:
Patient satisfaction is an indicator of quality of care and is reflective of the amount of time patients wait for health care services. Ameliorating practice inefficiencies can optimize performance, as well as reduce patient wait time. Incorporation of hands-free headsets in a Mohs/dermatology surgery practice setting may increase clinic work-flow accuracy and efficiency via real-time communication from remote locations within the clinic.

Design:
A headset consists of a receiver (speaker) and transmitter (microphone). Receptionists, nursing staff, physicians, and other staff members at distant locations within the clinic are electronically linked" with rechargeable headsets. Training should include correct use of the headset and volume control, and advice on how and when to clean and maintain the headsets. Questions and requests should be concise, enunciated clearly in a soft audible tone, repeated, and if applicable, the room number identified. Requests are acknowledged so that tasks are not duplicated, avoiding inefficient use of support staff.

Summary:
The handsets are used at our institution for almost all aspects of communication within the clinic, including the following: general location of individuals; patient has arrived and checked in at Reception; patient is running late; questions regarding follow-up appointment scheduling; nursing request assistance, supplies; requests for rooming of patients, dressings, and other patient-related services; notifying patients of the results of a Mohs stage; notifying physician that slides are ready for review.

Conclusions:
In most Mohs/dermatology surgery practice settings, clinic staff are located at distant sites throughout the clinic. Hands-free headsets may hasten communications and allow for efficient use of support personnel. Enhanced productivity and rapid turnaround time will lead to better service. We are in the process of systematic evaluation of this technology to quantify the potential impact on clinic flow and efficiency.

104

PRESENTER: James DeBloom, MD

TITLE: Reconstruction of Full Thickness Surgical Defects of the Calvarium: To Chisel or Not to Chisel?

AUTHORS: James DeBloom, MD; John A. Zitelli, MD.

Purpose:
To elucidate the potential risks of decorticating the outer table of the calvarium in preparation for full thickness skin grafting after Mohs surgical excision of skin cancer lesions.

Design:
A retrospective analysis of seven cases in which a bone chisel was used to decorticate the skull to improve recipient site vascularity in preparation for full thickness skin graft placement. The seven cases included one melanoma, one atypical fibroxanthoma, two basal cell carcinomas and three squamous cell carcinomas.

Summary:
Each of our seven reviewed cases developed subsequent bony metastases or bony tumor extension at or adjacent to areas of decortication. The clinical details of each case will be described as well as alternative closure options for full thickness defects of the scalp.

Conclusions:
This outcome strongly suggests that decortication of the outer table of the calvarium compromises inherent protection provided by the periosteum against metastatic extension into the bony structure of the skull. When designing full thickness repairs for the skull, maintenance of the periosteum and avoidance of bone chiseling should be pursued. When possible, alternatives to full thickness skin grafts that would require decortication such as flaps and secondary intention healing should be utilized on the scalp.

105

PRESENTER: Tejas Dilip Desai, DO

TITLE: Applications of High Frequency Ultrasound in Mohs Micrographic Surgery

AUTHORS: Tejas D. Desai, DO; Alpesh D. Desai, DO.

Purpose:
To evaluate if high frequency ultrasound can change therapeutic decision favoring Mohs micrographic surgery over other conventional methods for treatment of basal cell carcinomas less than 2 cm in size. Evaluate if high frequency sonography can discern between collision tumors or adjacent basal cell carcinomas to avoid a painstaking Mohs procedure.

Design:
Twenty-five patients were scanned using high frequency ultrasound to evaluate tumor margins. All varieties of basal cell carcinomas were included in this study. Sonography was not performed on recurrent basal cell carcinomas, areas of fibrosis or inflammation, and areas that are physically difficult to apply the ultrasound transducer (i.e. helix of the ear, fingers). These exclusion criteria may alter images by underestimating or overestimating tumor size. Depictions of various images of BCCs will be explained in full detail.

Summary:
Out of 25 BCCs, 15 showed extension beyond standard surgical margins (i.e. 3-4 mm). Nodular basal cell carcinomas were best defined by sonography. Collision tumors or adjacent neoplasms were visualized, and these patients were consequently scheduled for two separate surgeries.

Conclusions:
High frequency sonography allows visualization of basal cell carcinoma margins that may extend beyond the clinical border. It is accepted practice to perform Mohs Micrographic Surgery for basal cell carcinomas greater than 2 cm in size. With the use of high frequency ultrasound, one may preoperatively delineate tumor margins adequately, depicting that many BCCs less than 2 cm can be better treated with Mohs compared to simple excision or electrodessication and curretage. Finally, the use of high frequency ultrasound may be cost effective when one knows if there are two distinct tumors in close proximity. This prevents more stages, larger defects, and provides quality care to patients.

106

PRESENTER: Bradley Kent Draper, MD, PhD

TITLE: The Combination Melolabial Flap and Nasal Transposition Flap in Reconstruction of Difficult Nasal Defects

AUTHORS: Bradley K. Draper, MD, PhD; J. Michael Wentzell

Purpose:
Transposition flaps are particularly useful for the repair of nasal defects following extirpation of tumors using Mohs micrographic surgery. Occasionally, the surgeon finds it difficult to close the secondary or tertiary defect of a transposition flap without distortion or undue tension. In this instance, the addition of a melolabial advancement or Burow's flap to a single or double nasal transposition flap is exceptionally valuable. Herein, we detail the application of melolabial flap alternatives in combination with nasal transposition flaps in the reconstruction of problematic nasal defects.

Design:
We review flap planning and specific anatomic considerations when combining various melolabial flaps with nasal transposition flaps in the repair of difficult nasal defects.

Summary:
Patient photographs and illustrations demonstrate the utility of combined melolabial and nasal transposition flaps in the repair of troublesome nasal defects. The melolabial flap provides readily recruited tissue and is easily disguised in the boundaries of cosmetic units or other relaxed skin tension lines.

Conclusions:
Combining melolabial flaps with nasal transposition flaps is an extremely useful technique that facilitates the often-complicated closure of secondary and tertiary defects on nasal skin.

107

PRESENTER: Wade Foster, MD

TITLE: A Prospective Randomized Study comparing the Efficacy of Horizontal Mohs Tissue Processing to Vertical Breadloaf Tissue Processing in the Surgical Management of Superficial Melanoma

AUTHORS: Wade Foster, MD; Adam C. Esser, MD; Mandy Frith, PA; James E. Elder, MD; Gary D. Monheit, MD; Christopher B. Harmon, MD

Purpose:
Mohs micrographic surgery has been touted as an effective means of surgical treatment for superficial melanoma. While conventional means of margin examination by breadloafing with subsequent vertical sectioning assesses only about 1% of the surgical margin, horizontal orientation of tissue using the Mohs technique provides for complete examination of the surgical margin. The comparability of these methods of tissue orientation in the assessment of the surgical margin in melanoma is unclear. Since the Mohs technique offers a more complete analysis of margins, we hypothesized that it would be a clinically superior technique in detecting melanoma tumor cells at the surgical margin.

Design:
To test this hypothesis, patients with biopsy-proven melanoma (<1.0 mm) or melanoma in situ were randomized into two study arms: 1) a Mohs (horizontal sectioning) arm; and 2) a Breadloaf (vertical sectioning) arm. Patients in the Mohs arm were treated with initial debulking of the clinically visible lesion. Following debulking, a 5 mm micrographic layer was taken around the defect, and the resultant tissue was frozen, horizontally embedded, and sectioned using the Mohs technique. If no traces of melanoma were seen on frozen sections, another 5 mm margin was taken around the defect, and this tissue was embedded horizontally in paraffin and sectioned so as to allow complete histological examination of the surgical margin. Patients in the Breadloaf group had the clinical margin of their lesion outlined with a surgical pen, and a 10 mm surgical margin was taken around the clinical margin. The resultant tissue was breadloafed embedded vertically in paraffin, sectioned and examined histologically.

Summary:
Positive margins in superficial melanoma and melanoma in situ were more frequently detected using the Mohs technique. Disadvantages of horizontal sectioning included occasional technical difficulties in getting the tissue to lie flat during the paraffin embedding process and the risk of overcall, the designation of juxtaposed normal melanocytes as a component of the tumor.

Conclusions:
Horizontal embedding using Mohs technique is an effective means of margin assessment in the surgical management of superficial melanoma.

108

PRESENTER: Priya Sambandan, MD

TITLE: Air Embolus During Extracranial Scalp Surgery

AUTHORS: Glenn D. Goldman, MD; Priya Sambandan, MD

Purpose:
To alert surgeons about the potential for air embolus when operating on midline scalp lesions in the seated position.

Design:
Case review and review of the literature.

Summary:
An 83-year-old man underwent Mohs surgery for a squamous cell carcinoma of the posterior midline vertex scalp. The tumor involved periosteum and this was stripped while the patient was seated. Small amounts of bubbling were noted from the exposed bone. The patient rapidly developed multifocal motor defects, impaired speach, severe dyspnea, deafening tinnitus, and multifocal sensory loss. He was stabilized and immediately transported to the emergency room where he was noted on CT scan to have air in the saggital sinus and widespread throughout the soft tissues fo the face. He rapidly stabilized and all defects resolved. A followup CT scan demonstrated resolution of all intravascular air. His bone was burred and waxed, and the wound repaired with a scalp flap.

Conclusions:
Midline scalp lesions occasionally have connections to the underlying dura. Rarely, a genetic anomaly allows for communication directly between the diploic scalp veins and the saggital sinus. Air embolus is common in neurosurgical procedures, but to this date has never been reported with an extracranial procedure exposing bone on the scalp. We review the anatomy that can make such a case possible and recommend that patients having deep posterior midline lesions involving periosteum be positioned prone, with a flap performed during the procedure where feasible.

109

PRESENTER: Robert G Goodrich, MD

TITLE: Sharp Debulking of Skin Tumors in Mohs Micrographic Surgery: The Utility of Vertical Sections

AUTHORS: Robert G. Goodrich, MD; Joshua E. Lane, MD; David E. Kent, MD

Purpose:
Vertical sections have been used as an adjunctive tool in Mohs micrographic surgery to aid in histological confirmation of tumors. We propose that vertical sectioning of bulk tumor in Mohs surgery is underutilized and can provide practical and useful information.

Design:
The use of adjunctive vertical sections in Mohs micrographic surgery has been used postoperatively to assess aggressive neoplasms such as melanoma. In our Mohs surgical practice, we sharply debulk cutaneous neoplasms with a scalpel prior to taking the Mohs layer. This debulking layer consists of the clinically apparent tumor. We find sharp debulking to be beneficial as the debulked tumor is subsequently sectioned on the cryostat in a vertical orientation to allow confirmation and/or further sub-classification of tumor type. This is less representative following curettage, as the overall architecture is not preserved. Mohs layers are processed routinely as oblique histological sections to allow examination of the entire surgical margin. Once a working knowledge of the histologic features of the tumor has been obtained, the Mohs layer can be thoroughly evaluated for residual tumor at the margins, with a real-time vertical section for histologic comparison.

Summary:
Examination of debulking specimens intraoperatively as vertical sections is useful for several reasons. It allows the Mohs surgeon to visualize the tumor at the time of surgery with frozen sections. Vertical sections define key histologic features with regard to the pattern and aggressiveness of the tumor. This may or may not correlate with the information supplied by the initial biopsy report. The presence of perineural invasion, perineural inflammation, lymphatic invasion, or involvement of deeper tissues can also be identified. A working knowledge of this information at the time of surgery is helpful with regard to the ultimate success of the operation. Weisberg and Becker described three categories of limitations to the information provided by the preoperative biopsy regarding tumor pathology. The first category included small biopsies that do not represent the overall tumor histology. The second category included inaccurate assessment of tumor depth. The third category included small biopsies that by nature of size did not reflect the overall tumor architecture. Orengo et al. reported that of 297 primary basal cell carcinomas, the histologic subtype of the final Mohs stage correlated with the preoperative histologic subtype in only 42.7% of cases. This carries many implications, including patient follow-up care, need for post-operative radiation and reconstruction options for aggressive tumors.

Conclusions:
This is a simple, non-time consuming step that can be performed in the vast majority of patients in a Mohs practice and provides invaluable information at the time of surgery, thus making for a better operation.

110

PRESENTER: Stephen Hess, MD, Ph.D.

TITLE: Current Opinions Regarding Peri-operative Management of High-Risk Cutaneous Squamous Cell Carcinoma.

AUTHORS: Stephen D. Hess, Kenneth Katz, M.D., Daniel Berg, M.D., and Chrysalyne D. Schmults, M.D.,

Purpose: High-risk cutaneous squamous cell carcinoma (SCC) may be life-threatening. There is little data available to guide peri-operative management of high-risk SCC. This study aimed to ascertain current attitudes and practices among Mohs surgeons regarding the peri-operative management of high-risk cutaneous SCC. We were particularly interested in use and perceived indications for radiologic imaging, sentinel lymph node biopsy (SLNB), and post-operative adjuvant radiotherapy.

Design: Survey study. 250 randomly selected members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology were invited to complete a web-based survey regarding their peri-operative management of high-risk cutaneous SCC patients seen in the previous year. High-risk was defined as any tumor with a perceived risk of metastasis exceeding 10%. Participants were asked in how many cases they recommended radiologic imaging, SLNB and/or adjuvant radiotherapy to high-risk patients. Participants were also asked to rank the specific high-risk characteristics which would lead them to recommend these additional studies or treatments.

Summary: 117 surgeons responded, for a response rate of 47%. 73 surgeons (62%) spent the majority of their time in private practice. The median number of years practicing Mohs surgery was 8 (range 1-31). The median number of high-risk SCCs seen in the previous year was 10 (range 0-150). During this time, 77 surgeons (67%) reported recommending radiologic imaging at least once. Of these surgeons, 26 (34%) recommended imaging to less than 25% of patients with high-risk SCC and 22 (29%) recommended it to all patients with high-risk SCC. The median percentage of high-risk patients referred for imaging was 20% (range 0-100%). With respect to preferred imaging modality, CT scan was recommended by 54 (59%) of respondents, MRI by 38 (36%), and PET scan by 16 (15%), while 5 (4.7%) expressed no preference. Of the 29 surgeons (25%) who recommended SLNB at least once in the previous year, 22 (76%) did so for less than 25% of patients with high-risk SCC. Post-operative adjuvant radiotherapy was recommended at least once in the previous year by 102 (90%) of respondents, with 41 (40%) referring less than 25% of patients with high-risk SCC for adjuvant radiotherapy and 21 (21%) referring all patients with high-risk SCC for adjuvant radiotherapy.

Factors most frequently cited by surgeons as indications for radiologic imaging included satellite / in-transit metastasis (cited by 46 [43%]), perineural involvement (cited by 34 [32%]), and poor differentiation (cited by 24 [23%]). These same factors were most frequently cited as indications for SLNB. Perineural invasion ranked as the most commonly cited factor (cited by 53 [47%]) for referral for adjuvant radiotherapy.



Conclusions: No consensus exists among Mohs surgeons regarding peri-operative management of high-risk cutaneous SCC. Further epidemiologic research and ultimately, clinical trials should focus on further defining the utility of radiologic imaging, SLNB, and adjuvant radiotherapy in the management of high-risk cutaneous SCC.

111

PRESENTER: Allison Hoffman, MD

TITLE: A Modification of the Purse-String Closure for Large Defects of the Extremities

AUTHORS: Allison Hoffman, MD; Peter K. Lee, MD, PhD

Purpose:
We report a modification of the purse-string closure with use of epidermal sutures placed vertically, rather than horizontally, around the wound periphery.

Design:
The purse-string closure is used either as an adjunct to graft placement or as the primary method of closure. It is useful in repair of oval or round defects as it reduces the overall size of the lesion, distributes tension along the wound periphery, and eliminates the need for removal of standing cones. The traditional method involves the placement of sutures horizontally in the dermis and may be supplemented with additional closure along the wound edge. Our modified technique was considered for patients with large oval or round defects located on the extremities. Under local anesthesia, the lesions were excised either with standard surgical margins or using the Mohs technique. Without significant undermining, multiple vertically placed bites using 3-0 polypropylene suture were placed circumferentially approximately 5-10 mm from the wound edge. The distance of suture placement from the wound was determined by the amount of wound tension and by skin thickness. The suture was cinched and tied using a surgeon's knot, resulting in complete to near-complete closure of the original defect. Subcutaneous, buried vertical mattress sutures were placed along the incision, followed by epidermal simple interrupted sutures to provide approximation and prolonged wound strength. Patients returned for suture removal three weeks after the procedure and were evaluated for function and appearance six to eight weeks following surgery.

Summary:
All of the defects were closed completely with this modified purse-string technique, without need for skin grafting or healing by secondary intention. No adverse effects were noted. As expected, significant skin pleats were present at the time of the procedure but were significantly decreased in all wounds at the time of suture removal. At the six- to eight-week follow-up visit, scars were flat, without contour abnormalities such as pleats, atrophy, or skin spreading. All patients were satisfied with the functional and cosmetic outcome.

Conclusions:
This modification of the purse-string closure is an optimal method to close oval or round defects located on the extremities. Vertically placed sutures may be placed quickly and are beneficial in areas with atrophic dermis. The cosmetic outcome is excellent.

112

PRESENTER: Satori Iwamoto, MD, PhD

TITLE: Autologous Bone Marrow-Derived Stem Cells for Mohs Surgery Wounds

AUTHORS: Satori Iwamoto, MD, PhD; Gerald Colvin, DO; Vincent Falanga, MD

Purpose:
Earlier work had suggested a promising role for bone marrow-derived stem cells in healing chronic wounds. Their role in acute surgical wounds has not yet been investigated. The current aims were to characterize cultured bone marrow-derived cells (to confirm their stem cell phenotype) and to optimize a system to deliver the cultured cells to Mohs surgery wounds. These initial aims form the basis of a study to determine whether autologous bone marrow-derived stem cells are able to improve the healing of Mohs surgery wounds.

Design:
Bone marrow cells were harvested from the iliac crest and cultured using mesenchymal stem cell media after Ficoll separation. The cells were characterized by flow cytometry and immunocytochemical labeling. Functional assays were used to determine their ability to differentiate into osteogenic, adipogenic and chondrogenic lineages. A commercially available fibrin delivery system was optimized to apply the cultured cells to Mohs surgery wounds. Patients are now being enrolled in a study in which bone marrow-derived cells are topically applied to certain Mohs surgery defects in which secondary intention is indicated. Patients are randomized to receive either cultured cells in fibrin or fibrin alone. Wounds are monitored for healing rate, scarring, and histological changes.

Summary:
By flow cytometry, the bone marrow-derived cultured cells expressed CD29, CD44, CD90, CD105 and CD166. They did not express CD34 and CD45. Immunocytochemical labeling confirmed those results. Functional assays confirmed the ability of the cultured cells to differentiate into bone, fat and cartilage cells. The fibrin delivery system effectively incorporated the cultured stem cells into Mohs surgery defects. Two patients have completed the study with excellent outcomes and additional patients are being enrolled.

Conclusions:
Bone marrow-derived cultured cells express a phenotype consistent with mesenchymal stem cells. The fibrin system was effectively able to deliver these cells to wounds. Proof of principle has been obtained and early results appear promising as an approach to improving the healing of cutaneous surgical wounds.

113

PRESENTER: M. Amanda Jacobs, MD

TITLE: Clinical Outcome of Flaps Versus Full-Thickness Skin Grafts Following Mohs Surgery on the Nose.

AUTHORS: M. Amanda Jacobs, MD; Leslie J. Christenson, MD; Amy L. Weaver, MS; David L. Appert, MD; P. Kim Phillips, MD; Randall K. Roenigk, MD; Clark C. Otley, MD

Purpose:
A large number of facial skin cancers occur on the nose. Following tumor extirpation by Mohs surgery, the nasal defects often present a reconstructive challenge. For medium-sized defects, the choice of reconstruction is usually either a skin flap or skin graft. Ongoing debate exists as to which of these methods is most satisfactory. This study was performed to evaluate and compare clinical appearance of wound healing following surgical repair with a full-thickness skin graft or skin flap on the nose.

Design:
Patients who underwent Mohs surgery on their nose followed by flap or graft repair in the past 6-48 months at the Mayo Clinic were identified. Those patients living within a 50-mile radius were contacted by phone, and all patients who were able to participate in the study were enrolled (median follow-up = 20 months, range 6-43 months). Clinical and photographic assessment was performed. Patients were clinically evaluated using a Wound Evaluation Scale (WES) and a Visual Analog Scale (0=poor to 100=best). Baseline information was collected, including Fitzpatrick skin type (I-VI), Glogau photoaging level (I-IV) and sebaceous gland grade (0-3). Standardized photographs were obtained. Photographs were then blindly evaluated by three physicians using a Visual Analog Scale (VAS), and the average score for each patient was evaluated.

Summary:
Seventy surgical reconstructions in sixty-five patients were evaluated. Mean VAS (SD) from photographs was 72 (17.3) for skin flaps and 49 (20.7) for skin grafts, which was statically significant (p<0.001) even after adjusting for confounding variables. Additionally, 100% of flaps had an acceptable overall cosmetic appearance based on the WES compared to only 69.2% of skin grafts (p<0.001). Glogau photoaging level and sebaceous grade were not highly correlated with the VAS score.

Conclusions:
Overall, skin flaps had a better clinical outcome than skin grafts on the nose. In situations where both repairs represent a viable option, it is important to consider that skin flaps may have a better likelihood of acceptable cosmetic appearance. Further investigations are necessary to further delineate the clinical variables which favor each type of surgical repair.

114

PRESENTER: Ming H. Jih, MD

TITLE: Malignant Cellular Dermatofibroma

AUTHORS: Ming H. Jih, MD; Arash Kimyai-Asadi, MD; Leonard H. Goldberg, MD

Purpose:
Cellular dermatofibroma (benign cellular fibrous histiocytoma) is considered to be a variant of dermatofibroma that is characterized by large, deeply-penetrating lesions with a high propensity for recurrence and uncommon systemic metastases. Variants of cellular dermatofibroma include atypical and indeterminate fibrous histiocytomas, which demonstrate cellular atypia and overlap features with dermatofibrosarcoma, respectively.

Design:
We describe four patients with cellular dermatofibroma. We also review the literature with particular attention to the biologic behavior of this tumor.

Summary:
One lesion had recurred three times previously. Another had been biopsied multiple times and called a dermatofibroma each time, even as it grew to be 9.5 x 7.5 cm in size. This and a third lesion (7 x 7 cm) were invasive to the level of the deep fascia. All tumors expressed both CD34 and Factor XIIIa, although expression of CD34 was focal in two cases, making CD34 expression easy to miss on biopsy specimens.

Conclusions:
Cellular dermatofibromas have four features that together prove their malignant nature:

1. The large size tumors can attain.
2. The potential for significant deep subcutaneous infiltration and invasion.
3. The high rate of local recurrence.
4. The occurrence of distant metastases.

As such, we propose that cellular, atypical and indeterminate dermatofibromas be renamed as "malignant cellular dermatofibroma."

115

PRESENTER: Andrew Laurence Kaplan, MD

TITLE: Highly Aggressive Sarcoma of the Head Arising With or Within Cutaneous Squamous Cell Carcinoma: Clonal Divergence or Tumor Convergence?

AUTHORS: Andrew L. Kaplan, MD

Purpose:
Presented herein is the case of an 83-year-old male who developed a rapidly growing and highly aggressive malignancy in actinically damaged scalp skin. The case illustrates the unusual occurrence of a malignant tumor with both epithelial (carcinomatous) and mesenchymal (sarcomatous) components, and serves to highlight the debate over the etiology of such neoplasms as an example of clonal divergence or tumor convergence.

Design:
Clinical photographs were used to emphasize the rapid evolution of a scalp tumor showing invasive squamous cell carcinoma superficially with a large, deeper sarcomatous malignancy that invaded the calvarium as well as the dura mater. The spindle cell sarcomatous component demonstrates no epithelial markers, and may be characterized as a malignant fibrous histiocytoma (MFH). Magnetic resonance and computed tomography images from this case were featured. Photomicrographs, including immunohistochemistry, will demonstrate the distinct components of this rare malignancy.

Summary:
The clinicopathologic overlap between squamous cell carcinoma and atypical fibroxanthoma (AFX) and the related malignant fibrous histiocytoma has led to persistent controversy regarding the presumed etiology of these tumors, and whether AFX and MFH may represent dedifferentiated, anaplastic squamous cell carcinomas. This controversy and our current understanding of the entity of carcinosarcoma are discussed.

Conclusions:
A highly aggressive soft-tissue sarcoma arising within, or concurrently with, a cutaneous squamous cell carcinoma presents an unusual example to highlight an ongoing clinicopathologic and etiologic debate.

116

PRESENTER: Arash Kimyai-Asadi, MD

TITLE: Histologic Comparison of Superficial Basal Cell Carcinoma and Superficial Squamous Cell Carcinoma

AUTHORS: Arash Kimyai-Asadi, MD; Ming H. Jih, MD; Leonard H. Goldberg, MD

Purpose:
Superficial basal cell carcinoma (BCC) is a commonly seen neoplasm with specific clinical and histologic features. Even though there is no invasion into the dermis, this entity is universally accepted as a variant of basal cell carcinoma and routinely treated to prevent significant lateral growth as well as the development of more invasive forms of basal cell carcinoma. Recently, the concept of an analogous form of squamous cell carcinoma (SCC) has been proposed and termed "proliferative actinic keratosis" or "epidermal and periadnexal squamous cell carcinoma in situ". Clinically and histologically, these lesions share significant similarities with superficial basal cell carcinomas.

Design:
Several lesions of superficial squamous cell carcinoma are compared with superficial basal cell carcinoma in terms of clinical appearance, clinical behavior (resistance to superficial destructive methods and significant subclinical lateral spread), and histologic features.

Summary:
Lesions of both superficial basal cell carcinoma and superficial squamous cell carcinoma are generally flat, erythematous patches. Hyperkeratosis is usually more marked with superficial SCCs. Both lesions are often mistaken for actinic keratoses and treated using superficially destructive methods or topical agents, but subsequent recurrence is a common feature. Histologically, both entities have atypical keratinocytes that grow beneath the epidermis, typically in a multifocal nature. Significant-growth down-hair follicles are a common feature. Other adnexal epithelia are also affected by the superficial SCC. Sharply angulated cell clusters can be seen in both entities. Palisading, clefting and cellular crowding are present in superficial BCC, whereas acantholysis can be seen in superficial SCC. Superficial SCC must also be contrasted with actinic keratoses. Whereas actinic keratoses involve partial thickness atypia of the epithelium itself, the superficial SCC is a growth of neoplastic cells juxtaposed on the overlying or adjacent epithelium. This distinction is easily demonstrated histologically and is a simple and reproducible feature to distinguish an actinic keratosis from a superficial squamous cell carcinoma.

Conclusions:
Significant clinical and histologic similarities exist between superficial BCCs and superficial SCCs. Recognition of the clinical and histologic distinctions between superficial SCC and actinic keratosis can allow proper treatment of these lesions, as they are resistant to topical and destructive therapies and need to be surgically managed.

117

PRESENTER: Anna I. Kirkorian, BA

TITLE: Perioperative Management of Anticoagulant Therapy during Cutaneous Surgery: 2005 Survey of Mohs Surgeons

AUTHORS: Anna I. Kirkorian. BA; Ellen S. Marmur, MD

Purpose:
Our aim is to present a summary of current practice in anticoagulation management perioperatively during cutaneous surgery.

Design:
A questionnaire surveying current practice in perioperative management of anticoagulant therapy was mailed to 700 dermatologic surgeons, members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. The questions investigated physicians experience with and practice of the following: (1) number of procedures performed yearly; (2) continuation or discontinuation of aspirin (prophylaxis), aspirin (medically necessary), warfarin, non-steroidal anti-inflammatory drugs (NSAIDs) and vitamin E; (3) time of discontinuation; (4) qualitative reasoning behind decision to continue or discontinue each anticoagulant or platelet inhibitor; and (5) the involvement of other physicians in determining how to manage the patient.

Summary:
Our results are pending a December 1st deadline. We plan to perform both quantitative and qualitative analysis of the data. Our quantitative data will be compared to the latest survey of practice in the literature (Kovich O, Otley CC. Perioperative management of anticoagulants and platelet inhibitors for cutaneous surgery: a survey of current practice. Dermatol Surg 2002;28:513-517). Our qualitative data regarding the reasons dermatologic surgeons choose to discontinue or continue anticoagulation therapy perioperatively will be used to explain the trends in our data as compared to the Kovich et al. survey of practice in 2002.

Conclusions:
We expect to describe a trend of an increased percentage of dermatologic surgeons choosing to continue anticoagulation perioperatively in 2005 as compared to 2002.

118

PRESENTER: David R. Lane, MD

TITLE: Modified Alar Rotation Flap for Small Alar Defects

AUTHORS: David R. Lane, MD; Katarina Chiller, MD

Purpose:
Post-Mohs alar defects pose a unique challenge for the reconstructive surgeon. We describe reconstruction of small alar defects with a rotation flap created by an incision made laterally along the alar crease. Previous reports have described repair of similar defects with an alar 'spiral' rotation flap and an alar rotation flap with a through-and-through incision of alar rim tissue to prevent collapse of the alar rim. We describe a novel modification of the alar rotation flap that does not require full-thickness excision of alar tissue. We feel this modification produces equivalent functional and cosmetic results without shortening the alar rim.

Design:
This flap requires lifting a laterally based rotation flap by making an incision along the alar crease and taking an inferior standing tissue cone towards, but not through, the alar rim. If this standing tissue cone will cross the alar rim, it is our experience that this redundant tissue can be excised along the alar rim instead of crossing it.

Summary:
The laterally based alar rotation flap is an excellent, reproducible reconstruction technique for small defects of the nasal ala and can be carried out successfully without shortening the ala with a full-thickness alar incision.

Conclusions:
Several surgical flaps have been described for defects of the nasal ala. An ideal closure would incorporate local skin movement to provide the closest tissue match and hide as many incision lines in natural skin folds. The alar rotation flap described herein meets both of these requirements and provides optimum cosmesis by hiding many of the incision lines in the alar crease and replaces the defect with the closely matched alar skin. This flap can be carried out without significantly distorting the alar rim or compromising nasal valve function.

119

PRESENTER: Aimee L. Leonard, MD

TITLE: Rapid Preparation of High Quality Frozen Sections Using the CryoHist Embedding Machine

AUTHORS: Aimee L. Leonard, MD; C. William Hanke, MD

Purpose:
In a busy Mohs surgery practice, the rate-limiting factor in achieving tissue clearance and completing a surgical case is often tissue processing and slide preparation. A wide disparity exists in tissue processing time among trained Mohs histotechnicians in different Mohs frozen section laboratories. Larger specimens (> 2.5 cm) requiring multiple sectioning can be particularly cumbersome and time-consuming for a Mohs laboratory and may contribute to an increased margin of human error in the production of quality frozen sections. The CryoHist machine, a device tailored to the Mohs frozen section laboratory, utilizes a vacuum and rapid freezing technique which enables high quality frozen sections to be processed in significantly less time than standard methods. In addition, its utility extends to the preparation of high quality, large (>2.5 cm) en bloc Mohs specimens, which eliminates the need to further divide specimens and results in added time savings and increased accuracy. The purpose of this study was to compare the amount of time it takes to process tissue specimens using the CryoHist, the Cryo cup, and the Miami special embedding techniques. In addition, the quality of slides for large Mohs surgery tissue specimens (> 2.5 cm) obtained using the CryoHist machine was determined.

Design:
Thirty Mohs tissue specimens measuring 1 cm in diameter were randomized to processing via the CryoHist, the Cryo cup, or the Miami Special. Times for embedding and cutting were recorded and slide quality was evaluated using quality control parameters such as stain quality, epidermal edge, specimen thickness and presence of air bubbles. In a separate evaluation, fifty consecutive en bloc Mohs surgery tissue specimens measuring greater than 2.5 cm, which had been processed using the CryoHist machine, were retrospectively examined for slide quality using the above parameters.

Summary:
The average embedding time was 0.75 minutes with the CryoHist machine, 1.6 minutes with the Cryo cup and 1.0 minutes with the Miami special. The average cutting time per method was 1.3 minutes with the CryoHist machine, 2.5 minutes with the Cryo cup, and 2.6 minutes with the Miami Special. The total average time per slide (including 8 minutes standard staining time and 30 seconds for coverslipping) was 10.6 minutes using the Cryo Hist, 12.6 minutes using the Cryo cup, and 12.1 minutes using the Miami Special. Slide quality among the three methods was comparable. For large (>2.5 cm) en bloc sections, the staining quality was excellent with an average of 92.3% skin edge obtained.

Conclusions:
The CryoHist machine contributes significant time savings in the processes of embedding and cutting Mohs surgery specimens and results in decreased overall slide processing times. In addition, slide quality with this method is excellent, even for larger specimens. The use of the CryoHist for processing larger specimens en bloc further increases time efficiency and slide accuracy by eliminating the need to further divide specimens.

120

PRESENTER: Kevan G. Lewis, MD

TITLE: A Meta-Analysis of Postoperative Bleeding in Anticoagulated Patients Following Cutaneous Surgery

AUTHORS: Kevan G. Lewis; Raymond G. Dufresne

Purpose:
Postoperative bleeding is an uncommon but well-known complication of cutaneous surgery. The frequency of bleeding in patients receiving anticoagulant therapy has not been firmly established and consensus on perioperative continuation of treatment is lacking. There is a paucity of data on the risk of bleeding complications associated with combination prescription anticoagulants and over-the-counter herbal agents with anticoagulant properties.

Design:
A PubMed search (1966 2005) was performed to identify controlled studies reporting bleeding complications among patients undergoing cutaneous surgery who were taking anticoagulant medications. Data on patient demographics, diagnosis, surgical procedure performed, prescription anticoagulant medications (aspirin, NSAIDS, warfarin, clopidogrel), over-the-counter herbal agents with anticoagulant properties, and the occurrence and severity of bleeding complications were extracted.

Summary:
A total of six studies representing 1372 patients met criteria for inclusion. Among patients taking aspirin or warfarin, 1.4% and 7.4% experienced a severe bleeding complication, respectively. Patients taking warfarin were nearly seven times as likely to have a moderate-to-severe bleeding complication compared to controls (OR 6.69, 95% CI 3.03-14.7), a statistically significant difference (p<0.001). Patients taking aspirin or NSAIDS were twice as likely to have a moderate-to-severe bleeding complication compared to controls (OR 2.0, 95% CI 0.97-4.14), a strong trend toward statistical significance (p=0.06). The largest study (n=653) in the literature reported that the frequency of patients taking warfarin, aspirin or NSAIDS (1.6%) who experienced severe bleeding complications was not significantly higher than control subjects (0.7%); this study achieved only 33% power, however. More than 2000 subjects would have been required to exclude chance as an explanation for the results. There were no studies in the literature that examined the effects of combination anticoagulant therapy or the effect of herbal agents on postoperative risk of bleeding.

Conclusions:
The results of this meta-analysis suggest that while low, the risk of bleeding among anticoagulated patients is higher than baseline. Adequately powered prospective studies are required to more carefully delineate the risk of postoperative bleeding attributable to anticoagulation therapy. Particular emphasis should be placed on examining the effect of combination anticoagulant therapy as well as herbal agents with anticoagulant properties on risk of bleeding after cutaneous surgery.

122

PRESENTER: Kishwer S. Nehal, MD

TITLE: Progress in Confocal Reflectance Microscopic Imaging of Basal Cell Carcinomas in Excised Mohs Surgical Specimens

AUTHORS: Kishwer S. Nehal, MD; Yogesh G. Patel, MS; Allan C. Halpern, MD; Milind Rajadhyaksha, MD

Purpose:
Recent studies have shown that confocal reflectance microscopy can image basal cell carcinomas (BCCs) in freshly excised Mohs surgery specimens. Rapid brightening of nuclei and enhanced detection of BCCs is achieved with acetowhitening: immersing the excision specimen in acetic acid for a short time. The acetic acid condenses the chromatin, which increases chromatin backscatter and brightens the nuclei in BCCs. Confocal reflectance microscopy may enable rapid detection of BCCs directly in Mohs surgical specimens, with minimal need for frozen histology, and thus may expedite Mohs surgery. Preliminary confocal imaging studies have shown that large foci of BCCs can be detected on excised Mohs surgery specimens, but further improvement and consistency in confocal imaging is necessary for useful clinical application.

Design:
To improve detection of BCCs, confocal reflectance instrumentation and imaging software were refined. Experiments to optimize the acetowhitening technique and enhance detection of BCCs were conducted using acetic acid concentrations from 1% to 10% and treatment times from 30 seconds to 5 minutes.

Summary:
Acetic acid experiments showed that effective acetowhitening can be achieved with 10% and 5% acetic acid concentrations in 30 seconds; 3% acetic acid in 1 minute; 2% acetic acid in 2 minutes; 1% acetic acid in 5 minutes. The most useful technique was 2% acetic acid for 2 minutes for optimal acetowhitening while minimizing acetic acid concentration and immersion time. Confocal instrumentation developments include a microscope mount for the Mohs surgical specimen which stabilizes the tissue analogous to Mohs embedding. Confocal imaging software has been enhanced and now displays a field-of-view of 15 mm, which is comparable to 2x magnification typically used for examining Mohs frozen histology. The improved confocal mosaic has greater resolution, allowing distinct visualization of the epidermis, dermoepidermal junction, and normal dermal structures as seen in routine frozen histology. At present, this confocal imaging technique requires 9 minutes compared to the 20-45 minutes typically required for processing of Mohs frozen histology. Comparison to Mohs frozen histology shows that large nodules of BCCs are easily and consistently detected with confocal microscopy. However, small aggregates of BCCs, such as micronodular and infiltrative, are not consistently visualized and tend to be obscured by surrounding dermal structures.

Conclusions:
Continued improvements in confocal instrumentation, image quality, and detection of BCCs suggest that confocal reflectance microscopy can potentially expedite Mohs surgery, reduce patient treatment times, and increase surgeon efficiency. Further work is necessary to enhance detection of small foci of BCCs relative to the surrounding dermal structures and may require supplemental imaging techniques.

123

PRESENTER: George Richard Nichols, MD

TITLE: Auricular Crusotomy For Enhanced Surgical Exposure

AUTHORS: George R. Nichols, MD; Mark A. Russell, MD

Purpose:
Tumors of the scaphoid fossa, triangular fossa, and superior concha are sometimes challenging to treat due to the complex topography of the ear. While tumors in these locations are relatively rare, they are commonly referred to Mohs surgeons for removal. We present an example of the successful use of the crusotomy technique for enhanced visualization and removal of a scaphoid fossa tumor.

Design:
We review a variation of the crusotomy technique with respect to tumor location, anatomic considerations, surgical technique, repair and cosmetic result.

Summary:
We present a case of an excision of a tumor in the scaphoid fossa facilitated by the crusotomy technique. Intraoperative and postoperative photographs demonstrate excellent surgical exposure, mapping, and cosmetic outcome

Conclusions:
The crusotomy technique is a simple, safe and effective surgical technique for poorly accessible tumors in the scaphoid fossa. This technique is also potentially useful for tumors located in the superior concha, triangular fossa, antihelix, and crura of the antihelix. The crusotomy improves surgical exposure and allows enhanced access for excision, repair, or use of other treatment modalities when encountering poorly accessible auricular tumors. The crusotomy is a valuable addition to the surgeon's armamentarium.

124

PRESENTER: John Perrotto, DO

TITLE: Using 3-D Imaging to Demonstrate the Unifocality of Melanomas

AUTHORS: John Perrotto, DO; Daniel Rivlin, MD

Purpose:
Twenty years ago many people thought that the collection of follicular germinative cells of superficial basal cell carcinomas, seen on H&E, were proof that the neoplasms were multifocal. Subsequent 3-D mapping of the nests debunked that myth. The goal of this study was to examine the nests of melanocytic neoplasms to see if the multifocality of the neoplasms truly is a myth. This study uses 3-D imaging of both melanomas and nevi to see if the melanocytic nests, which are separated in 2-D imaging (standard H&E sections) are really connected.

Design:
Six melanomas and three nevi were biopsied and fixed for permanent sections on paraffin block. Multiple serial sections, ranging anywhere from 60 to 150, were taken from each of these paraffin block samples. Photos were taken of each 2-D section and then melanocytic nests within these melanomas and nevi were mapped. 3-D imaging computer software was then utilized to reconstruct 3-D images of the melanocytic nests within these melanomas and nevi by superimposing the 2-D images, a process called segmentation.

Summary:
3-D imaging demonstrated six out of six melanomas and three out of three nevi had melanocytic nests, which were all connected.

Conclusions:
Melanocytic neoplasms (both melanomas and nevi) are unifocal neoplasms. The nests, which give the appearance of multifocality on standard H&E sections, are connected to each other. Therefore, the utilization of Mohs for melanoma should not be criticised on the basis that these neoplasms are multifocal.

125

PRESENTER: Michelle A. Pipitone, MD

TITLE: IRB Use Among Dermatology Researchers

AUTHORS: Michelle A. Pipitone, MD; Brian Adams; Hugh Gloster

Purpose:
Guided by the World Medical Association Declaration of Helsinki1 and the Belmont report2, researchers must submit protocols to an ethical review committee for intended research with human subjects. Many respected journals alert the researcher to the need for IRB (Institutional Review Board) review. Despite these reminders, dermatologists continue to note confusion. The aim of this study was to identify the frequency with which dermatologic surgeons were obtaining IRB approval for studies involving human subjects.

Design:
After obtaining IRB approval from the University of Cincinnati, the authors sent a four-item questionnaire regarding use of IRBs to all 800 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. In this questionnaire, respondents were asked to identify if they performed research with human subjects and if they had, how often they obtained IRB approval. Pure chart review was explicitly excluded from inclusion in terms of research" for simplicity purposes even though retrospective chart review should also be submitted for IRB approval, albeit "expedited review". "

Summary:
Of the 1,211 members solicited, 459 (37.9%) responded which is a typical acceptable response rate for a questionnaire of this type. Of the 459 respondents, 290 (63.2%) performed research on human subjects. Eighty-nine percent (N=257) of these researchers have sought IRB approval, while 11.1% (N=32) have never obtained IRB approval and 1 individual did not respond. Not all researchers who have sought IRB approval have done so all the time. Only 71% of researchers obtain IRB approval 100% of the time. The exact frequency of IRB use was unknown for four researchers so the number of overall researchers (the denominator) used for the percentage calculations in figure 1 was 286.

Conclusions:
Clearly, confusion exists regarding obtaining IRB approval for research involving human subjects and dermatology. Even though the Declaration of Helsinki1, the Belmont report2 and even journals instructions to authors are clear, researchers are not always obtaining IRB approval for their studies. Surprisingly 15% of researchers, in this study, obtain IRB approval less than a quarter of the time and shockingly, 11% of researchers never obtain IRB approval. Confusion may exist as a result of the perceived indeterminate area between clinical practice and research. While boundaries exist between practice and research, it is not uncommon to have the two approaches occurring at the same time. Clinicians, with intent to test hypotheses among patients while treating individual patients, should respect their patients' autonomy. This principle of respect for individuals demands that potential human subjects have the opportunity to give informed consent for participation in research, even research with no obvious risks, such as those involving anonymous questionnaires. There are several limitations of this study. There may be inherent bias as the 62% of individuals who failed to return the survey might differ from the proportion that returned it. This study also may not be generalizable to all dermatology researchers as only the 800 Mohs surgeon members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology were included. Lastly, the use of IRBs may be over-reported in this study because pure chart review was excluded from consideration of research. Researchers intent on performing research by utilizing charts from their practice also should obtain IRB approval (albeit, likely through expedited review). In conclusion, all researchers planning to perform research of any type which will involve human subjects should seek IRB (or its equivalent) approval. 1.

126

PRESENTER: Christopher R. Rouse, MD

TITLE: Correlation of Wood's Lamp and Histopathologic Assessment of Melanoma

AUTHORS: Christopher R. Rouse, MD; Scott Fosko, MD; M. Yadira Hurley, MD; Eddy Hsueh, MD; Evan Jones, MD; Summer Youker, MD; Cherise Cortese, MD

Purpose:
The clinical margin of a melanoma is currently determined with unaided, direct visualization. A Wood's lamp is a hand-held ultraviolet light source that enhances the contrast of a pigmented epithelial lesion, but not a pigmented dermal lesion. Some individuals have advocated Wood's lamp assessment of skin melanoma margins. However, it is unknown whether the melanoma margins delineated by Wood's lamp correspond with histopathologic tumor margins or not. The purpose of this study is to examine the correlation of Wood's-lamp-defined margins and the histopathologic assessment of melanoma.

Design:
This is a prospective study of melanoma patients (both invasive and in situ) defined by previous biopsy. During excision of the tumor, the perimeter of skin enhancement with Wood's lamp and the visible margin was surgically scored and later inked (two colors respectively). A wide local excision of the melanoma was performed, which included the visible and Wood's lamp margin within the specimen. Once sectioned, the slides were independently evaluated to determine those with both a visible score and a Wood's lamp score. These slides will be evaluated by a board-certified dermatopathologist or pathologist to determine the distance the tumor extends from the two scored margin lines, and any remarkable histopathologic feature differences between the margins.

Summary:
Twenty-six subjects with both invasive and in situ melanoma have been enrolled. Data is currently being evaluated.

Conclusions:
Deferred for results of data analysis.

127

PRESENTER: Eli R. Saleeby, MD

TITLE: Setting Up a Permanent Sections Laboratory

AUTHORS: Eli R. Saleeby, MD

Purpose:
To show members what is involved in starting a permanent sections laboratory

Design:
The equipment and personnel necessary to start a lab will be discussed. Cost will also be addressed.

Summary:
Setting up a permanent sections laboratory is a feasible project.

Conclusions:
Mohs surgeons, especially those in busy practices, should consider setting up their own laboratory.

128

PRESENTER: Patrick J Sniezek, MD

TITLE: High Viscosity Octylcyanoacrylate Tissue Adhesive Versus Traditional Sutures in Repairing Surgical Defects of the Face Following Mohs Micrographic Surgery.

AUTHORS: Patrick J. Sniezek, MD; Hobart Walling, MD, PhD; James DeBloom, MD; Christopher Arpey, MD; Duane Whitaker, MD


Purpose:
To compare aesthetic outcome and overall patient satisfaction between high viscosity octylcyanoacrylate tissue adhesive versus traditional sutured closure of surgical defects of the face repaired by primary linear closure following Mohs micrographic surgery

Design:
Patients with either biopsy-proven primary basal cell carcinoma or squamous cell carcinoma of the face, excised by Mohs technique, with wound lengths of at least 2 cm, were randomized with half of their excision site closed primarily with high viscosity octylcyanoacrylate tissue adhesive and the other half closed with traditional sutured closure (5-0 polypropylene). In each case, the entire dermis/subcutis was re-approximated with absorbable buried sutures (4-0 polyglactin-910). Standardized photographs were obtained three months post-procedure, and scar cosmesis was evaluated by comparing both halves of the scar by a blinded surgeon using a visual analogue scale. Patients also completed a patient satisfaction survey.

Summary:
Twelve patients were enrolled and completed all study endpoints. There were no intra- or post-operative complications. No significant differences in cosmetic outcome were appreciated between high viscosity octylcyanoacrylate tissue adhesive and traditional epidermal sutured closure by the operating physician or the patients evaluating three- month post-procedure photographs. All patients preferred the high viscosity skin adhesive closure for ease of postoperative care. The skin adhesive also required less application time compared to placement of epidermal simple interrupted sutures.

Conclusions:
In properly selected cases (surgical defects remaining within a facial cosmetic subunit and under minimal tension), high viscosity octylcyanoacrylate skin adhesive is a viable alternative to traditional epidermal sutures for surgical defects capable of primary multilayer repair following Mohs micrographic surgery. The use of tissue adhesive mandates meticulous placement of dermal sutures for proper wound edge eversion and alignment prior to its application, and may best be viewed not as a replacement, but rather an additional option in the surgeon's armamentarium for enhancing surgical efficiency and ease of postoperative care for both patient and physician while maintaining a cosmetically pleasing outcome.
Patrick Sniezek MD, Hobart Walling MD PhD, James DeBloom MD, Christopher Arpey MD, and Duane Whitaker MD have indicated no significant interest with commercial supporters.

129

PRESENTER: Patrick J. Sniezek, MD

TITLE: Discordance between preoperative biopsy specimen and microscopic findings at Mohs surgery

AUTHORS: Patrick J. Sniezek, MD; Michael J. Messingham, MD; Duane C. Whitaker, MD

Purpose:
Biopsy techniques employed most commonly in cutaneous oncology are shave (superficial incision) or incisional (deeper subtotal incision), with the latter performed with either punch or scalpel. There is no current consensus on which method is preferable in management of non-melanoma skin cancer. It is common anecdotal experience of Mohs surgeons that the biopsy specimen does not always reflect morphology of the tumor seen at deeper surgical stages. This adds a complicating factor to preoperative planning for the extent of surgery, time involved, dimension of defect, and complexity of repair.

Design:
Case logs were reviewed to collect data representing frequency and quality of variance in microscopic findings of basal cell carcinoma between initial biopsy and histopathologic examination at surgery.

Summary:
Variance from biopsy to surgery in microscopic finding represents a minority but significant portion of basal cell carcinoma seen in a referral practice.

Conclusions:
The large majority of basal cell carcinomas treated with Mohs surgery are in facial and critical anatomic locations. Consequently, the resultant surgical defect appears large, disfiguring, or both to the patient and family. More accurate preoperative predictability of outcome helps to prepare the patient and surgical team, thus increasing the likelihood of an optimal outcome. Strategies to obtain maximal information and reliability of biopsy information are analyzed.

130

PRESENTER: Benjamin A. Solky, MD

TITLE: Which Sunscreens Do People Prefer? A Split-Face Randomized Double-Blinded Study to Assess Facial Sunscreen Preferences

AUTHORS: Benjamin A. Solky, MD; Clark C. Otley, MD; Pamela K. Phillips, MD; Leslie J. Christenson, MD; Randall K. Roenigk, MD

Purpose:
A major impediment to sunscreen use is patient dislike of applying itto their facial skin. Little objective information is available for patients or physicians to guide them toward formulations that are most tolerable. To objectively quantify patient preferences with regard to facial application of sunscreen formulations in order to better recommend sunscreen to patients and improve sunscreen compliance. To evaluate factors which affect individuals willingness and ability to apply sunscreen on a regular basis.

Design:
A randomized, split-face, double-blinded study was performed with 131 subjects recruited at a transplant center fundraiser and at a local grocery store in Rochester, Minnesota. Participants completed a baseline survey, underwent application of sunscreen preparations in a split-face manner, and after 10-15 minutes, completed a post-application survey to assess preferences. All tested sunscreens were low-cost, widely available products that represented the various categories of formulations, including: alcohol-based spray (chemical); zinc oxide and dimethicone-containing face cream (chemical and physical); dimethicone-containing face cream (chemical); dimethicone-containing lotion (chemical); titanium-containing lotion 1 (physical); titanium-containing lotion 2 (chemical and physical); alcohol-based gel (physical). Statistical analysis of results was performed.

Summary:
When asked whether subjects would use a sunscreen again, the endorsements were significantly different between the formulations (p=0.004), with alcohol-based sprays being most likely to be used. 82% agreed with the statement that they would use the alcohol spray again, compared to 61% and 53% for sunscreens dimethicone-containing face cream and titanium containing lotion 1, respectively (p<0.0012). While there was a trend towards a better overall rating for alcohol spray and gel formulations, statistical significance was not achieved. When asked if a sunscreen was too greasy, alcohol spray sunscreen was felt to be less greasy than zinc oxide and demethicone-containing cream and titanium-containing lotions 1 and 2.

Conclusions:
In this study involving facial application of seven different sunscreen formulations, alcohol-based spray was rated as less greasy and having less tendency to leave a film. Participants were significantly more likely to report a willingness to use alcohol-based spray in the future. However, there was no significant differences in the overall ratings of various sunscreens. Recommending alcohol-based spray formulations of sunscreen to patients may lead to better compliance and, therefore, better protection from skin cancer and photo-aging.

131

PRESENTER: Andrea Willey, MD

TITLE: Biphenotypic Tumor with Squamous and Melanocytic Differentiation Demonstrating Ultrastructural Features of Malignant Melanoma

AUTHORS: Andrea Willey, MD; Scott Nelson; David Kist; Valda Kaye, MD

Purpose:
Cutaneous tumors with squamous and melanocytic differentiation have been rarely reported. Such tumors are of uncertain biologic behavior and must be distinguished from melanomas and pigmented squamous cell carcinomas. Of the six reported cases of such biphenotypic tumors, ultrastructural studies were performed on one. This tumor showed melanocytes without definite evidence of malignancy. In the present study, we describe a biphenotypic tumor that demonstrates ultrastructural atypia within the melanocytic component, which has not previously been reported.

Design:
The dermal tumor with focal attachment to an abnormal epidermis was composed of atypical epithelial cells with focal keratinization admixed with smaller atypical cells containing intracytoplasmic melanin. Immunohistochemical staining shows areas of strong reactivity with cytokeratins, admixed with cells staining positively with S-100, HMB45, Mart-1, and tyrosinase. Electron microscopy revealed numerous keratinocytes with desmosomes and tonofilaments containing melanosomes in all stages of development. Melanocytes were highly activated, containing numerous mitochondria, stage II melanosomes, and aberrant melanosomal forms.

Summary:
These histologic, immunotypical, and ultrastructural features are characteristic of malignant melanoma and raise the possibility that the melanocytic component of this tumor may exhibit biologic behavior characteristic of malignant melanoma.

Conclusions:
Electron microscopy may be valuable in the evluation of the melanocytic component of such rare biphenotypic tumors.

132

PRESENTER: Priya Zeikus, MD

TITLE: A Novel Flap for the Repair of Nasal Ala and Lateral Nasal Tip Defects

AUTHORS: Priya Zeikus, MD; Nathaniel Jellinek, MD; Mary Maloney, MD

Purpose:
The repair of defects occurring along the nasal ala and adjacent tissue can be difficult. Preservation of the alar rim, the alar grove, and the maintenance of skin color and texture are important factors that must be considered when designing the repair. We propose a novel method of alar reconstruction with an advancement flap that preserves this cosmetic unit in a one-staged, minimally invasive procedure.

Design:
The application of this flap is presented in a series of patients with up to 1cm defects of the nasal ala and lateral tip. The flap utilizes the alar and the nasal tip skin as a reservoir. The standing cone is removed first, parallel to the nasal ridge. This area is undermined and closed, which reduces the size of the original defect, leaving the inferior defect to close. An advancement flap is then designed either from the lateral tip or more medial ala. Given the sebaceous quality of the skin, this flap is sharply undermined with the scalpel blade to provide mobility and advanced to close the remainder of the defect. Care is taken in flap design to avoid buckling of the alar cartilage. Temporary flattening of the alar rim is tolerated, and returns to normal by two weeks postoperatively.

Summary:
Five patients who underwent repair using this flap technique had excellent cosmetic and functional outcomes without complications. Initial flattening of the alar rim was experienced at the time of surgery without alar buckling. By two weeks post-operatively, the ala had returned to its normal shape. The skin color and texture, the alar rim, and alar crease were maintained in each of the patients. No patients had functional breathing difficulty following this surgical repair.

Conclusions:
The nasal alar advancement flap is a novel reconstructive method to repair small, deep nasal ala and lateral tip defects. This flap has not been previously reported in the literature to our knowledge. This repair is a one-staged procedure that maintains the shape and contour of the alar crease and rim, with good cosmetic and functional results. Potential limitations of this flap can include buckling of the alar rim cartilage, and obliteration of the alar crease if the defect is too lateral or larger than 1cm.

LATE BREAKING 133

PRESENTER: Nicole Marie Annest, MD, M.S.

TITLE: Intralesional Methotrexate both as Monotherapy and as a Tumor Debulking Agent Prior to Mohs Micrographic Excision of Keratoacanthoma-Like Squamous Cell Carcinoma.

AUTHORS: Nicole M. Annest, MD; Christopher J. Arpey, MD; Duane C. Whitaker, MD

Purpose:
To elucidate the potential efficacy of a non-invasive treatment for cutaneous malignancy either as monotherapy or as an adjunct to surgical treatment.

Design:
Retrospective case series.

Summary:
Keratoacanthoma-like squamous cell carcinoma (KA-SCC) is a cutaneous tumor characterized by a rapid growth pattern, often leading to significant cutaneous deformity. KA-SCC commonly present in elderly, debilitated patients with multiple medical comorbidities, rendering them poor surgical candidates. In 1991, Melton et al. published a sentinel article demonstrating the efficacy of intralesional methotrexate (IL-MTX) in the treatment of keratoacanthoma. Our data from the University of Iowa Hospitals and Clinics (UIHC) provides the largest published series of keratoacanthoma cases treated with intralesional methotrexate. From 1992 to 2006, sixteen tumors (15 primary tumors and one recurrent tumor) in twelve patients were treated at UIHC. Treatment with IL-MTX provided an overall clinical cure rate of 81% (13 of 16 lesions). Tumor resolution was not achieved in 19% of lesions (3/16), requiring subsequent surgical intervention. Successfully treated patients required an average of 1.8 injections of MTX spaced an average of 22.2 days apart. The average total amount of MTX injected was 37mg. No patient required more than three total injections for any given site. In our series, the average patient age was 74 years, with 50% (8/16) of the treated tumors located on the head, 25% (4/16) located on the hand, and 25% (4/16) located on the anterior leg. None of the treated patients experienced any significant adverse treatment effects, including pain, infection, or cytopenias. Of the three tumors that did not resolve with IL-MTX, two were located on the face and one was a recurrent tumor on the hand. All treated tumors (16/16) improved after the first MTX injection, regardless of ultimate treatment outcome, however all of the overall treatment failures (3/16) failed to demonstrate continued tumor regression after a second and third intralesional injection.

Conclusions:
In conclusion, our data support previous case series and individual case reports demonstrating the use of MTX as a primary therapeutic modality in the treatment of KA-SCC. This provides an effective treatment option in patients with poor surgical candidacy. In addition, our data provide new insight into the utility of IL-MTX as an initial adjuvant tumor debulking agent prior to Mohs micrographic excision or other surgical extirpation of KA-SCC in all patients.

LATE BREAKING 134

PRESENTER: Jeremy Scott Bordeaux, MD, MPH

TITLE: The Mohs College Family Tree

AUTHORS: Jeremy S. Bordeaux, MD, MPH; Mary E. Maloney, MD

Purpose:
The Mohs College has grown, and continues to grow at an astounding rate. This 'Family Tree' will help preserve the rich history of the Mohs College.

Design:
The Mohs College membership directory, internet, and personal communication through electronic mail and telephone were all used to assemble The Mohs College Family Tree.

Summary:
The first formal meeting of the American College of Chemosurgery occurred at the annual AAD meeting in Chicago in 1967 with 23 attendees. With the 40th anniversary of that meeting approaching in one year, the Mohs College now boasts over 700 current members and over 70 fellowship training programs.

Conclusions:
The Mohs College is a growing, vibrant organization that continues to foster the development of physicians who provide the optimum care for patients with cutaneous malignancies.

LATE BREAKING 135

PRESENTER: Aimee L. Leonard, MD

TITLE: Large Mucosal Lip Defects: Management by Second Intention Healing

AUTHORS: Aimee L. Leonard, MD; C. William Hanke, MD

Purpose:
It is well recognized that small and superficial lip vermillion and mucosal defects heal rapidly with excellent cosmesis. We present a series of 25 patients who had intermediate and large Mohs surgical defects of the lip vermillion and mucosa, including those with extension to the orbicularis oris and to the cutaneous lip. These defects, which could have been surgically repaired, demonstrated superior results by second intention healing with minimal complications. The purpose of this study is to reinforce the advantages and indications of second intention healing for the lip, compared with surgical closure.

Design:
Patients included in this series underwent Mohs micrographic surgery for non-melanoma skin cancer involving lip vermillion and mucosa and were selected for second intention healing based on defect size and depth, as well as patient preference. Photos were taken pre-operatively and at an average of 4-6 weeks post-operatively. Patients were followed for the development of complications, such as difficulty with dysphonia, dysphagia, pain, infection, and bleeding. The time to reepithelialization was recorded as well as patient satisfaction with resultant function and cosmesis.

Summary:
Post-operative defects averaged 1.5 cm with a range in size from 0.7 to 3.2 cm. All patients in this series achieved good to excellent function and cosmesis by second intention healing. Complications such as dysphonia (0%), dysphagia (24%), pain (10%), infection (0%), and bleeding (24%) were minimal and short-lived. Time to complete reepithelialization averaged 25 days. Overall patient satisfaction was high. On a 5-point scale (1 = not satisfied at all, 5 = very satisfied), the average patient satisfaction with healing was 4.8, and with cosmesis was 4.5. One hundred percent of patients stated they would opt for second intention healing again in lieu of alternative surgical repair options for a similar lip defect.

Conclusions:
Second intention healing is a highly satisfactory option not only for superficial Mohs surgical defects, but also for selected large and deep defects of the lip mucosa and vermillion, including those extending to the orbicularis oris. Despite traditional wisdom which recognizes the importance of the free margin of the lip and asserts that defects crossing the vermillion and cutaneous lip subunits are poor candidates for second intention healing, our series demonstrates defects with minor cutaneous lip involvement can result in satisfactory cosmesis by granulation. This option simplifies the management of lip mucosal defects and has many advantages, making it an important alternative to surgical closure. Advantages include the achievement of good to excellent cosmesis, optimized surveillance for recurrences, minimal postoperative morbidity, low rate of complications, cost-efficacy, minimal restriction of patient activity, and simplicity of wound care.

LATE BREAKING 136

PRESENTER: Neda Mehr, BS

TITLE: Bowen's Disease and Risk of Subsequent Malignant Neoplasms: A Population-Based Cohort Study of 8,969 People in British Columbia.

AUTHORS: Neda Mehr, BS; Samireh Z. Said, MD; Alastair Carruthers, MD; Norman Phillips, MS; Laurence Warshawski, MD; David Zloty, MD; Richard P. Gallagher, MA, FACE.

Purpose:
To determine the risk of subsequent malignant neoplasm following the diagnosis of Bowen's disease in the British Columbia population.

Design:
Data were abstracted from the population-based BC cancer registry files, which include all incident cases of Bowen's disease between 1979 and 1994. Standardized incidence ratios, SIRs (i.e. the tario of observed divided by expected) and p-values were calculated for 40 outcome site groups in BC residents with Bowen's disease lesions of the skin.

Summary:
Among the 8,969 persons with incident Bowen's disease who were followed for a total of 65,037 person-years at risk, 1,316 subsequent cancers, excluding non-melanoma skin cancers, were observed versus 1,186 expected. Our data shows that following the diagnosis of Bowen's disease of the skin, the subsequent risk of lip cancer (SIR=2.94; 95% CI, 1.76-4.93; P=0.0003; n=14); larynx cancer (SIR=1.84; 95% CI, 1.17-2.90; P=0.01; n=18); trachea/bronchus/lung cancer (SIR=1.18; 95% CI, 1.03-1.34; P=0.02; n=222); basal cell carcinoma, BCC (SIR=2.89; 95% CI, 2.69-3.11; P=0; n=721); melanoma (SIR=3.34; 95% CI, 2.63-4.24; P=0; n=67); and chronic lymphocytic leukemia, CLL (SIR=160; 95% CI, 1.04-2.47, P=0.03; n=20) appear to be higher than the general population in BC.

Conclusions:
We conclude that patients with Bowen's disease are at a significantly increased risk of developing specific cancers. Based on physician judgment and clinical acuity, patients with a newly diagnosed BD lesion may benefit from a modest cancer work-up, including a screening blood test for CLL in those patients over 70 and close monitoring by a dermatologist aimed at the early detection of melanoma. The excess of cutaneous melanoma, BCC and lip cancers diagnosed within one year of Bowen's disease also suggest that a close, full-body skin examination should be conducted for simultaneously occurring skin caners.

LATEBREAKING 137

PRESENTER: Lucile E White, MD

TITLE: Topical 4% Aminocaproic Acid for Postoperative Hemostasis of Cutaneous Wounds

AUTHORS: Lucile E. White, MD; Mark T. Villa, MD; Simon S. Yoo, MD; Murad Alam, MD

Purpose:
Antifibrinolytic agents promote clotting by inhibiting fibrinolysis. Aminocaproic acid is an antifibrinolytic agent that binds to the lysine site on plasminogen and plasmin, preventing plasmin from binding to fibrin, thus, preventing clot dissolution. The purpose of this study was to develop a technique for obtaining post-operative hemostasis in large and/or deep cutaneous wounds with topical use of 4% aminocaproic acid in water.

Design:
Two alternate techniques were devised: (1) aminocaproic-acid-soaked gauze was applied directly to open wounds and covered with a pressure dressing (including dry gauze); (2) aminocaproic acid solution was mixed with collagen hemostat powder, and the resulting granular paste was applied to open wounds under a similar pressure dressing. Once these methods had been successfully used on four index patients, 89 patients were treated from December 2003 to February 2005 with one of the two methods described. Inclusion criteria were excessive intraoperative bleeding in the context of anticoagulation at the time of surgery with aspirin, clopidogrel (Plavix), or both, and also one of the following post-surgical states: (a) facial or lower extremity wounds greater than 3 cm in diameter; (b) facial or lower extremity wounds greater than 1.5 cm in diameter that were deep to fascia. In both cases (a) and (b), wounds were either left to heal by second intent or were pending reconstruction within 1-7 days. The first 24 enrolled patients treated were treated with method (1) and the remainder, with method (2). All enrolled patients were compared to age, sex, and anatomic site-matched controls treated from September 2002 to December 2003 with collagen hemostat alone.

Summary:
Outcomes were assessed for three groups: (1) 89 patients treated postoperatively with collagen hemostat alone; (2) 24 patients treated with aminocaproic acid alone; and 65 patients treated with aminocaproic acid and collagen hemostat. In group (1), 28 patients (29%) experienced partial or total saturation of their pressure dressing with blood or serosanguinous drainage within 24 hours, 8 (9%) bled through their bandages and had to change them at home or present to the office the next day for the same, and 5 (6%) presented to the emergency department overnight for management of slow but persistent bleeding. In group (2), the numbers were 4 (17%), 2 (9%), and 2 (9%), respectively. In group (3), the numbers were 8 (12%), 3 (5%), and 1 (1%).

Conclusions:
Topical use of 4% aminocaproic acid before applying a pressure dressing can reduce the risk of post-operative bleeding in anticoagulated patients with large or deep open cutaneous wounds. Topical aminocaproic acid may be even more effective when mixed with collagen hemostat prior to application. Possibly, the aminocaproic acid provides immediate hemostasis, and once the solution dries after several hours, any reinitiated bleeding is stopped by the then dry collagen hemostat.