FOR PHYSICIANS
Journal Club
Led by Dr. Ian Maher — a Professor, Director of Dermatology, and Mohs Fellowship Director at the University of Minnesota — the American College of Mohs Surgery's Virtual Journal Club meets each month to discuss the best new literature related to dermatologic surgery.
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May 2025
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- Article 1 take home points:
- NUM treated with MMS and MART-1 has low LR
- Precise MMS technique and anatomical knowledge is essential
- While MMS can spare bone amputation, it may need to be done for reconstruction especially if there is extension to volar surface or proximal distal joint
- Article 2 take home points:
- MMS superior to WLE for treatment of high-stage SCC and should be offered as first line
- MMS led to halving of 3-year cumulative incidence of recurrence, metastasis, and DSD
- Future research should continue to focus on exploring the role of adjuvant therapies and surveillance for recurrence in high-stage SCC
- Article 3 take home points:
- This study demonstrates excellent concordance between Mohs surgeon and dermatopathologist (95%, with the Mohs surgeon erring on the side of caution and taking an additional layer in the 2 cases in which there was discordance), serving as reassurance that with proper training, margin assessment by a surgeon performing MMS for MIS or LM using H&E and IHC is equivalent to dermatopathology assessment
- A combination of H&E and IHC stains (either MART-1 or SOX10) was the most useful for assessing margins of MIS for the Mohs surgeon
- Faster staining protocols and further studies at a larger scale are required to determine the technical standards of MMS for melanoma
- Article 4 take home points:
- PDS is associated with higher risk clinical features than AFX, including significantly higher incidence of PNI, preoperative area, and rate of recurrence
- Factors associated with increased risk of tumor recurrence or death: female gender, immunosuppression, PNI
- Patients with PDS have a much higher overall mortality rate of 60% compared with 26.5% in patients with AFX
- It is important to continue researching the pathophysiology of these malignancies to provide better treatment options
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Lydia Luu (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals:
- Article 1: Nail unit melanoma treated with Mohs micrographic surgery: Technique, local recurrence rate, and surgical outcomes
- Article 2: Mohs Surgery vs Wide Local Excision in Primary High-Stage Cutaneous Squamous Cell Carcinoma
- Article 3: Concordance Between a Mohs Micrographic Surgeon and Dermatopathologist on Margin Status for Melanoma In Situ and the Role of Immunohistochemical Stains
- Article 4: Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma: A Retrospective Review and Survival Analysis at a Single Academic Institution
April 2025
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- Article 1 take home points:
- This study successfully trained a machine learning segmentation model to automatically highlight the location of BCC on MMS frozen section slides
- Model sensitivity was higher for BCC subtypes with fewer individual foci
- Model specificity was higher for subtypes with many individual foci
- Novel performance metrics that are not so heavily influenced by BCC subtype are needed
- Future studies need to train models that reach near 100% accuracy and are externally validated before they can be used in clinical settings
- Article 2 take home points:
- More twists -> stronger knots
- Optimal knot security at 3-5 twists
- BUT more twists -> bulkier knots, higher variability in knot strength
- Poliglecaprone 25 more reliable than polyglactin 910 across all sizes
- More twists -> stronger knots
- Article 3 take home points:
- WW can be an adequate option, cost sparing and averting complications without detriment to patient health
- A skilled physical examination capable of distinguishing healthy scar tissue from residual SCC is crucial for selection which WW may yield a very low risk of local recurrence
- Larger, multicenter, randomized studies with long-term follow-up are needed
- Article 4 take home points:
- Potential association of ICI therapy, originally used in cancer treatment, with significant reduction of clinical AKs
- Observed reduction in cSCCs occurrence was not statistically significant
- Underscore ICIs potential as a novel approach to mitigating field cancerization in high-risk populations
Dr. Lydia Luu (University of Minnesota) and Dr. Igor Kapetanovic (University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals:
- Article 1: Deep Learning for Automated Segmentation of Basal Cell Carcinoma on Mohs Micrographic Surgery Frozen Section Slides
- Article 2: A New Twist on the Surgeon's Knot: Quantifying Suture Security
- Article 3: Oncologic outcomes for invasive squamous cell carcinoma with a clinically resolved biopsy site managed by watchful waiting: A retrospective cohort study
- Article 4: Immune Checkpoint Inhibitors in Field Cancerization and Keratinocyte Cancer Prevention
March 2025
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- Article 1 take home points:
- 9.4% of melanomas are upstaged from initial biopsy to definitive excision
- This upstaging may require further surgical or medical management, and may be associated with increased mortality
- It is important to obtain an adequate initial biopsy when suspicious for melanoma
- Article 2 take home points:
- There are differences in recurrence and survival outcomes between patients with NAAM vs DNAM
- Patients with NAAM are more likely to have melanomas on the sole, and exhibit longer RFS and OS compared to patients with DNAM
- Biological mechanisms behind these differences remain unclear and further basic research is needed
- Article 3 take home points:
- MCC-AJCC pathological staging criteria can risk stratify DSD better than OS
- Multiple patient and tumor features are predictive of DSD, beyond AJCC tumor features alone
- Incorporating these additional features into a multivariable FG model enhances the prognostic utility of current MCC staging
- Non-staging features should be considered in future research
- Article 4 take home points:
- It could not be concluded that SC + IMQ is non-inferior to SE, but SC + IMQ was substantially less effective than SE.
- Most treatment failures occurred in the first year after treatment
- Probability of tumor-free survival 5 years after treatment with SC + IMQ was still 77.8%
Dr. Lydia Luu (University of Minnesota) and Dr. Igor Kapetanovic (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals:
- Article 1: Tumor upstaging in invasive melanoma is associated with changes in clinical management and worse prognosis
- Article 2: Nevus-associated acral melanoma has lower risk of recurrence and mortality than de novo acral melanoma: A multicenter, retrospective analysis of 482 patients
- Article 3: A multivariable disease-specific model enhances prognostication beyond current Merkel cell carcinoma staging: An international cohort study of 10,958 patients
- Article 4: Imiquimod Cream Preceded by Superficial Curettage vs Surgical Excision for Nodular Basal Cell Carcinoma: A Secondary Analysis of a Randomized Clinical Trial
February 2025
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- Article 1 take home points:
- Earlier pedicle division did not have increased complications
- Differences in medical history between groups, though not statistically significant
- Potential to enhance quality of life for patients
- Article 2 take home points:
- Enhanced treatment response of SCCis with 5FU with longer treatment duration and smaller tumor size
- Article 3 take home points:
- Existing literature on this topic demonstrates conflicting results
- This study found no significant reduction in total MMS stages using dermoscopy and did not improve lateral/deep margin assessment
- There may be a role for other noninvasive imaging modalities, and future studies on these modalities could be helpful
- Article 4 take home points:
- Patients with lesions 0.8-mm to 1.0-mm thick had a significantly higher relative risk of melanoma-related death compared with patients with lesions smaller than 0.8 mm
- First analysis to use methods that take into account the competing risk of death from other causes
- The authors suggest that a change of the T1 threshold from 1 mm to 0.8 mm should be considered when the AJCC staging system is next reviewed
- Approximately 1 in 4 melanoma-related deaths occurred after 10 years, emphasizing the importance of long-term follow-up for patients with T1 melanomas
Dr. Katherine Thompson, Dr. Shanelle Briggs, and Dr. Daniel Knabel present the best dermatologic surgery relevant literature from the February Journals:
- Article 1: Accelerated Takedown of Melolabial Interpolation Flaps at 1 to 2 Weeks, Indications and Safety for Improved Patient Experience
- Article 2: 5-fluorouracil 5% cream for squamous cell carcinoma in situ: Factors impacting treatment response
- Article 3: Surgical Margins of Nonmelanoma Skin Cancers in Mohs Surgery: Dermoscopy Versus Naked Eye
- Article 4: Risk of Death Due to Melanoma and Other Causes in Patients With Thin Cutaneous Melanomas
January 2025
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- Article 1 take home points:
- Hemostasis with fewer limitations and reduced risk of bleeding vs. traditional methods
- Systematic review shows positive results in patient outcomes, reducing surgical time and increasing overall patient satisfaction
- Establishing standardized protocols and guidelines for use of TXA in MMS
- Article 2 take home points:
- EMPOWER-CSCC-1 is the largest prospective data set to date on long term efficacy and safety for an anti-PD1 therapy in advanced CSCC
- Cemiplimab provides clinically meaningful activity in both mCSCC and laCSCC as evidenced by ORR, DOR, and PFS
- Close monitoring of this patient population for AE is imperative
- Article 3 take home points:
- Mohs is a promising surgical approach for the treatment of malignant adnexal tumors of the skin.
- Article 4 take home points:
- N/A
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Lydia Luu present the best dermatologic surgery relevant literature from the January Journals:
- Article 1: Tranexamic Acid in Mohs Micrographic Surgery: A Systematic Review
- Article 2: A phase 2 open-label study of cemiplimab in patients with advanced cutaneous squamous cell carcinoma (EMPOWER-CSCC-1): Final long-term analysis of groups 1, 2, and 3, and primary analysis of fixed-dose treatment group 6
- Article 3: Enhanced Disease-Specific Survival Among Individuals With Malignant Adnexal Tumors of the Skin Treated With Mohs Surgery: A National Database Study
- Article 4: Efficacy of 0.25% Lidocaine Versus 0.5% Lidocaine in Dermatologic Surgery: A Double-Blind, Randomized Controlled Trial
December 2024
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- Article 1 take home points:
- N/A
- Article 2 take home points:
- N/A
- Article 3 take home points:
- N/A
Annie Wang (Hofstra University) presents the best dermatologic surgery relevant literature from the December Journals:
- Article 1: Low Rate of Upstaging of Melanoma in Situ When Central Debulk Sent for Permanent Sections During Mohs Micrographic Surgery
- Article 2: How dermatologic surgeons decide to proceed with surgery for nonmelanoma skin cancer when site identification is initially uncertain: A nationwide, multicenter, prospective study
- Article 3: Clinical Versus Histologic Margins for Cutaneous Squamous Cell Carcinoma: Comparing Outcomes for High-Risk Tumors Treated With Mohs Micrographic Surgery
November 2024
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- Article 1 take home points:
- DFSP incidence is 2-fold higher among Black individuals
- Risk of DFSP metastasis is significantly increased with tumor size < 3 cm and located on head and neck, and genitalia
- Larger tumor size (< 3 cm), regardless of location, and age (< 60 years) are the most important prognostic indicators of survival
- Article 2 take home points:
- See the Carroll manuscript for IHC validation tips.
- See the Etzkorn manuscript for operational tips.
- Repetitions with an experienced colleague helps perceive the trees (criteria) and forest (all together) of margin analysis.
- High quality slides and stain necessary for margin analysis accuracy.
- Article 3 take home points:
- Early water exposure in the immediate postoperative period does not lead to increased risk of infection, hematoma, or bruising
- Scar cosmesis is not compromised
- No significant difference in QoL
- Development of better evidence-based guidelines for immediate post-op care is needed
- Article 4 take home points:
- TM51614 in combination with nivolumab has an overall response rate of 25.9%
- It is well tolerated in anti-PD-1 Ab-refractory unresectable melanoma cohort
- Larger sample size and longer follow-up is needed for better assessment
Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Igor Kapetanovic (University of Minnesota) present the best dermatologic surgery relevant literature from the November Journals:
- Article 1: The epidemiology of dermatofibrosarcoma protuberans incidence, metastasis, and death among various population groups: A Surveillance, Epidemiology, and End Results database analysis
- Article 2: Mohs for Melanoma: A Review of MART-1 Frozen Section Interpretation
- Article 3: Early postoperative water exposure does not increase complications in cutaneous surgeries: A randomized, investigator-blinded, controlled trial
- Article 4: A phase II multicentre study of plasminogen activator inhibitor-1 inhibitor (TM5614) plus nivolumab for treating anti-programmed cell death 1 antibody-refractory malignant melanoma: TM5614-MM trial
October 2024
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- Article 1 take home points:
- RT+cemiplimab significantly improved PFS vs. cemiplimab alone in patients with la/mCSCC
- Further research needed to validate data from real-world studies
- Article 2 take home points:
- Save this article and study it before boards.
- Article 3 take home points:
- Skin grafts provide a versatile, reliable, and simple approach for reconstructing scalp defects
- FTSG can be used on exposed calvarium
- FTSG has increased graft take and decreased wound complications on exposed calvarium and intact pericranium vs. STSG
- Risk factors affecting outcomes: Grafting exposed bone, larger graft sizes, previous exposure to head and neck radiation, and immunosuppression
- Similar to study of Jiang et al analyzing FTSG on LE wounds after Mohs where 72/80 cases (90%) had full graft survival, 6/80 (7.5%) had partial failure, and 2/80 (2.5%) had complete failure. Complications included infections in 9/80 (11%) cases and hematoma formation in 2/80 (2.5%).
- Article 4 take home points:
- TXA safely reduced postoperative ecchymosis and edema
- Clinical superiority suggested with IV dosing
- Improved Early-Postoperative Experience
- Lower levels of postoperative edema and ecchymosis
- Faster recovery time
- Enhance patient satisfaction
- Intraoperative hemostasis
- Helps control bleeding during surgery
- Ensures a clear surgical field
- No adverse effects
- IV doses 1000mg
Dr. Igor Kapetanovic (University of Minnesota), Dr. Ian Maher (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Kathryn Shahwan (Ohio State University) present the best dermatologic surgery relevant literature from the October Journals.:
- Article 1: Previous radiotherapy increases the efficacy of cemiplimab in the treatment of locally advanced and metastatic cutaneous squamous cell carcinoma: A retrospective analysis
- Article 2: Histologic Hitchhikers: A Review of Common Exogenous Artifacts Encountered During Mohs Micrographic Surgery
- Article 3: Full-thickness versus split-thickness skin graft reconstruction of scalp defects with and without calvarium exposure
- Article 4: Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study
September 2024
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- Article 1 take home points:
- Findings suggest that a running SQ may result in a less noticeable scar when compared to a running HM at 3 months.
- Superior observer and patient overall opinion scores
- However, there were no significant differences in patient or observer POSAS scores
- The decision of suture technique should remain dependent on surgeon and patient preference.
- Maybe deep layer quality is a more significant contributor
- Findings suggest that a running SQ may result in a less noticeable scar when compared to a running HM at 3 months.
- Article 2 take home points:
- Patients diagnosed with AFX/PDS had an increased risk of developing subsequent SC when compared to the general population, especially SCC and BD and to a lesser extent BCC.
- Might reflect the similar pathogenesis of SCC/BD and AFX/PDS.
- Emphasizes the importance of proper instruction on UV-protection, self-examination and routine total body skin examination in patients with AFX/PDS, particularly in those with a history of SC.
- Article 3 take home points:
- There is no evidence that prior WLE meaningfully impacts SLNB in terms of false-negative findings or recurrence.
- There is mixed anecdotal data on the impact of large rotation flaps on SLNB accuracy.
- Further trials needed to evaluate this notion, especially with larger rotation flaps on the trunk.
- Article 4 take home points:
- NIT is given more selectively to clinical stage III patients with more advanced N category disease
- Despite significant differences in N category between groups there was no difference in OS observed at 3 years
- In subgroup analysis, NIT was associated with a survival advantage among N2/N3 patients
- The national data support the continued usage and study of NIT approaches in patients with high-risk resectable melanoma
- Article 5 take home points:
- SRT/eBT may very well have role in the skin cancer armamentarium
- They themselves are cheaper than traditional radiotherapy, can be offered in outpatient settings, and may offer a good alternative for non-surgical candidates
- However, in practice they are commonly bundled with codes of questionable value to patient care (e.g. ultrasound, hyperthermia, etc.)
- There is a limited amount of healthcare resources and a small number of individuals are going to make life tougher for the rest of us.
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the September Journals.:
- Article 1: Aesthetic outcome of running subcuticular suture versus running horizontal mattress suture in closure of linear wounds of the trunk and extremities: A randomized evaluator-blinded split-wound comparative effectiveness trial
- Article 2: The risk of subsequent skin cancer in patients with atypical fibroxanthoma or pleomorphic dermal sarcoma compared to the general population
- Article 3: Wide Local Excision Before Sentinel Lymph Node Biopsy in Melanoma
- Article 4: Sequencing of Immunotherapy and Outcomes in Operable Clinical Stage III Melanoma: A National Cohort Study
- Article 5: Volume and distribution of radiotherapy performed by dermatologists from 2016 to 2021: A national Medicare trend analysis
August 2024
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- Article 1 take home points:
- MMS seems to be the best active management strategy
- Lowest rate of recurrence or persistence in this review
- Majority of DTE on the face
- Frozen histology helpful in cases where BCC and MAC cannot be ruled out.
- Larger-scale studies necessary to improve understanding on outcomes of DTEs
- MMS seems to be the best active management strategy
- Article 2 take home points:
- BWM is a viable technique for nasal reconstruction after Mohs
- Can achieve definitive coverage in soft-tissue defects much larger than previously described.
- The use of ADM as an adequate departure from the traditional algorithm for nasal reconstruction.
- Patient selection important, must be accepting of a granulating wound scar.
- Helps to preserve future autologous reconstruction options
- Promotes tissue scaffolding that can facilitate reepithelization by secondary intent, or accept a subsequent skin graft, even in defects with exposed cartilage.
- Plan ahead as insurance coverage in the outpatient setting is varibale.
- BWM is a viable technique for nasal reconstruction after Mohs
- Article 3 take home points:
- AI applications currently being assessed for integration into MMS and dermatologic surgery for NMSC have the potential to improve the accuracy of tumor detection and enhance surgical planning
- Extent of these benefits is contingent upon the specific AI models, their integration into clinical workflows, and the quality of the underlying data sets.
- Methodological transparency of AI needed (disclosure of inclusion criteria of data sets, clear descriptions of the diversity and representativeness of this data with acknowledgement of potential biases, and a thorough assessment of performance metrics)
- Further research is warranted to establish standardized protocols and validate these findings across diverse clinical environments
- Article 4 take home points:
- Mohs surgeons steadily integrating IHC into clinical practice across all regions
- Adoption rates higher in the Northeast but volume greatest in the South and West
- Significantly higher utilization rates among ACMS members, recipients of MDS certification, and those in academics likely highlights the importance of formalized training and exposures in improving IHC comfort
- Recent IHC trends may permit approximation of future IHC adoption rates and further encourage training and educational experiences to drive comfort and proficiency among Mohs surgeons
Dr. Igor Kapetanovic (University of Minnesota) and Dr. Adam Mattox (University of Minnesota) present the best dermatologic surgery relevant literature from the August Journals.:
- Article 1: A Systematic Review of the Epidemiology, Clinical Characteristics, Treatment, and Outcomes for Desmoplastic Trichoepithelioma: Underscoring Mohs Micrographic Surgery in Management
- Article 2: Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience
- Article 3: Artificial Intelligence for Mohs and Dermatologic Surgery: A Systematic Review and Meta-Analysis
- Article 4: Growing Adoption of Immunohistochemistry by Mohs Micrographic Surgeons: A National Medicare Trend Analysis
July 2024
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- Article 1 take home points:
- Longer course based on ID literature showing lower bacterial counts with longer courses
- Could be useful in very compliant patients
- Article 2 take home points:
- MRI most common modality for detecting perineural spread, with high sensitivity
- CT most common for detecting bony invasion with high specificity and relatively high sensitivity
- US, PET-CT, and CT most commonly used to detect NM
- All perform reasonably well, but CT has the highest sensitivity and specificity
- US: low-risk and cost-effective, but highly operator dependent and less able to detect deeper nodes
- Imaging for DM is poorly studied
- Overall, imaging in CSCC appears to change management and improve outcomes
- Additional research is needed to develop practice guidelines
- Article 3 take home points:
- Watchful waiting for SCCIS with a clinically resolved biopsy site has a local recurrence rate of 4%
- Exercise caution in solid organ transplant recipients, tumors on the head/neck (especially vermilion lip or ear), and with positive deep biopsy margins
- Article 4 take home points:
- Local recurrence of invasive melanoma is significantly lower after MMS and staged excision with IHC as opposed to without IHC
- No statistical difference between IHC and H&E in regards to nodal or distal recurrence and disease-specific mortality
- Efforts should be made to implement IHC with MMS to improve patient outcomes and decrease local recurrence
- Prospective studies with uniform reporting and long-term follow-up needed
Dr. Ian Maher (University of Minnesota), Dr. Katie Shahwan (The Ohio State University) and Dr. Andrea Tan (The Ohio State University) present the best dermatologic surgery relevant literature from the July Journals.:
- Article 1: The Effect of Preoperative Chlorhexidine Gluconate Cleanse on Lower Extremity Surgical Site Infections: A Retrospective Cohort Study
- Article 2: Use of Imaging in Cutaneous Squamous Cell Carcinoma to Detect High-Risk Tumor Features, Nodal Metastasis, and Distant Metastasis: A Systematic Review
- Article 3: Oncologic Outcomes for Squamous Cell Carcinoma In Situ With a Clinically Resolved Biopsy Site Managed by Watchful Waiting
- Article 4: Intraoperative Immunohistochemistry During Mohs Micrographic Surgery and Staged Excision Decreases Local Recurrence Rates for Invasive Cutaneous Melanoma: A Systematic Review and Meta-Analysis
June 2024
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- Article 1 take home points:
- This doesn't count settlements which are the vast majority
- Consistent with previous studies risk points are:
- Being a male dermatologist
- Doing cosmetic procedures
- Doctors who are well liked by their patients are FAR less likely to be sued
- Article 2 take home points:
- MIS on head and neck requires larger margins to achieve clearance
- Cheek associated with larger subclinical spread
- Reinforces previous data
- Subtle differences expected with single center studies
- Article 3 take home points:
- Peer comparison and intervention can influence outliers
- Still relatively sticky. Not much movement.
- 0.16 stages/case improvement in outliers
- Also reduced stages in non-outliers
- Gross savings in inliers ~4x that in outliers.
- Even these marginal gains resulted in big $$ savings
- $80m over three-year period
- Article 4 take home points:
- Significant risk of SCC metastases for SOTR within 2 years of index SCC
- Holds with previous risk factors
- Clinical finding of ulceration also associated with risk
- Combination of ulceration and high stage had additive negative effect
- Identifies patients who should be monitored closely
- Potential area for study of interventions to improve outcomes for these patients
Dr. Ian Maher (University of Minnesota) presents the best dermatologic surgery relevant literature from the June Journals.:
- Article 1: Retrospective Analysis of US Litigations Involving Dermatologists From 2011 to 2022
- Article 2: Excision margins for melanoma in situ on the head and neck-A single-center 10-year retrospective review of treatment with Mohs micrographic surgery
- Article 3: 5-Year Follow-Up of a Physician Performance Feedback Report Intervention to Reduce Overuse and Excess Cost: A National Cohort Study
- Article 4: Cumulative incidence and risk factors for cutaneous squamous cell carcinoma metastases in organ transplant recipients: The Skin Care in Organ Transplant Patients in Europe-International Transplant Skin Cancer Collaborative metastases study, a prospective multicenter study
May 2024
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- Article 1 take home points:
- Updated staging during MMS is important
- Central debulks for cSCC >= 2 cm, poor diff, IS patients
- Upstaging during MMS occurs more commonly in SOC tumors
- Greater subclinical extension, results in more MMS layers
- No difference in rate of high-risk features in SOC cSCC
- Updated staging during MMS is important
- Article 2 take home points:
- Subq TXA without waiting period significantly decreases post-op ecchymosis in eyelid surgery but not intra-op bleeding
- The effect of TXA on non-ecchymosis bleeding complications are unknown
- Local TXA + 15 minute waiting period may reduce intra-op bleeding
- AEs/complications are extremely rare with subq TXA
- Subq TXA without waiting period significantly decreases post-op ecchymosis in eyelid surgery but not intra-op bleeding
- Article 3 take home points:
- Large lip repairs can be safely and effectively done under local anesthesia
- Complication rate ~8% actually low for literature averages
- Durable in smokers
- Durable to radiation
- Design keys flap width = defect height. Spilling past MLF > making the flap too narrow
- Really only need full thickness to ~oral commissure then just incise to prefascial plane ergo no risk of motor nerve injury
- Article 4 take home points:
- While a nicely presented article with rational approach, Dr. Demer's concerns about use of SRT for skin cancer treatment in the US persist
- Despite careful pt/tumor selection: recurrence rate 10%+ at 10 years
- Cost-effectiveness significantly overestimated
- If performed, consider: low risk tumor, elderly patient, non-surgical candidate, careful counseling, and hypofractionated course without image guidance
- Article 5 take home points:
- In otherwise immunocompetent patients with non-inflamed skin, prophylactic antibiotics may not be necessary
- There are no RCTs assessing the efficacy of antibiotic prophylaxis for prevention of bacteremia, IE, or PJI.
- Data is limited to small case series and prospective studies, many of which were published several decades ago.
- There is a need for further research and updated guidelines.
Dr. Anderson (University of Minnesota), Dr. Demer (Mayo Clinic College of Medicine and Science), Dr. Mattox (University of Minnesota), and Dr. Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals.:
- Article 1: Tumor size associated with upstaged cutaneous squamous cell carcinoma in patients with skin of color
- Article 2: Effect of Tranexamic Acid on Intra- and Postoperative Bleeding in Eyelid Surgery: A Prospective, Randomized, Multicenter, Double-Masked, Control Trial
- Article 3: Reconstruction of Broad Lower Lip Defects Using Karapandzic-Type Flaps
- Article 4: Superficial X-ray in the treatment of nonaggressive basal and squamous cell carcinoma in the elderly: A 22-year retrospective analysis
- Article 5: Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review
April 2024
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- Article 1 take home points:
- Discordance in interpretation of IS and variance of IS/VS diagnosis suggest that reviewing IS and VS is something that is reasonable to consider.
- The nastier something is on vertical sections the more likely you are to have to chase it on layers
- Learners like more information
- We’re always challenged to review each slide without bias
- Article 2 take home points:
- Staph aureus and Pseudomonas aeruginosa are the most common isolates and can occur in clinically infected or non-clinically infected wounds. Supports that these bacteria can be colonizers in some.
- Exception - MRSA was seen in only clinically infected wounds.
- Some clinically infected wounds just grew normal flora.
- Authors recommend that culture be collected if a wound is clinically infected, but not treat with oral antibiotics initially unless clinical concern for cellulitis. Authors suggest topical antibiotics (mupirocin and gentamicin) until culture data has returned.
- Article 3 take home points:
- Overall, patient-centered communication skills, referral to the surgeon by the patient’s physician or family and friends, and staff members who made a favorable impression were some of the most notable factors associated with patients’ confidence.
- Identifying characteristics that foster confidence can provide ways to strengthen patient–physician relationships (and health outcomes).
- Article 4 take home points:
- If you’re already doing CK-7 for EMPD, the protocol is the same for Sebaceous Carcinoma.
- Knowing the tumor’s CK-7 staining pattern on the original biopsy can help you determine its utility in each case.
- If CK-7 is not available on the biopsy tissue, a sharp debulk could be used as control tissue.
- Staining and lack of staining may aid in confirming positive and negative margins.
- Article 5 take home points:
- Mail vs mail + phone call had similar level of patients’ sense of preparedness
- Higher satisfaction ratings if additional pre-op phone call but satisfaction still high without phone call
- If it’s vital that patient has a driver home, might be worth while to have phone call in addition to mailed materials
Dr. Laura Archibald (University of Minnesota), Dr. Adam Mattox (University of Minnesota), and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the April Journals.:
- Article 1: Using Initial Biopsies and Vertical Sections to Improve Trainees' Confidence in Performing Mohs Surgery
- Article 2: Bacterial Organisms Colonizing Mohs Surgical Wounds Healing by Second Intention on the Lower Extremities: A Prospective, Controlled Study
- Article 3: Factors Influencing Patients' Confidence in Their Mohs Surgeons
- Article 4: Utility of Intraoperative Cytokeratin-7 Immunostaining During Mohs Micrographic Surgery for Sebaceous Carcinoma
- Article 5: A Comparison of Preoperative Telephone Call Versus Mailed Educational Materials on Patient-Reported Outcomes in Mohs Micrographic Surgery
March 2024
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- Article 1 take home points:
- mBCC is rare
- Consider salvage surgery + radiation for nodal mets
- 50% chance of CR
- For distant mets Hhi and immunotherapy are the first options in that order
- Long course
- Remission is unlikely
- Article 2 take home points:
- Useful tool for counseling patients
- Good reminder of MCC risk factors for those that have to take exams
- Article 3 take home points:
- Upstaging of cutaneous melanoma during MMS occurs at a low rate (2.3%)
- Authors say unclear why their rate is lower than previously published literature. Possibly earlier detection of melanoma, more accurate initial biopsies, or expedited surgery.
- Majority of those upstaged had either base transected or positive peripheral margin on original biopsy.
- No statistically significant demographic or tumor-specific risk factors for upstaging were identified.
- Upstaging of cutaneous melanoma during MMS occurs at a low rate (2.3%)
- Article 4 take home points:
- No significant difference in scar outcomes when comparing sutures vs sutures + cyanoacrylate
- No difference in rates of adverse events
- Not statistically significant but patients tended to prefer wound care on the cyanoacrylate side
- Article 5 take home points:
- Injection of a mixture of bleomycin and triamcinolone seems to be an effective therapy for treatment-resistant keloids. About 80% of patients had an excellent response.
- Very low recurrence rate (3.3%) at 6 months
- One-third of patients each experienced ulceration, hyperpigmentation, post-operative pain, and/or infection
Dr. Laura Archibald (University of Minnesota) and Dr. Ian Maher (University of Minnesota) present the best dermatologic surgery relevant literature from the March Journals.:
- Article 1: A multicenter real-world analysis of risk factors, therapeutics, and outcomes of patients with metastatic basal cell carcinoma
- Article 2: Merkel cell carcinoma recurrence risk estimation is improved by integrating factors beyond cancer stage: A multivariable model and web-based calculator
- Article 3: Pathologic Upstaging of Cutaneous Melanoma After Mohs Micrographic Surgery
- Article 4: Aesthetic outcome of intermediate closure versus intermediate closure followed by 2-octyl cyanoacrylate: A randomized evaluator-blinded split-wound comparative effectiveness trial
- Article 5: The Combined Application of Bleomycin and Triamcinolone for Treating Refractory Keloids
February 2024
Click for meeting recording and notes
- Article 1 take home points:
- Our current staging systems can be used to predict poor outcomes for non-head and neck CSCC
- Its performance is on-par with what is seen for head and neck CSCC
- Our current staging systems can be used to predict poor outcomes for non-head and neck CSCC
- Article 2 take home points:
- Delay of PORT is associated with increased LRR, usually outside radiation field
- Each week is a 20% increase in the rate of LRR
- Starting PORT within 8 weeks (ideally 2-3 weeks) reduces rate of LRR and DSD
- Delay of PORT is associated with increased LRR, usually outside radiation field
- Article 3 take home points:
- N/A
- Article 4 take home points:
- N/A
Dr. Aatman Shah and Dr. Kyle Rismiller present the best dermatologic surgery relevant literature from the February Journals.:
- Article 1: Performance of Staging Systems for Non-Head and Neck Cutaneous Squamous Cell Carcinoma
- Article 2: Increased risk of recurrence and disease-specific death following delayed postoperative radiation for Merkel cell carcinoma
- Article 3: Temporoparietal Fasciocutaneous Island Flap for Forehead and Anterior Scalp Reconstruction
- Article 4: Anatomic Location Influences Duration of Local Lidocaine Anesthesia in Dermatologic Surgery
January 2024
Click for meeting recording and notes
- Article 1 take home points:
- Excision of SCCIS with 5 mm margin has very high cure rates
- Rate of clearance with 4 weeks of 5-FU was 85% (c/w past literature)
- Non-inferiority studies need to be big to achieve a useful margin of non-inferiority
- Topical 5-FU remains a reasonable treatment options for low risk tumors in patients willing to accept a lower cure rate to avoid surgery
- Doing this with 2 groups would have improved the non-inferiority margin (also would have made a positive study less likely)
- Article 2 take home points:
- NOAC monotherapy does not have an increased bleeding risk
- Combo therapy does
- Supports continuation of therapy
- ~1/1000 risk of serious event if discontinue anticoagulation
- Potential tailoring of regiment should be done in consultation with prescribing doctor
- Article 3 take home points:
- CAPABLE survey offers a succinct, practical method to assess multiple aspects of the postoperative patient experience
- Incorporation of the CAPABLE survey in Mohs surgical centers has the potential to improve patient experience and satisfaction
- Article 4 take home points:
- Both STSG and SIH can be great options for defects on the cartilaginous ear.
- Favorable scar outcomes, minimal complications, well-tolerated
- Patients who underwent STSG had increased pain in the first 3 days after surgery but had faster healing time compared to SIH
- For majority of patients with STSG, pain still only mild to moderate
- Both STSG and SIH can be great options for defects on the cartilaginous ear.
Dr. Ian Maher and Dr. Laura Archibald present the best dermatologic surgery relevant literature from the January Journals.:
- Article 1: Surgical excision versus topical 5% 5-fluorouracil and photodynamic therapy in treatment of Bowen's disease: A multicenter randomized controlled trial
- Article 2: Postoperative Bleeding Complications Associated With Novel Oral Anticoagulants in Mohs Micrographic Surgery
- Article 3: CAPABLE: A Scoring System Utilizing Patient-Reported Measures to Evaluate Patient Experience After Mohs Surgery
- Article 4: Assessment of Pain, Healing Time, and Postoperative Complications in the Healing of Auricular Defects After Secondary Intent Healing Versus Split Thickness Skin Graft Placement
To view earlier recordings in the Journal Club archive, click the desired year below.
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Invitations to join each Journal Club meeting are sent to an opt-in mailing list. To receive invitations to future Journal Club meetings, email Kira Burk at kburk@nm.org.