Research Abstract Session – Friday, April 30: 7:15 – 8:45 am

7:17 – 7:25 am Summary: Of the forty patients enrolled in the study Presenter: Cort McCaughey 25/40 (62.5%) were completely concordant meaning that either no residual tumor was seen or residual tumor was Title: A Concordance Study Comparing Histology identified in the same locales between the two parties Reports from Permanent Sections and Frozen with a 95% confidence interval of 45.8%-76.8%. 12/40 Sections for Staged Surgical Excisions for Lentigo (30%) patients were incompletely concordant meaning Maligna that there was incomplete agreement between the two maps but without the consequence of leading to a Cort McCaughey3; Mark Hyde, MMS, PA-C1; Authors: differing surgical/treatment recommendation with a 95% Scott Florell, MD2; Anneli Bowen, MD2; Glen M. Bowen, confidence interval of 17.1%-46.7%. 3/40 (7.5%) patients MD1, 2 were completely discordant as there was disagreement Institutions: 1. Melanoma and Cutaneous Oncology, between the two maps and therefore led to differing Huntsman Cancer Institute at the University of Utah, clinical decisions with a 95% confidence interval of 2.0%- Salt Lake City, UT, United States 2. Department of 21.5%. Of the 3 cases of complete disconcordance, 2 , University of Utah, Salt Lake City, UT, United (5%) were thought to be over-read by the Mohs surgeon States 3. School of Medicine, University of Utah, Salt Lake when comparing immunostains with permanent sections City, UT, United States and additional unnecessary surgical stages were taken and 1 (2.5%) was under-read by the Mohs surgeon and Purpose: Staged excisions for lentigo maligna (LM) required the patient to have additional tissue excised. and lentigo maligna melanoma (LMM) are generally This under-read case had a nidus of invasion that on done with either overnight rush permanent sections frozen immunostaining was interpreted as a compound or with frozen sections frequently augmented with nevus by both the Mohs surgeon and a consulted immunostaining such as MART-1/Melan-A. Proponents of dermatopathologist but was called invasive melanoma permanent sections argue that frozen sections lack the by the two dermatopathologists in this study who viewed ability to capture cellular detail to the degree that can the permanent sections of that specimen. This failure to be rendered with permanent sections. To date there are distinguish between invasive melanoma and a benign no published studies comparing the two techniques within compound nevus was attributed to the lack of cellular the same tumors. We sought to ascertain whether tumor detail in the frozen sections making the theques more margins determined at the time of using frozen banal in appearance than was more obvious with tissue immunostained with a melanoma-specific antibody permanent sections. was equivalent to the accuracy of standard overnight permanent sections in the detection of margins of LM/ Conclusion: The inter-observer concordance rates LMM. between the Mohs surgeon viewing frozen sections with H and E and immunostaining with Melan-A and two Design: Forty patients with biopsy proven LM/LMM dermatopathologists looking at permanent sections were prospectively enrolled in the study. Each patient with H and E compares favorably with prior published underwent a staged excision beginning with two studies of inter-observer concordance rates between millimeter margins if they had been previously treated dermatologists viewing permanent sections for LM/LMM. with imiquimod 5% cream and five millimeter margins if Permanent sections were superior in quality with regards they had not been pretreated beyond the visible tumor to cellular detail that could not be reproduced with frozen observed with a Wood’s lamp. The excised tumor was sections. Frozen sections stained with Melan-A provide divided into sixteen radial pie-wedge sections, with odd a good method of evaluating the quantity and pattern sections submitted for frozen sections, and opposing of melanocyte distribution in LM/LMM but in specific even sections submitted for permanent sections. Care circumstances, the inability to assess cellular detail with was taken to make sure cuts were made from opposing frozen sections can present a serious pitfall. In such cases of the tissue to optimize the observation of the it seems that the Mohs surgeon is well served to error on same tissue area with both techniques. A negative the side of caution, especially with regards to potential control from sun-damaged was taken and stained invasion. with Melan-A in all cases to give a picture of background melanocytic hyperplasia in an uninvolved site. Two 7:25 – 7:33 am dermatopathologists interpreted the permanent Presenter: Kavitha K. Reddy, MD sections while the Mohs surgeon interpreted the frozen sections of hematoxylin-eosin (H and E) staining as well Title: Cost-effectiveness of Non-melanoma Skin as Melan-A immunostaining. The results were recorded Cancers Treated with Mohs Micrographic Surgery with each group blinded to the others’ interpretation. versus Traditional Surgical Excision with Permanent Once the tumor maps were completed, the final Sections and Excision with Intraoperative Frozen maps were compared and concordance rates were Sections calculated. Concordance rates were based on complete concordance (maps and recommendations identical), Authors: Kavitha K. Reddy, MD1; Emily P. Tierney, MD1; incomplete concordance (map disagreement but Alexa B. Kimball, MD, MPH2; C. William Hanke, MD3 surgical recommendations identical), and complete 1. Dermatology, Boston University School discordance (map and surgical recommendation Institutions: of Medicine, Boston, MA, United States 2. Dermatology, disagreement). Harvard Medical School, Boston, MA, United States 3. Laser and Skin Surgery Center of Indiana, Carmel, IN, United States Research Abstract Session – Friday, April 30: 7:15 – 8:45 am

Purpose: Analysis of the existing literature on efficacy Conclusion: Analysis of the existing literature on efficacy of Mohs micrographic surgery (MMS) relative to surgical of MMS relative to surgical excision confirms the value excision confirms the value of MMS in obtaining both of MMS in obtaining both the highest initial cure rates the highest initial cure rates and lowest recurrence and lowest recurrence rates. We found MMS to be cost rates. In the current health care climate, cost-effective effective for tumor removal, where the incremental costs treatment of non-melanoma skin cancer is an increasingly of MMS associated with one percentage point reduction important issue. Identification of treatments that provide in recurrence rate ranged from $0.99 to $44. Future cost the greatest reduction in morbidity and mortality effectiveness analysis demonstrating the outcomes based and maximize outcomes with reasonable associated efficiency of MMS are critical in the current health care incremental cost is of benefit to patients. We set out to climate with heightened sensitivity to financial pressures compare the incremental cost-effectiveness ratio (ICER) and declining reimbursement rates which challenge our of Mohs micrographic surgery (MMS) with traditional ability to provide patients with the most optimal treatment surgical excision (TSE) and excision with intra-operative for NMSC. frozen sections (EIOFS) in the treatment of non-melanoma skin cancers (NMSC). 7:33 – 7:41 am Presenter: Natalie M. Curcio, MD, MPH Design: Cost-effectiveness analysis was performed for treatment of facial non-melanoma skin cancers (primary Title: Mortality Due to Skin Cancer after First and basal cell carcinoma (BCC) < 2 cm, primary BCC > 4 Second Renal Transplants cm, recurrent BCC, primary squamous cell carcinoma Authors: Natalie M. Curcio, MD, MPH1; Li Wang, MS2; (SCC) < 2 cm, primary SCC > 4 cm, high-risk SCC (ear), 1 and recurrent SCC), with MMS, TSE, or EIOFS. For MMS Thomas Stasko, MD and EIOFS, repair modalities of complex linear closure Institutions: 1. Dermatology, Vanderbilt University, (CLC), adjacent tissue transfer (ATT), full thickness skin graft Nashville, TN, United States 2. Biostatistics, Vanderbilt (FTSG), island pedicle (IP), and granulation were analyzed. University, Nashville, TN, United States For TSE, complex linear closure only was analyzed, consistent with standard practice. Costs were calculated Purpose: In the renal transplant population cutaneous utilizing CPT codes and reimbursement data from the malignancies are more frequent, more aggressive, and American Medical Association 2009 RUC Database. The carry an increased risk of death. Dermatologists are multiple surgery reduction rule was applied. Effectiveness frequently asked for an opinion as to the advisability was defined by 5-year cure rate as derived from meta- of a second renal transplant in a graft recipient with analysis by our group of Pubmed literature reviewing over a history of skin cancer and a failing transplant. The 250 studies reporting recurrence rates of non-melanoma purpose of this study was to determine whether the skin cancer after Mohs micrographic surgery and excision. intense immunosuppression required after a second renal Incremental cost-effectiveness ratios (ICERs) were then transplant increased the risk of death from cutaneous calculated from the cost-effectiveness data according malignancy vs. the risk after only one transplant. We also to methodology described by the Centers for Disease intended to identify what types of skin cancer most often Control. lead to mortality in the renal transplant population and to determine howG:\Mohs\Annual long after Meeting\P transplantublications\2010\Final death occurs. Program\2010 Draft Final program Copy.doc Summary: When comparing tumor removal with MMS to TSE with permanent section margins, incremental costs of MMS associated with one percentage point reduction in recurrence rate (ICERs) were: BCC < 2 cm $3.28 per additional 1% recurrence rate reduction, BCC > 4 cm $44.15, recurrent BCC $1.11, SCC < 2 cm $2.62, SCC > 4 cm $15.16, high-risk SCC $0.99, and for recurrent SCC $0.99. When comparing tumor removal with MMS to TSE with permanent section margins, incremental costs of MMS associated with avoidance of one tumor recurrence (ICERs) were: BCC < 2 cm $328 per recurrent tumor avoided, For BCC > 4 cm $4415, recurrent BCC $111, SCC < 2 cm $262, SCC > 4 cm $1516, high-risk SCC $99, and for recurrent SCC $99. When MMS was compared to excision with intra-operative frozen sections (EIOFS), MMS was lower in cost for all tumor types and sizes, given the higher costs for ambulatory surgery center fees and more costly pathology fees associated with EIOFS. When the cost of repair was added to the cost of tumor removal, the incremental cost of MMS became larger with flap and graft repairs. However, for large and high Figure 1: Kaplan-Meier estimate for patients who died from skin cancer (one transplant vs. two risk tumors, the increased effectiveness of MMS relative transplants).Figure 1: Kaplan-Meier estimate for patients who died from skin to excision lead to lower incremental cost per recurrent cancer (one transplant vs. two transplants). tumor avoided for all repair modalities. Table 1: Skin Cancer Causes of Death by Incidence Types of Skin Cancer Cases (N) Percent (%) Squamous Cell Carcinoma 120 38 Melanoma 90 29 Merkel Cell Carcinoma 42 13 Skin Cancer 24 7.6 Head and Cancer 23 7.3 Sarcoma 5 1.6 Anogenital Cancer 4 1.3 Basal Cell Carcinoma 3 0.95 Kaposi Sarcoma 2 0.63 Spindle Cell Carcinoma 2 0.63 TOTAL 315 100

7:41 – 7:49 am Presenter: Howard W. Rogers, MD, PhD Title: Incidence Estimate of Non-melanoma Skin Cancer in the United States, 2006 1 2 2 Authors: Howard W. Rogers, MD, PhD ; Martin Weinstock, MD, PhD ; Ashlynne Harris, MSIV ; Michael Hinckley, MD3; Steven Feldman, MD, PhD3; Alan B. Fleischer, Jr., MD3; Brett M. Coldiron, MD, FACP4 Institutions: 1. Advanced Dermatology, Norwich, CT, United States 2. Brown Medical School, Providence, RI, United States 3. Wake Forest University School of Medicine, Winston-Salem, NC, United States 4. University of Cincinnati Hospital, Cincinnati, OH, United States

Purpose: To estimate the incidence of non-melanoma skin cancer in the United States population in 2006.

Design: This is a cross sectional study employing multiple US government data sets including the

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Figure 1: Kaplan-Meier estimate for patients who died from skin cancer (one transplant vs. two transplants). Research Abstract Session – Friday, April 30: 7:15 – 8:45 am Table 1: Skin Cancer Causes of Death by Incidence Types of Skin Cancer Cases (N) Percent (%) transplants who died of skin cancer (log rank test, p < Squamous Cell Carcinoma 120 38 0.001). According to the Cox proportional hazards model, Melanoma 90 29 the estimated risk of death in patients with one transplant is 1.94 times that of patients with two transplants (p = Merkel Cell Carcinoma 42 13 0.003). Skin Cancer 24 7.6 Conclusion: In the UNOS database population there Head and Neck Cancer 23 7.3 is no significant increase in skin cancer mortality after a second renal transplant. However, it is likely that the Sarcoma 5 1.6 absolute incidence of skin cancer death among the Anogenital Cancer 4 1.3 renal transplant population is underrepresented due to under-reporting and a lack of standard terminology in Basal Cell Carcinoma 3 0.95 the database. Kaposi Sarcoma 2 0.63 7:41 – 7:49 am Spindle Cell Carcinoma 2 0.63 Presenter: Howard W. Rogers, MD, PhD TOTAL 315 100 Title: Incidence Estimate of Non-melanoma Skin Cancer in the United States, 2006 Table 1: Skin Cancer Causes of Death by Incidence Authors: Howard W. Rogers, MD, PhD1; Martin 7:41 – 7:49 am Weinstock, MD, PhD2; Ashlynne Harris, MSIV2; Michael Howard W. Rogers, MD, PhD Design:Presenter: We conducted a retrospective case-series using Hinckley, MD3; Steven Feldman, MD, PhD3; Alan B. theTitle: United Incidence Network Estimate for Organ of Sharing Non-melanoma (UNOS) database. Skin Cancer in the United3 States, 2006 4 1 Fleischer, Jr.,2 MD ; Brett M. Coldiron, MD,2 FACP Patients,Authors: both Howard living andW. Rogers, deceased, MD, who PhD received; Martin only Weinstock, MD, PhD ; Ashlynne Harris, MSIV ; Michael renalHinckley, transplants MD3; fromSteven 1987 Feldman, to 2008, wereMD, PhDincluded3; Alan in B.the Fleischer, Institutions: Jr., MD3; Brett1. Advanced M. Coldiron, Dermatology, MD, FACP Norwich,4 CT, United States 2. Brown Medical School, Providence, RI, study.Institutions: We used 1.primarily Advanced descriptive Dermatology, statistics Norwich, to analyze CT, United States 2. Brown Medical School, patientProvidence, demographics, RI, United geographical States 3. Wake distribution, Forest Univercausessity SchoolUnited ofStates Medicine, 3. Wake Winston-Salem, Forest University NC, School United of Medicine, Winston-Salem, NC, United States 4. University of Cincinnati ofStates death 4. due University to malignancy of Cincinnati and skin Hospital, cancer, Cincinnati, and time OH, United States to death. A Kaplan-Meier estimate and Cox proportional Hospital, Cincinnati, OH, United States hazards model were used to analyze survival. Purpose: To estimate the incidence of non-melanoma skinPurpose: cancer inTo the estimate United the States incidence population of non-melanoma in S2006.ummary: Between October 1, 1987 and May 16, skin cancer in the United States population in 2006. 2008, there were 255,115 patients who underwent renal Design: This is a cross sectional study employing transplants in the United States, with 231,418 patients Design: This is a cross sectional study employing multiplemultiple US government US government data sets data including sets including the the Centers receiving kidney-only transplants. Of these patients, for Medicare and Medicaid Services Fee-for-Service 214,141 received a single renal transplant and 17,227 Physicians Claims databases to calculatePage 39 totals of 114 of skin received two renal transplants. The median age at first cancer procedures performed for Medicare beneficiaries transplant for patient receiving one transplant is 47 years in 1992 and from 1996 to 2006 and related parameters. vs. 33 years for patients with two transplants. For both The National Ambulatory Medical Care Service database groups, approximately 60% of patients were male and was used to estimate non-melanoma skin cancer related nearly 90% were Caucasian. office visits. We combined these to estimate totals of new During the period analyzed, 19.4% of patients died. Of skin cancer diagnoses and affected individuals in the the 44,849 deaths, 2,909 were due to malignancy and overall US population. 315 of those were due to skin cancer. The three leading Summary: The total number of procedures for skin causes of death from cutaneous malignancy were cancer in the Medicare fee-for-service population squamous cell carcinoma, melanoma, and Merkel cell increased by 77% from 1,158,298 in 1992 to 2,048,517 in carcinoma, respectively. See Table 1 for the full list of skin 2006. The age-adjusted procedure rate per year per cancers contributing to death after transplant and their 100,000 beneficiaries increased from 3514 in 1992 to 6075 incidences. The median age at first transplant of patients in 2006. From 2002 to 2006 (years in which the databases who died from skin cancer was 54 years for patients with allow procedure linkage to patient demographics and one transplant compared to 47.5 years for those with 2 diagnoses), the number of procedures for non-melanoma transplants. Males comprised 80% of patients with one skin cancer in the Medicare population increased transplant who died from skin cancer, but only 67% of by 16%. In this period, the number of procedures per those with two transplants. Caucasians comprised 98% affected patient increased by 1.5%, and the number of and 100% of the patients with one and two transplants, persons with at least one procedure increased by 14.3%. respectively. We estimate the total number of non-melanoma skin When analyzing time to death for patients who died of cancers in the US population in 2006 at 3,507,069 and the skin cancer, patients who underwent one renal transplant total number of persons in the US treated for NMSC at died an average of 7 years after transplantation. Patients 2,152,500. who underwent two renal transplants died an average of 11.3 years after their first transplant and 5.5 years after Conclusion: The number of skin cancers in Medicare their second transplant. Figure 1 depicts a Kaplan-Meier beneficiaries increased dramatically over the years estimate of time to death for patients with one vs. two 1992 to 2006, due mainly to an increase in the number G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc Centers for Medicare and Medicaid Services Fee-for-Service Physicians Claims databases to calculate totals of skin cancer procedures performed for Medicare beneficiaries in 1992 and from 1996 to 2006 and related parameters. The National Ambulatory Medical Care Service database was used to estimate non- melanoma skin cancer related office visits. We combined these to estimate totals of new skin cancer diagnoses and affected individuals in the overall US population.

Summary: The total number of procedures for skin cancer in the Medicare fee-for-service population increased by 77% from 1,158,298 in 1992 to 2,048,517 in 2006. The age-adjusted procedure rate per year per 100,000 beneficiaries increased from 3514 in 1992 to 6075 in 2006. From 2002 to 2006 (years in which the databases allow procedure linkage to patient demographics and diagnoses), the number of procedures for non-melanoma skin cancer in the Medicare population increased by 16%. In this period, the number of procedures per affected patient increased by 1.5%, and the number of persons with at least one procedure increased by 14.3%. We estimate the total number of non-melanoma skin cancers in the US population in 2006 at 3,507,069 and the total number of persons in the US treated for NMSC at 2,152,500.

Conclusion: The number of skin cancers in Medicare beneficiaries increased dramatically over the years 1992 to 2006, due mainly to an increase in the number of affected individuals. Using nationally representative databases, we provide evidence of much higher overall totals of skin cancer diagnoses and patients in the United States population than previous estimates. These data give the most complete evaluation to date of the under recognized epidemic of skin cancer in the United States.

7:49 – 7:57 am Presenter: Joshua Spanogle, MD Title: Risk of Second Primary Malignancies Following Cutaneous Melanoma Diagnosis: A Population-based Study 1, 2 3 3 1, Authors: Joshua Spanogle, MD ; Christina Clarke, PhD, MPH ; Sarah Aroner ; Susan M. Swetter, MD 4 Institutions: 1. Dermatology, Stanford University Medical Center, Stanford, CA, United States 2. Dermatology, Mayo Clinic, Rochester, MN, United States 3. Northern California Cancer Center, Fremont, CA, United States 4. Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States

Purpose: To describe incidence patterns of second primary malignancies (SPMs) occurring after cutaneous melanoma (CM).

Design: Using the Surveillance, Epidemiology and End Results (SEER) program data from 1973-2003, we calculated incidence rates and relative risks for the development of 65 different SPMs occurring in 16,591 CM survivors and over 1.3 million person-years of observation.

Summary: Characteristics for all patients with CM and for those who had at least one SPM are shown in Table 1. Compared with the general population, CM survivors had a 32% higher risk of developing any SPM and demonstrated significantly elevated risks for 13 cancers: melanoma of the skin (SIR 8.99), soft tissue (SIR 2.80), melanoma of the eye and orbit (SIR 2.64), non-epithelial skin (SIR 2.31), salivary gland (SIR 2.18), bone and joint (SIR 1.70), thyroid (SIR 1.90), kidney (SIR 1.29), chronic lymphocytic leukemia (SIR 1.29), brain and nervous system (SIR 1.31), non-Hodgkin lymphoma (SIR 1.25), prostate (SIR 1.13), and female breast (SIR 1.07) (Table 2; only statistically significant data shown). Risks of second primary melanoma of the skin, melanoma of the eye and orbit, and cancers of the prostate, soft tissue, salivary gland, bone and joint were elevated throughout the study period, implying no surveillance bias (Table 2).

Conclusion: The increased risks for developing particular SPMs after CM may be explained by surveillance bias or shared risk factors. However, these probably do not explain the increased risks observed for prostate, soft tissue, salivary gland, and bone and joint cancers years after CM diagnosis. Further investigation into genetic or environmental commonalities between CM and these cancers is warranted. Research Abstract Session – Friday, April 30: 7:15 – 8:45 am Table 1: Distribution of patients by first cutaneous melanoma (CM) and second primary malignancy (SPM) diagnosis. of affected individuals. Using nationally representative First Primary CM SPM After CM databases, we provide evidence of much higher overall Characteristic G:\Mohs\AnnualNo. Meeting\P %ublications\2010\Final No. Program\201 % 0 Draft Final program Copy.doc totals of skin cancer diagnoses and patients in the United 151,996 100 16,591 100 States population than previous estimates. These data Total Patients Page 40 of 114 give the most complete evaluation to date of the under Sex 69,853 46.0 6,107 36.8 recognized epidemic of skin cancer in the United States. Women Men 82,143 54.0 10,484 63.2 7:49 – 7:57 am Age at G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc Presenter: Joshua Spanogle, MD Diagnosis Total Patients 151,996 79,804 100 16,591 52.5 100 5,256 31.7 Sex<56 y Title: Risk of Second Primary Malignancies Following Women56-65 y 69,853 27,658 46.0 6,107 18.2 36.8 4,188 25.2 Men 82,143 54.0 10,484 63.2 Cutaneous Melanoma Diagnosis: A Population- 66-74 y 24,780 16.3 4,622 27.9 Age at based Study Diagnosis≥75 y 19,754 13.0 2,525 15.2 <56 y 79,804 52.5 5,256 31.7 Authors: Joshua Spanogle, MD1, 2; Christina Clarke, PhD, 56-65 y 27,658 18.2 4,188 25.2 66-74 y 24,780 16.3 4,622 27.9 3 3 1, 4 Table 2: Standardized incidence ratios (SIRs) of second primary malignancies (SPMs) after MPH ; Sarah Aroner ; Susan M. Swetter, MD Table≥75 1: y Distribution19,754 of patients 13.0 by 2,525 first cutaneous 15.2 melanoma (CM) cutaneous melanoma (CM) according to time to diagnosis of SPM, 1973-2003. and second primary malignancy (SPM) diagnosis. Table 2: Standardized incidence ratios (SIRs)All study of second primary malignancies (SPMs) after Institutions: 1. Dermatology, Stanford University Site 2-11 mo 12-59 mo 12-59 mo �120 mo cutaneous melanoma (CM) according to timeperiod to diagnosis of SPM, 1973-2003. All study Medical Center, Stanford, CA, United States 2. Site 2-11 mo 12-59 mo 12-59 mo �120 mo period Observed O/E Observed O/E Observed O/E Observed O/E Observed Dermatology, Mayo Clinic, Rochester, MN, United States Observed O/E Observed O/E Observed O/E Observed O/E Observed O/E ratio Cases ratio Cases ratio CasesO/E ratioratio Cases ratio Cases 3. Northern California Cancer Center, Fremont, CA, United Cases ratio Cases ratio Cases ratio Cases ratio Cases All sitesAll sites 16,591 1.32 16,5912135 1.69 1.32 6382 21351.40 42051.69 1.23 38696382 1.151.40 4205 1.23 3869 1.15 States 4. Veterans Affairs Palo Alto Health Care System, Salivary gland 67 2.18 5 1.59 29 2.58 17 2.03 16 1.99 Salivary gland 67 5 1.59 29 17 16 Palo Alto, CA, United States Pharynx 27 0.61 4 0.812.18 7 0.40 11 0.89 5 0.452.58 2.03 1.99 HypopharynxPharynx 14 0.54 272 0.720.61 3 0.314 6 0.81 0.86 3 7 0.490.40 11 0.89 5 0.45 Purpose: To describe incidence patterns of second Other oral cavity 2 0.21 0 0.00 2 0.54 0 0.00 0 0.00 EsophagusHypopharynx 102 0.78 12 14 0.910.54 40 0.852 30 0.72 0.86 20 3 0.590.31 6 0.86 3 0.49 primary malignancies (SPMs) occurring after cutaneous Liver 72 0.77 9 0.90 28 0.77 19 0.69 16 0.58 Other oral cavity 2 0.21 0 0.00 2 0.54 0 0.00 0 0.00 melanoma (CM). Larynx 72 0.58 10 0.72 34 0.70 17 0.49 11 0.36 Lung and other Esophagus 1572 167 102 0.860.78 565 12 4300.91 410 40 0.85 30 0.86 20 0.59 respiratory 0.83 0.81 0.82 0.79 Design: Using the Surveillance, Epidemiology and Bones and jointsLiver 21 1.70 721 0.730.77 7 1.459 5 0.90 1.45 8 28 2.56 0.77 19 0.69 16 0.58 Soft tissue (including 158 16 59 42 41 End Results (SEER) program data from 1973-2003, we heart)Larynx 2.80 72 2.700.58 2.7610 0.722.64 34 2.660.70 17 0.49 11 0.36 calculated incidence rates and relative risks for the Skin-melanomaLung and other 3923 8.99 672 16.02 1561 10.16 897 7.73 793 7.06 1572 167 0.86 565 430 410 development of 65 different SPMs occurring in 16,591 CM Other non-epithelialrespiratory skin 95 2.31 15 3.670.83 32 2.14 31 2.69 17 1.440.81 0.82 0.79 Female breast 1565 1.07 146 1.13 560 1.15 428 1.08 431 1.01 survivors and over 1.3 million person-years of observation. BonesCervix uteri and joints 40 0.57 214 0.481.70 18 0.581 9 0.730.39 9 7 0.44 1.45 5 1.45 8 2.56 SoftProstate tissue (including 2870 1.13 322 1.27 1140 1.25 721 1.08 687 1.09 Characteristics for all patients with CM and Kidney 359 1.29 15861 2.21 129 1.2816 84 1.11 8559 1.14 42 41 Summary: heart) 2.80 2.70 2.76 2.64 2.66 for those who had at least one SPM are shown in Table Eye and orbit-melanoma 45 2.64 7 4.07 17 2.74 8 1.74 13 2.93 Brain and other nervous Skin-melanoma186 392321 1.458.99 76 672 4616.02 1.20 1561 43 1.2110.16 897 7.73 793 7.06 1. Compared with the general population, CM survivors system 1.31 1.46 had a 32% higher risk of developing any SPM and OtherThyroid non-epithelial 217 skin 1.90 45 95 4.062.31 90 2.2015 42 3.67 1.37 4032 1.402.14 31 2.69 17 1.44 Non-HodgkinFemale lymphoma breast 601 1.25 1565111 2.40 206 1461.23 1491.13 1.17 135 560 1.06 428 1.08 431 1.01 demonstrated significantly elevated risks for 13 cancers: Chronic lymphocytic 1.07 1.15 168 1.29 28 2.28 56 1.28 40 1.23 44 1.38 lymphomaCervix uteri 40 0.57 4 0.48 18 0.58 9 0.39 9 0.44 melanoma of the skin (SIR 8.99), soft tissue (SIR 2.80), Nonlymphocytic leukemia 133 0.78 10 0.59 42 0.70 35 0.78 46 1.05 Myeloid andProstate monocytic 2870 322 1140 721 687 melanoma of the eye and orbit (SIR 2.64), non-epithelial 118 9 0.631.13 35 33 1.27 0.87 41 1.101.25 1.08 1.09 leukemia 0.82 0.69 Kidney 359 61 129 84 1.11 85 1.14 skin (SIR 2.31), salivary gland (SIR 2.18), bone and joint Other leukemia 15 0.58 1 0.371.29 7 0.74 2 2.21 0.29 5 0.751.28 (SIR 1.70), thyroid (SIR 1.90), kidney (SIR 1.29), chronic Eye and orbit-melanoma 45 2.64 7 4.07 Page 41 of17 114 2.74 8 1.74 13 2.93 lymphocytic leukemia (SIR 1.29), brain and nervous TableBrain 2: and Standardized other nervous incidence ratios (SIRs) of second primary 186 1.31 21 1.45 76 1.46 46 1.20 43 1.21 system (SIR 1.31), non-Hodgkin lymphoma (SIR 1.25), malignanciessystem (SPMs) after cutaneous melanoma (CM) according prostate (SIR 1.13), and female breast (SIR 1.07) (Table 2; to time toThyroid diagnosis of SPM, 2171973-2003. 1.90 45 4.06 90 2.20 42 1.37 40 1.40 only statistically significant data shown). Risks of second BoldNon-Hodgkin denotes thatlymphoma 95% confidence 601 1.25 intervals111 (CIs) 2.40excluded 206 1.0. 1.23 149 1.17 135 1.06 primary melanoma of the skin, melanoma of the eye and ExcessChronic risk is lymphocytic per 10,000 person-years. 168 28 56 1.28 40 1.23 44 1.38 orbit, and cancers of the prostate, soft tissue, salivary lymphoma 1.29 2.28 gland, bone and joint were elevated throughout the Nonlymphocytic leukemia 133 0.78 10 0.59 42 0.70 35 0.78 46 1.05 study period, implying no surveillance bias (Table 2). 7:57Myeloid – 8:05 and monocyticam 118 9 0.63 35 33 0.87 41 1.10 leukemia 0.82 0.69 Conclusion: The increased risks for developing particular Presenter: Julie Gladsjo, MD, PhD Other leukemia 15 0.58 1 0.37 7 0.74 2 0.29 5 0.75 SPMs after CM may be explained by surveillance bias Title: Treatment of Surgical Scars with the 595nm Page 41 of 114 or shared risk factors. However, these probably do not Pulsed Dye Laser Using Purpuric and Nonpurpuric explain the increased risks observed for prostate, soft Parameters: A Comparative Study tissue, salivary gland, and bone and joint cancers years after CM diagnosis. Further investigation into genetic or Authors: Julie Gladsjo, MD, PhD; Shang I.B. Jiang, MD environmental commonalities between CM and these Institution: Medicine (Dermatology), UC San Diego, cancers is warranted. San Diego, CA, United States Purpose: Since the 1980’s, the pulsed dye laser has been used to improve the cosmetic appearance of scars. However, the optimal laser parameters for treating scars are not known. The purpose of this study was to determine whether treatment of fresh surgical scars with a pulsed dye laser using purpura-inducing settings will improve Research Abstract Session – Friday, April 30: 7:15 – 8:45 am clinical appearance better than one using non-purpura- micrographic surgery from 1998-2008. We included the inducing settings or no treatment. A secondary goal is anatomical location, tumor size, patient age, number of to determine whether multiple treatment sessions are Mohs layers, and recurrence rate. superior to a single treatment. Summary: Cutaneous lymphadenoma is a rare, benign, Design: Patients with a linear surgical wound measuring slow growing tumor that presents on the head and neck at least 4.5 cm located anywhere on the body except in young and middle aged adults. The usual clinical for hands, feet or genitals, were enrolled at the excision presentation is a slow growing papule resembling a basal visit. At the post-operative suture removal visit, patients cell carcinoma. Metastasis has not been documented. received the first of 3 pulsed dye laser treatments, spaced Cutaneous lymphadenomas are treated with surgical 4 weeks apart (at 2, 6, and 10 weeks after surgery). The excision. The tumor usually presents in an anatomically surgical wounds were divided in 3 equal contiguous sensitive area where margin control and conservative parts, each measuring at least 1.5 cm. One segment was excision are indicated; therefore, Mohs micrographic treated using purpuric settings (pulse duration of 1.5msec), surgery may be preferred over wide local excision. We a second segment was treated at the same fluence but present four cases of cutaneous lymphadenoma treated nonpurpuric settings (10msec pulse duration), while a with Mohs micrographic surgery from 1998 to 2008. The third control segment received no treatment. Fluence average age of the patient at diagnosis was 49.5 years old. delivered was determined by Fitzpatrick skin type. In order All of the patients had tumors presenting on the . The to minimize the effects of wound tension, position of each average pre-operative tumor size was 0.9 cm. The average treatment condition was randomly assigned. Outcome number of MMS layers was 2. Follow up was available of each scar segment was assessed by the investigator for three patients with an average follow up period of 29 using the Vancouver Scar Scale which evaluates months. None of the three patients had a recurrence. overall scar appearance, visibility of scar, erythema, hyperpigmentation, and hypopigmentation; and by Conclusion: To our knowledge, this is the largest series a blinded evaluator who rated the overall cosmetic describing the use of Mohs micrographic surgery for appearance. Outcomes assessments were performed at the treatment of cutaneous lymphadenoma. Our data 6, 10, and 14 weeks. indicate that cutaneous lymphadenoma patients treated with Mohs micrographic surgery had a favorable Summary: Preliminary results of 6 patients showed that recurrence rate making it a treatment option for this rare there were no significant differences in the appearance tumor. of the three scar segments between the three study conditions overall, or at the 14 week assessment visit, as 8:13 – 8:21 am rated on the Vancouver Scar scale. Neither was there any Presenter: Jason Litak, MD difference in the subjective rating of pain between the purpuric and nonpurpuric treatment settings. No subject Title: The Routine Use of Adjuvant Cytokeratin reported any adverse event. Immunostaining in Mohs Micrographic Surgery for Non-melanoma Skin Cancer At the meeting, we will present our study results, projected to include data from 20 patients, comparing the ratings of Authors: Jason Litak, MD; Jeffrey Altman, MD; Heydar scar appearance for the three treatment parameters. We Karimi, PhD; Lady C. Dy, MD will also report whether multiple laser treatments result in Dermatology, Rush University Medical significantly better appearance than a single treatment. Institution: Center, Chicago, IL, United States Conclusion: The differences between purpuric versus The respective recurrence rates for basal cell nonpurpuric settings with the pulsed dye laser and single Purpose: carcinoma (BCC) and squamous cell carcinoma (SCC) versus multiple treatments for improving the cosmetic treated with conventional Mohs micrographic surgery appearance of scars will be discussed. (MMS) are 1-2% and 3.1% for primary tumors, and 5-6% 8:05 – 8:13 am and 7% for recurrent tumors. These recurrences may be due to residual tumor not identified with standard Presenter: Allison M. Hanlon, MD, PhD hematoxylin and eosin (H&E) staining. Title: Mohs Micrographic Surgery for the Treatment To determine whether the addition of of Cutaneous Lymphadenoma immunohistochemical staining with a mixture of AE1/AE3 Authors: Allison M. Hanlon, MD, PhD1; Anna S. Clayton, cytokeratin monoclonal antibodies will identify residual MD1; Brent R. Moody, MD2; Thomas Stasko, MD1 tumor cells in sections in which the H&E-stained frozen sections were negative. Institutions: 1. Dermatology, Vanderbilt University, Nashville, TN, United States 2. Skin Cancer and Surgery Design: One hundred consecutive cases of non- Center, Nashville, TN, United States melanoma skin cancer were treated with the Mohs procedure under standard conditions using H&E-stained Purpose: The purpose of the study was to investigate slides. Once the “final layer” was determined to be tumor the clinical characteristics and outcome of cutaneous free by the Mohs surgeon, an extra slide from the “tumor lymphadenoma patients treated with Mohs micrographic free” tissue block was stained with a mixture of AE1/AE3 surgery. cytokeratin monoclonal antibodies. Any cases identified Design: We performed a retrospective chart review of four with residual tumor cells were further evaluated with cutaneous lymphadenoma patients treated with Mohs an additional frozen section slide processed with H&E staining. Research Abstract Session – Friday, April 30: 7:15 – 8:45 am

Summary: Of the 100 cases of non-melanoma skin prevent SSIs but in all cases sterile technique was used cancer determined to be tumor free on H&E-stained during wound reconstruction. We sought to evaluate the frozen sections, the adjuvant use of immunostaining with rate of SSIs among patients undergoing MMS with the use AE1/AE3 cytokeratin monoclonal antibodies identified: of clean surgical technique for all steps of MMS including 1. # cases showing no positivity wound reconstruction in the absence of prophylactic 2. # cases with positivity corresponding to occult tumor antibiotics. cells (#BCC, #SCC) (#obscured with inflammatory cells) Design: We prospectively evaluated 1000 patients Preliminary Results: Of 4 cases and 5 slides, 1 G:\Mohs\Annual undergoingMeeting\Publications\2010\Final MMS using clean surgicalProgram\201 technique0 Draft Finalfor program Copy.doc slide was positive for residual tumor identified by SSIs. Clean surgical technique includes the use of clean immunohistochemistry (Figure 1). Correlation to the surgical gloves and towels and a single pack of sterile original H&E slide (Figure 2) revealed occult residual tumor instruments for all steps including wound reconstruction. not originally indentified. Figure 1: Positive AE1/AE3 cytokeratin immunostaining revealing tumor cells in theSummary: dermis. There were 11 among 1000 patients Conclusion: The routine use of adjuvant cytokeratin with 1204 tumors; the SSI rate was 0.91% (CI 0.38% to immunostaining in MMS for the treatment of non- 1.45%). Three of the 11 infections were complications of melanoma skin cancer is useful in identifying residual hematomas. Four of the 11 infections occurred in flap tumor cells not identified on standard H&E-stained closures, with the highest rate of SSI of 2.67% (4/146). frozen sections. This technique is limited by the This is the first study to examine the rate of experience of the Mohs surgeon in the interpretation of Conclusion: SSIs with the use of clean surgical technique for all steps immunohistochemical frozen section slides. The technique of MMS including wound reconstruction in the absence is also limited by the technicalG:\Mohs\Annual skill of Meeting\P the histotechnologistublications\2010\Final Program\2010 Draft Final program Copy.doc of antibiotic prophylaxis. Our rate of SSIs of 0.91% is in the preparation of the immunohistochemical slides. exceedingly low, underscoring the overall safety of MMS and its performance in the outpatient setting without the

Figure 1: Positive AE1/AE3 cytokeratuse ofin antibiotic immunostaining prophylaxis revealing or sterile tumor technique. cells in the dermis. Figure 2: Original H&E slide from Mohs procedure initially called "tumor- free". Occult8:29 tumor – 8:37 identifiedam by correlation with IHC slide. Presenter: Jason D. Givan, MD

Title: Post-operative Lower Leg Wound Infections Following Mohs Micrographic Surgery: A Comparison of Incidence Rates Pre- and Post- implementation of a Clinical Care Protocol

Figure 2: Original H&E slide Authors: Jason D. Givan, MD; Dori Goldberg, MD; David 8:21 from – Mohs 8:29 procedure am E. Geist, MD; Mary E. Maloney, MD initially calledJohn “tumor- Starling, III, MD Figure 1: Positive Presenter: Institution: Dermatology, University of Massachusetts, free”. Occult tumor AE1/AE3 cytokeratin Title: identifiedOutcome by correlation of Six Years of ProtocolWorcester, Use MA,for Preventing United States Wrong Site Office Surgery immunostaining revealing Authors:Figurewith IHC 2: slide.John Original Starling, H&E III, slide MD; fromBrett MoM. hsColdiron, procedure MD, FACPinitially called "tumor- tumor cells in the dermis. Institution: The Skin Cancer Center,Purpose: Cincinnati, The OH, purpose United of States this study is to evaluate the free". Occult tumor identified by effectivenesscorrelation with of a IHCsimple slide. clinical care protocol with

regard to the incidence of post-operative lower leg 8:21 – 8:29 am Purpose: As future medical legislation brings increased emphasis on both patient outcomes and measures of quality, patient safety is(i.e. emerging below theas an knee) integral wound part infections of the overall following strategy Mohs to improve Presenter: Heather D. Rogers, MD micrographic surgery. Pre- and post-protocol wound healthcare in the United States. Wrong site, wrong procedure, and wrong person surgery are considered rates will be compared. Title: Prospective Study of Wound Infections in sentinel events (an unexpected occurrence involving death or serious physical or psychological injury) by Design: We designed and implemented a simple Mohs Micrographic Surgerythe Joint Using Commission Clean Surgical and have been identified by the American Academy of Dermatology Association clinical care protocol for patients undergoing Mohs Technique in the Absence(AADA) of Prophylactic Ad Hoc Task Force as major patient safety issues in dermatology. The true incidence of wrong Antibiotics site surgery is difficult to determine asmicrographic the medical surgeryliterature on on the the lower subject leg. mostlyThe protocol limited was to operating 8:21 – 8:29 am invoked for all patients requiring on a site John Starling,room III, MD situations.1 A recent survey of 300 Mohs surgeons revealed that 14% of malpractice cases were due Presenter:Authors: Heather D. Rogers, MD ; Edward B. Desciak, below the knee and involved pre-operative, operative, 2 to 2wrong site surgery. We3 sought to determine the incidence of wrong site, wrong procedure, and wrong Title:MD ; RebeccaOutcome Marcus, of Six Years MD ; Shuang of Protocol Wang, Use PhD for; Julian Preventing and Wrong post-operative Site Office aspects. Surgery Pre-operatively patients person2 surgery following2 implementation of a preoperative protocol in patients presenting for treatment of Authors:MacKay-Wiggan, John Starling, MD, MS III,; MD;Yehuda Brett D. M. Eliezri, Coldiron, MD MD, FACPwere instructed to wash the entire involved leg with skin cancer at a high-volume, Joint Commission accredited, tertiary referral center for dermatologic Institution: The Skin Cancer Center, Cincinnati, OH, United Statesanti-bacterial soap the night prior to and the morning of Institutions: 1. Medicine,surgery. University of Washington School of Medicine, Seattle, WA, United States 2. surgery. Prior to the initiation of surgery, all patients were As future medical legislation brings increased emphasis on both patient outcomes and Purpose:Dermatology, Columbia University Medical Center, New instructed to remove both shoes and both socks, as well measures of quality, patientDesign: safety Over is emerging six years as we an prospectivel integral aspart longy ofcollected thepants. overall Ana series initial strategy surgicalof 7983 to improve prepcases of of the Mohs entire micrographic involved surgery York, NY, United States 3. (MMS)Biostatistics, performed Columbia on patients University presenting for treatment of skin cancer. The three components of the Joint healthcareMedical Center, in the UnitedNew York, States. NY, UnitedWrong States site, wrong procedure,lower and wrongleg from person the knee surgery to the are toes, considered including the toe sentinel events (an unexpectedCommission occurrence Universal involving Protocol death (i.e. or webpre-procedure serious spaces, physical was verification orperformed psychological of withpatient Hibiclens injury) identity, by scrub. site Thisidentification, was and thePurpose: Joint Commission Mohs micrographic andperformance have surgery been identified(MMS)of a "time-out"), has by a tlowhe Americanwere appliedfollowed Academy to bydaily a of standardpatient Dermatology care. Hibiclens Patient Association surgical identity prep was locally established at during (AADA)rate of surgicalAd Hoc siteTask infection Forceconsultation as (SSI) majo withoutr patientprior the to safetyusethe ofprocedure issues in by dermatology.the confirming surgical site. patient The Post-operatively, true name incidence and date ofpatients wrong of birth were on officegiven provided siteprophylactic surgery is antibiotics. difficult to determinedisposableIn the studies as wristbands tothe date, medi therecal placed literature has on patients' onspecific the subjectleft wristswound mostly atcare registration. limited instructions to operating Patients including personally instructions confirmed to roombeen situations. variation in A the recent steps operativesurvey taken of by sites300 each Mohsin surgeonthe surgeonpresence to s revealedof there-wash operating that the14% physic surgical of malpracticeian site via separately use cases of a mirror, wereafter showering dueand the sites to were then both to wrong site surgery. Weclearly sought circled to determine and initialed the incidence with surgical of wrong marker site, by wrong the dermatologic procedure, andsurgeon wrong performing the procedure. person surgery following Digitalimplementation photos of of each a preoperativ marked surgicale protocol site in were patients taken presenting and printed for for treatment inclusion of in the medical record. A skin cancer at a high-volume,"time-out" Joint Commissionconfirming correct accredi patient,ted, tertiary correct referral site, and center correct for dermatologicprocedure was taken prior to performing all surgery. procedures, and recorded with doctor's initials on the reverse side of the patient's micrographic surgery map. Numbers of wrong site office skin surgery were then obtained from prospective mandatory adverse Design: Over six years wereporting prospectivel data yfrom collected the last a tenseries year ofs 7983 in the cases state of MohsFlorida micrographic and the last surgerysix years in the state of Alabama. (MMS) performed on patients presenting for treatment of skin cancer. The three components of the Joint Commission Universal ProtocolSummary: (i.e. pre-procedureAnalysis of 7983 verification cases of ofMMS patient for treatmentidentity, site of skinidentification, cancer revealed and no cases of wrong site, performance of a "time-out"),wrong were procedure, applied toor dailywrong patient person care. surgery Patient in a identity dermatologic was established surgery practice. during Detailed study of consultation prior to the proceduremandatory by adverse confirming reporting patient data name from and ten date years of birthin the on state office of providedFlorida and six years in the state of disposable wristbands placed on patients' left wrists at registration. Patients personally confirmed Page 44 of 114 operative sites in the presence of the operating physician via use of a mirror, and the sites were then both clearly circled and initialed with surgical marker by the dermatologic surgeon performing the procedure. Digital photos of each marked surgical site were taken and printed for inclusion in the medical record. A "time-out" confirming correct patient, correct site, and correct procedure was taken prior to performing all procedures, and recorded with doctor's initials on the reverse side of the patient's micrographic surgery map. Numbers of wrong site office skin surgery were then obtained from prospective mandatory adverse reporting data from the last ten years in the state of Florida and the last six years in the state of Alabama.

Summary: Analysis of 7983 cases of MMS for treatment of skin cancer revealed no cases of wrong site, wrong procedure, or wrong person surgery in a dermatologic surgery practice. Detailed study of mandatory adverse reporting data from ten years in the state of Florida and six years in the state of Page 44 of 114 Research Abstract Session – Friday, April 30: 7:15 – 8:45 am remove bacteria that may have been carried over and into the wound. Mupirocin ointment was prescribed in all cases. Local compression wraps and leg elevation were utilized. Strenuous exercise and prolonged standing/ walking were prohibited. Post-operative wound infection rates will calculated and compared to pre-protocol infection rates to determine protocol effectiveness. Summary: Our research efforts are on going. However, early statistical trends suggest that there has been a clear decrease in post-operative wound infection (and wound dehiscence) rates following the implementation of this clinical care protocol. Conclusion: Lower extremity post-operative wound infections following Mohs micrographic surgery are not uncommon. Multiple factors are likely to contribute to this clinical scenario including bacterial contamination during the operative procedure and wound contamination post-operatively as microorganisms are carried over and directly into the surgical wound through the act of bathing. Additionally, increased venous and lymphatic pressures, inherent to the lower leg, contribute to micro and macroscopic wound dehiscence and prolonged healing time. We have addressed each of these issues via the implementation of a simple clinical care protocol with clear preliminary benefit. Research Abstract Session – Saturday, May 1: 7:15 – 8:45 am

7:17 – 7:25 am surgery into practice after graduation compared to Presenter: Erica H. Lee, MD injectable fillers and sclerotherapy. Title: Resident Training in Mohs Micrographic Surgery The surgical procedures residents feel competence should and Procedural Dermatology: A Survey Assessing be achieved at the end of training include excisional surgery, chemical peels, , injectable fillers the Residents’ Role and Perceptions and the laser treatment of vascular lesions. Authors: Erica H. Lee, MD1; Kishwer S. Nehal, MD1; Conclusion: Resident training in Mohs micrographic Stephen W. Dusza, MPH1; Elizabeth K. Hale, MD3; Vicki J. surgery is primarily limited to the assistant role. Levine, MD2 Competency in Mohs micrographic surgery is not Institutions: 1. Dermatology Service, Memorial Sloan- achieved during residency and post-residency training Kettering Cancer Center, New York, NY, United States is warranted for proficiency. Residents feel confident in 2. Dermatology, New York University Langone Medical likely due to increased exposure Center, New York, NY, United States 3. Laser & Skin Surgery in training, but may not reflect true competency. Center of New York, New York, NY, United States Residents are performing laser and cosmetic procedures; however, experience varies widely among various types In the past decade the scope of surgical Purpose: of procedures. Overall, residents are satisfied with their training in dermatology residency has increased. training in procedural dermatology. Understanding the residents’ role in Mohs surgery and procedural dermatology provides insight to current 7:25 – 7:33 am training practices, trends and overall compliance. To Presenter: Keoni Nguyen, DO assess the residents’ surgical experience and training perceptions, a survey was sent to third year dermatology Title: A Novel Interactive High-fidelity Cutaneous residents. Surgical Training Model of the Head, Neck, and Design: A 34-question survey was sent to 107 Shoulders dermatology residency programs accredited by Authors: Keoni Nguyen, DO; Joseph McGowan, MD; the Accreditation Council for Graduate Medical Tom G. Olsen, MD; Brett M. Coldiron, MD, FACP; Heidi B. Education (ACGME). The survey was mailed to third year Donnelly, MD dermatology residents in March 2009. The survey was designed to assess: 1) resident experience in Mohs surgery Institution: Dermatology, Wright State University, and procedural dermatology, 2) resident self-evaluation Dayton, OH, United States of competency and preparation level, 3) resident Purpose: Dermatologic surgery continues to take perspective of procedural dermatology training and 4) on an important role in the surgical arena due to the overall satisfaction. A follow-up survey was mailed to non- increase in skin cancers in an aging population. Although responders in April 2009. the dermatology surgical curriculum is changing to Summary: Two hundred forty one surveys were returned, accommodate the demands of our healthcare system, for a response rate of 66%. A total of 95 programs there is great variation in the surgical training received responded (89%). among dermatology residencies and procedural dermatology fellowships. In 2008, Reid et al. reviewed Sixty three percent of respondents spend more than 211 training anonymous surveys of recent graduates one month in a Mohs surgery rotation, 24% spend two and confirmed that residents were dissatisfied with their to four weeks and 9% spend less than two weeks during surgical and cosmetic training. One factor that may an academic year. In the majority of Mohs cases, 18% of restrict residents from acquiring more hands-on surgical responding residents are the primary surgeon, 66% assist experience is the ethical concerns of “practicing” on live and 10% observe. In flap reconstructive surgery, forty-nine patients. Adequate cutaneous surgical models for residents percent of residents are the primary surgeon (designing, and fellows are lacking to repetitively practice their surgical cutting and suturing) and 45% assist only (supplement skills. Currently, eighty-four percent of dermatology training , undermine, suture and cauterize). A programs are utilizing pig’s feet models to instruct and similar response pattern was observed for skin graft evaluate dermatology residents. Pig’s feet are low-fidelity reconstruction. The primary surgeon and assistant role models, meaning they do not accurately simulate skin were clearly defined in the survey. elasticity and turgor. Low-fidelity models are suboptimal for Residents are generally the primary surgeon in botulinum teaching advanced concepts of flap vectors, dissecting toxin, injectable fillers, sclerotherapy, superficial chemical planes, danger zones, and tumor free margins. Our peels and nail surgery, however experience is limited in objective is to introduce a novel three-dimensional “high- dermabrasion, and medium depth peels. Over fidelity” cutaneous surgical training model. 50% are not exposed to transplantation, ambulatory Design: A high-fidelity cutaneous surgical model of the phlebectomy, and rhytidectomy during head, neck, and shoulders was developed. Over thirty training. tumors are strategically placed on the head, neck, and Competency level was self-assessed by residents. shoulders (Figure 1a). Beneath the cutaneous layer, Residents felt competent in suturing techniques and there are simulated subcutaneous fat, , blood excisional surgery (>90%), advancement flaps (60%) and vessels, muscles, fascia, cartilage, and bony structures full thickness skin grafts (48%). Residents generally felt of the head, neck, and shoulders (Figures 1b - 1c). This better prepared to integrate botulinum toxin and laser is a useful adjunct for learning and understanding head Research Abstract Session – Saturday, May 1: 7:15 – 8:45 am

and neck anatomy, including danger zones and planes Institutions: 1. Dermatology, Mayo Clinic-Rochester, for undermining. The “high-fidelity” model allows a close Rochester, MN, United States 2. Biomedical Statistics & simulation of human tissue properties facilitating the Informatics, Mayo Clinic-Rochester, Rochester, MN, United instruction of flap dynamics and advanced reconstruction States 3. Radiation Oncology, Mayo Clinic-Scottsdale, in a controlled, reproducible setting (Figures 2a – 2b). Rochester, MN, United States 4. Radiation Oncology, Ten skin-simulant samples composed of various mixtures Mayo Clinic-Jacksonville, Jacksonville, FL, United States of elastomers and fibers were tested on an Instron E3000 Purpose: To clarify the utility of various imaging dynamic testing machine to simulate normal mechanical modalities including CT, PET/CT, and MRI in detecting values of . Sample four was selected for the nodal involvement in patients with primary Merkel cell cutaneous layer of the model. Values include: specimen carcinoma. width of 14.47 mm, thicknessG:\Mohs\Annual of 1.45 mm, Meeting\P strain atublications\2010\Final break of Program\2010 Draft Final program Copy.doc 93.36 percent, Young’s Modulus of 12.76 MPa, and tensile Design: A multi-center, retrospective, consecutive study strength of 9.05 MPa. reviewing 105 patients diagnosed with known primary Merkel cell carcinoma (MCC) between 1986 and 2008 was completed. All patients had a documented imaging study evaluating their regional lymph node basin as part of the staging process, followed by an elective or therapeutic nodal dissection or sentinal lymph node biopsy. Data from three academic medical centers was collected and combined for analysis. Summary: Of the 105 patients reviewed 75 patients had a CT, 33 patients had a PET/CT, and 10 had an MRI. CT scan (75 patients) demonstrated a sensitivity of 54%, We believe this novel high-fidelity cutaneous Summary: a specificity of 95%, a positive predictive value of 90%, surgical training model is optimal for teaching basic and and a negative predictive value of 70% in detecting advanced concepts of flap vectors, dissecting planes, nodal basin involvement. PET/CT scan (33 patients) danger zones, and tumor free margins (Figures 2a – 2d). G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc demonstrated a sensitivity of 77%, a specificity of 95%, 7:33 – 7:41 am a positive predictive value of 91%, and a negative Michael B. Colgan, MD Presenter: predictive value of 87% in detecting nodal basin Title: The Predictive Value of Imaging Studies in Evaluatinginvolvement. Regional MRI Lymph(10 patients) Node demonstrated Involvement a insensitivity Merkel Cell Carcinoma of 0%, a specificity of 86%, a positive predictive value of 1 1 4 Authors: Michael B. Colgan, MD ; Tina I. Tarantola, MD ;0%, Laura and A. a Vallow,negative MD predictive; Michele value Y. Halyard,of 67% in detecting 3 2 1 1 1 MD ; Amy L. Weaver, MS ; Randall K. Roenigk, MD ; Jerrynodal D. Brewer, basin involvement. MD ; Clark C. Otley, MD Institutions: 1. Dermatology, Mayo Clinic-Rochester, Rochester,Conclusion: MN, UnitedThe use States of PET/CT 2. Biomedical in the evaluation of a Statistics & Informatics, Mayo Clinic-Rochester, Rochester,regional MN, Unit lymphed States node basin3. Radiation in primary Oncology, MCC is significantly Mayo Clinic-Scottsdale, Rochester, MN, United States 4. Radiationmore sensitive Oncology, and equally Mayo specific Clinic-J acksonville,when compared Jacksonville, FL, United States to traditional CT. For this reason, it may be the most appropriate imaging study when determining regional

Purpose: To clarify the utility of various imaging modalitiesnodal including involvement CT, PET/CT, in these and patients. MRI in MRI detecting does not appear nodal involvement in patients with primary Merkel cell carcinoma.to provide a high sensitivity or predictive value as an imaging technique for nodal involvement, although 7:33 – 7:41 am our study had too few numbers to draw any statistical Conclusion:A multi-center, This cutting edge retrospective, three-dimensional consecutive study reviewing 105 patients diagnosed with known Presenter: Michael B. Colgan, MD Design: significance. interactiveprimary Merkel high-fidelity cell carcinoma surgical training (MCC) betweenmodel is unique1986 and 2008 was completed. All patients had a Title: The Predictive Value of Imaging Studies in Evaluatingand Regional optimal Lymph to teach Node and Involvement evaluate dermatology in documented imaging study evaluating their regional lymph node basin as part of the staging process, Merkel Cell Carcinoma residents and fellows. The training model can be 7:41 – 7:49 am Michael B. Colgan, MD1; Tina I. Tarantola, MD1; Laura A. Vallow, MD4; Michele Y. Halyard, Authors: integratedfollowed by into an dermatology elective or therapeutic training programs nodal dissectiand on or sentinalPresenter: lymph Mark node Hyde, biopsy. MMS, Data PA-C from three MD3; Amy L. Weaver, MS2; Randall K. Roenigk, MD1; Jerry D. Brewer, MD1; Clark C. Otley, MD1 proceduralacademic medicalfellowships centers such that was residents collected and and fellows combined for analysis. 1. Dermatology, Mayo Clinic-Rochester, Rochester, MN, United States 2. Biomedical Title: Utilization of Physician Assistants in Mohs Institutions: may develop an effective surgical technique prior to Statistics & Informatics, Mayo Clinic-Rochester, Rochester, MN, United States 3. Radiation Oncology, Micrographic Surgery, a Survey of Fellowship Trained clinicalSummary: practice. Of the The 105 surgical patients model reviewed has the 75 potential patients to had a CT, 33 patients had a PET/CT, and 10 had an Mayo Clinic-Scottsdale, Rochester, MN, United States 4. RadiationrevolutionizeMRI. Oncology, CT scan dermsurgery Mayo(75 patients) Clinic-J training.acksonville, demonstrated a sensitivity of 54%,Mohs a Micrographicspecificity of 95%, Surgeons a positive predictive Jacksonville, FL, United States Authors: Mark Hyde, MMS, PA-C1; Michael L. Hadley, value of 90%, and a negative predictive value of 70% in detecting nodal basin involvement. PET/CT scan 7:33 – 7:41 am MD3,1; Conrad Roberson1; Lisa Pappas2; Abby A. To clarify the utility of various imaging modalities including(33 patients) CT, PET/CT, demonstrated and MRI in a detecting sensitivity of 77%, a specificity of 95%, a positive predictive value of 91%, Purpose: Presenter: Michael B. Colgan, MD Jacobson, MS, PA-C4; Glen M. Bowen, MD3,1 nodal involvement in patients with primary Merkel cell carcinoma.and a negative predictive value of 87% in detecting nodal basin involvement. MRI (10 patients) Tdemonstrateditle: The Predictive a sensitivity Value ofof 0%, Imaging a specificity Studies of in 86%, a positiveInstitutions: predictive 1. Cutaneousvalue of 0%, Oncology, and a negative Huntsman Design: A multi-center, retrospective, consecutive study reviewingEpredictivevaluating 105 patients value Regional diagnosedof 67% Lymph in withdetecting N odeknown I nvolvementnodal basin involvement.in Cancer Institute at the University of Utah, Salt Lake City, UT, primary Merkel cell carcinoma (MCC) between 1986 and 2008Merkel was completed. Cell Carcinoma All patients had a United States 2. Biostatistics Shared Resources, Huntsman documented imaging study evaluating their regional lymph node basin as part of the staging process, Cancer Institute at the University of Utah, Salt Lake City, UT, Conclusion: The use of PET/CT1 in the evaluation of 1a regional lymph node basin in primary MCC is followed by an elective or therapeutic nodal dissection or sentinalAut lymphhors: node Michael biopsy. B. Colgan,Data from MD three; Tina I. Tarantola, MD ; United States 3. Department of Dermatology, University of significantly more sensitive4 and equally specific3 when compared to traditional CT. For this reason, it may academic medical centers was collected and combined for analysis.Laura A. Vallow, MD ; Michele Y. Halyard, MD ; Amy L. Utah, Salt Lake City, UT, United States 4. Physician Assistant be the most2 appropriate imaging st1udy when determining regional nodal involvement in these patients. Weaver, MS ; Randall K. Roenigk, MD ; Jerry D. Brewer, Program, Hahnemann/Drexel University, Philadelphia, PA, MRI1 does not appear to1 provide a high sensitivity or predictive value as an imaging technique for nodal Of the 105 patients reviewed 75 patients had a CT,MD 33 ;patients Clark C. had Otley, a PET/CT, MD and 10 had an United States Summary: involvement, although our study had too few numbers to draw any statistical significance. MRI. CT scan (75 patients) demonstrated a sensitivity of 54%, a specificity of 95%, a positive predictive value of 90%, and a negative predictive value of 70% in detecting nodal basin involvement. PET/CT scan (33 patients) demonstrated a sensitivity of 77%, a specificity of 7:4195%, – a 7:49positiv ame predictive value of 91%, and a negative predictive value of 87% in detecting nodal basinPresenter: involvement. Mark MRI Hyde,(10 patients) MMS, PA-C demonstrated a sensitivity of 0%, a specificity of 86%, a positiveTitle: predictive Utilization value of of 0%, Physician and a negative Assistants in Mohs Micrographic Surgery, a Survey of Fellowship predictive value of 67% in detecting nodal basin involvement. Trained Mohs Micrographic Surgeons 1 3,1 1 2 Authors: Mark Hyde, MMS, PA-C ; Michael L. Hadley, MD ; Conrad Roberson ; Lisa Pappas ; Abby A. Conclusion: The use of PET/CT in the evaluation of a regionalJacobson, lymph node MS, basin PA-C in primary4; Glen MCC M. Bowen, is MD3,1 significantly more sensitive and equally specific when comparedInstitutions: to traditional 1.CT. Cutaneous For this reason, Oncology, it may Huntsman Cancer Institute at the University of Utah, Salt Lake City, be the most appropriate imaging study when determining regionalUT, nodal United involvement States 2. inBiostatistics these patients. Shared Resources, Huntsman Cancer Institute at the University of Utah, MRI does not appear to provide a high sensitivity or predictive valueSalt Lake as an City, imaging UT, technique United States for nodal 3. Department of Dermatology, University of Utah, Salt Lake City, UT, involvement, although our study had too few numbers to draw any statistical significance. United States 4. Physician Assistant Program, Hahnemann/Drexel University, Philadelphia, PA, United States 7:41 – 7:49 am Presenter: Mark Hyde, MMS, PA-C Title: Utilization of Physician Assistants in Mohs Micrographic Surgery, a Survey of Fellowship Page 48 of 114 Trained Mohs Micrographic Surgeons 1 3,1 1 2 Authors: Mark Hyde, MMS, PA-C ; Michael L. Hadley, MD ; Conrad Roberson ; Lisa Pappas ; Abby A. Jacobson, MS, PA-C4; Glen M. Bowen, MD3,1 Institutions: 1. Cutaneous Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, United States 2. Biostatistics Shared Resources, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, United States 3. Department of Dermatology, University of Utah, Salt Lake City, UT, United States 4. Physician Assistant Program, Hahnemann/Drexel University, Philadelphia, PA, United States

Page 48 of 114 Research Abstract Session – Saturday, May 1: 7:15 – 8:45 am

Purpose: An increasing number of dermatologists are Purpose: To compare the efficacy, tolerability and cost- using Physician Assistants (PAs) in their practices. A lack effectiveness of topical 5-fluorouracil to imiquimod for the of information regarding the utilization of PAs in Mohs treatment of superficial basal cell carcinoma. micrographic surgery (MMS) served as the driving force for Design: A prospective, randomized, double blind, this research. vehicle-controlled clinical trial. Design: 576 fellow members of the American College of Summary: Results are based on an intent-to-treat Mohs Surgery were sent surveys via the US postal service G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Finalanalysis program ofCopy.doc 18 subjects (9 female, 9 male; ages 39-77, in January 2009. The survey was focused on what portion mean 71y) meeting the criteria for inclusion who enrolled of Mohs surgeons are using PAs and how those PAs are An increasing number of dermatologists are using Physician Assistants (PAs)in in the their study. practices. Subjects were randomized to one of two Purpose: being utilized. A lack of information regarding the utilization of PAs in Mohs micrographic surgery (MMS)study served groups: as the (N=7) 5-fluorouracil 5% cream (twice driving forceSummary: for this research. Of the 576 surgeons surveyed, 143 (24.8%) daily application for 6 weeks), or (N=11) imiquimod responded. Of those, 43/143 (30.1%) currently employed 5% cream (once daily application of drug and once Design: 576 fellow members of the American College of Mohs Surgery were sent surveys via the US postal service1 or in more January PA. 2009. 15/43 The (34.9%) survey was surgeons focused reportedon what portion that of PAs Mohs surgeonsdaily are application using PAs of vehicle cream for 6 weeks). Sixteen and how thosein their PAs practice are being utilized.perform preoperative consults. 25/43 subjects completed the study; 2 terminated early due (58.1%) surgeons noted that PAs are performing the to exuberant local skin reactions. Primary lesions were Summary:postoperative Of the 576 surgeons follow surveyed, up. 18/43 143 (24.8%) (41.9%) res surgeonsponded. Of reported those, 43/ 143 (30.1%)located currently on the trunk (n=8), extremities (5), and head/ employed 1 or more PA. 15/43 (34.9%) surgeons reported that PAs in their practice perform preoperative consults. 25/43that (58.1%)PAs were surgeons participating noted that inPAs some are performing aspect of the repairs. postoperative followneck up. 18/43(5). Histopathologic evaluation of formalin fixed, (41.9%) surgeons35/43 (81.4%) reported surgeonsthat PAs we reportedre participating that in PAs some were aspect seeing of repairs. 35/43paraffin (81.4%) surgeons embedded, H&E stained step-sections of post- reported thatgeneral PAs were dermatology seeing general patients. dermatology patients. treatment excision specimens demonstrated residual basal cell carcinoma in 2 cases (both following treatment Conclusion: It appears that some Mohs surgeons are Conclusion: It appears that some Mohs surgeons are utilizing PAs for perioperative carewith as imiquimod).well as Histopathologic assessment of complete utilizing PAs for perioperative care as well as seeing seeing general dermatology patients. A smaller percentage of Mohs surgeons are usingresponse PAs to perform (no residual tumor) occurred in 7 of 7 (100%) portions ofgeneral Mohs surgery dermatology or the consequent patients. repairs. A smaller percentage of subjects in the 5-fluorouracil group and in 9 of 11 (82%) Mohs surgeons are using PAs to perform portions of Mohs subjects in the imiquimod group. The proportion of cases Breakdownsurgery of or tasks the delegatedconsequent to Physician repairs. Assistants by Mohs Micrographic Surgeons This data was in response to the question: “What portions of the MMS process are being delegatedwith histopathologic to PAs?” evidence of persistent tumor was Presurgical consults 15/43 (34.88%) not statistically different (p=0.23) between study groups. Excision of Mohs sections 1/43(2.33%) Subject reported symptoms of pain, burning or itching Mapping Mohs sections 0/43 were similar between study groups. Investigator assessed Inking excised tissue 1/43(2.33%) signs of erythema, edema, induration, vesicles, ulceration, crusting, excoriation were similar between groups. Interpreting pathology 0/43 Although insurance coverage and market price varies Primary repair-design 8/43(18.6%) over time, the cost of 5-fluorouracil may be less than Primary repair-dermal sutures 12/43 (27.91%) imiquimod for treatment of superficial BCC. One limitation Primary repair-epidermal sutures 18/43 (41.86%) of the study is less than 100% margin control with bread Adjacent tissue transfer-design 2/43 (4.65%) loaf sectioning of excision specimens. Adjacent tissue transfer-dermal sutures 8/43(18.6%) Conclusion: The data suggest that 5-fluorouracil and Adjacent tissue transfer-epidermal sutures 14/43(32.56%) imiquimod are effective and well tolerated topical Skin graft-design 6/43 (13.95%) medical therapies for superficial basal cell carcinoma. Skin graft-dermal sutures 10/43 (23.26%) Skin graft-epidermal sutures 16/43 (37.21%) 7:57 – 8:05 am Surgical follow-ups 25/43 (58.14%) Presenter: Joshua B. Wilson, MD Title: Staged Excision for Lentigo Maligna and 7:49 – 7:57Breakdown am of tasks delegated to Physician Assistants by Mohs Lentigo Maligna Melanoma: Analysis of Surgical Presenter:Micrographic Kevan G. Lewis, Surgeons MD Title: Efficacy, Tolerability and Cost-effectiveness of Topical 5-Fluorouracil vs. ImiquimodMargins for and the Long-term Recurrence in 71 Cases from TreatmentThis of Superficialdata was in Basal response Cell Carcinoma: to the question: A Randomized “What portions Double of Blind the Clinicala S Trialingle Practice 1, 2 2 2 Authors: KevanMMS process G. Lewis, are MD being; Katherine delegated Cordova, to PAs?” MD ; Nathaniel J. Jellinek 1 Institutions: 1. Dermatology, Mayo Clinic, Rochester, MN, United States 2. Dermatology,Aut Brownhors: Medical Joshua B. Wilson, MD ; Hobart W. Walling, MD, School, Providence, RI, United States PhD3; Roger I. Ceilley, MD1; Andrew K. Bean, MD1; Richard 7:49 – 7:57 am Scupham, MD2 Purpose: Presenter:To compare the Kevan efficacy, G. tolerability Lewis, MDand cost-effectiveness of topical 5-fluorouracil to imiquimod for the treatment of superficial basal cell carcinoma. Institutions: 1. Dermatology PC, West Des Moines, Title: Efficacy, Tolerability and Cost-effectiveness IA, United States 2. Iowa Pathology Associates, Iowa Design: Aof prospective, Topical randomized,5-Fluorouracil double vs.blind, Imiquimod vehicle-controlled for theclinical trial. Methodist Medical Center, Des Moines, IA, United States 3. Treatment of Superficial Basal Cell Carcinoma: A Summary: Results are based on an intent-to-treat analysis of 18 subjects (9 female, 9 Townmale; ages Square 39-77, Dermatology, Coralville, IA, United States Randomized Double Blind Clinical Trial mean 71y) meeting the criteria for inclusion who enrolled in the study. Subjects were randomizedPurpose: to Margin one control surgery offers the highest cure of two study groups: (N=7) 5-fluorouracil 5% cream1, 2 (twice daily application for 6 weeks), or (N=11) imiquimodAut 5% creamhors: (once Kevan daily G.application Lewis, MDof drug; andKatherine once daily Cordova, application of vehiclerate cream for lentigofor 6 maligna (LM) and LM melanoma (LMM). MD2; Nathaniel J. Jellinek2 However, recommended margins often prove inadequate. LimitedPage data 49 of 114are available regarding recurrence after Institutions: 1. Dermatology, Mayo Clinic, Rochester, staged excision. The purpose of this was to assess the MN, United States 2. Dermatology, Brown Medical School, surgical margins necessary for clearance of LM and LMM Providence, RI, United States and the long-term recurrence rate of LM/LMM treated by staged excision with rush permanent sections. Research Abstract Session – Saturday, May 1: 7:15 – 8:45 am

Design: Retrospective chart review of patients with LM expression analysis. Immunofluorescence microscopy treated by staged excision. was performed to determine the source of VEGF-C in the tumor microenvironment. Summary: Seventy-one patients (41 male, 30 female, mean age 68.3 ± 10.1 years) were treated for LM (61) Summary: We found increased lymphatic density and or LMM (10) from 1986 to 2005, with ongoing follow-up reorganized lymphatic endothelial vessels in the dermis through 2009. Fifty-one tumors (72%) were located on the adjacent immediately to SCC tumor nests. RT-PCR head and neck (32% cheek). Mean follow-up duration confirmed the presence of VEGF-C in skin immediately was 91.3 months (range 8-266 months). Four tumors adjacent to SCC. Laser capture microdissection allowed (all facial LM) recurred after a mean interval of 24.3 us to isolate the inflammatory infiltrate adjacent to months (range 8-35). The recurrent tumors did not vary SCC which confirmed the increased expression of significantly compared to the non-recurrent tumors in any VEGF-C. The presence of CD163+/VEGFC+ cells by parameter, including pre-operative size, post-operative immunofluorescence microscopy suggested that VEGF-C size, or number of stages. The 5-year recurrence risk (via is macrophage derived. Kaplan-Meier calculations) was 5.8% (95% confidence Conclusion: Tumor associated macrophages may be interval 1.9% - 14.7%). This recurrence risk remained stable an important source of VEGF-C contributing to increased at 10 years. Among 67 tumors that did not recur, clear lymphatic vessel density surrounding SCC. Based on this, margins were obtained in one stage in 36 cases (54%), a higher density of tumor associated macrophages may two stages in 19 cases (28%), three stages in 7 cases (10%), be associated with a “pro-tumor” rather than “anti- and four or more stages in 5 cases (7%) The overall margin tumor” effect. Clarification of mechanisms governing for tumor clearance was 6.1 ± 0.5 mm for LM and 9.0 ± 1.5 lymphangiogenesis in the tumor microenvironment may mm for LMM. LM of the cheek required more stages (2.5 lead to identification of novel targets for therapeutic ± 0.4) and a wider margin (8.0 ± 1.2 mm) than LM at other intervention for high risk SCC. sites (p<0.04). Recommended margins (0.5 cm for LM, 1 cm for LMM) would have been adequate for 29/54 (54%) 8:13 – 8:21 am LM cases, 19/40 (48%) of head/neck LM, and 7/8 (88%) Presenter: Leonid Izikson, MD cases of LMM. Title: Prevalence of Underdiagnosed Aggressive Conclusion: Staged excision of LM and LMM is associated with a low recurrence rate. Tumors of the Non-melanoma Skin Cancers Treated with Mohs cheek required more stages and a greater margin for Micrographic Surgery: Analysis of 468 Cases clearance. The finding that nearly half of tumors were Authors: Leonid Izikson, MD; Marie Seyler; Nathalie C. not cleared with the recommended surgical margin Zeitouni, MDCM, FRCPC underscores the importance of margin-control surgery. Institution: Dermatology, Roswell Park Cancer Institute, 8:05 – 8:13 am Buffalo, NY, United States Presenter: John A. Carucci, MD, PhD Purpose: To examine the prevalence of biopsy-based Title: Human Cutaneous Squamous Cell Carcinoma underdiagnosis of aggressive non-melanoma skin is Associated with Increased Lymphatic Density cancer (NMSCA) subtypes in cases referred for Mohs micrographic surgery (MMS). in the Tumor Microenvironment and Increased Expression of Macrophage Derived VEGF-C Design: A retrospective chart review was performed

1 of 468 consecutive cases of primary NMSCA with a Authors: John A. Carucci, MD, PhD ; Dariush Moussai, biopsy-proven diagnosis of basal (BCC) or squamous MD1; Hiroshi Matsui, MD2; Katherine C. Pierson2; James G. 2 cell (SCC) carcinoma treated with MMS. All histological Krueger, MD, PhD tumor layers were reexamined by two dermatologists to Institutions: 1. Dermatology, Weill Medical College establish an intraoperative diagnosis. Correlation was of Cornell, New York, NY, United States 2. Investigative then made between the preoperative lesion diagnosis Dermatology, Rockefeller University, New York, NY, United and the histological tumor layer diagnosis. Tumors were States classified as aggressive subtypes (invasive SCC, as well as basosquamous carcinoma and infiltrating, morpheaform, Purpose: Metastases from primary cutaneous SCC micronodular, and keratinizing BCC) or non-aggressive account for the majority of deaths from non-melanoma subtypes (SCCIS, as well as superficial, nodular, adenoid skin cancer in the United States each year. We studied cystic, and follicular BCC). Cases were divided into lymphangiogenesis in human SCC because of the categories based on whether the preoperative and potential link to metastasis. intraoperative diagnosis showed discordance in Design: Human SCC samples were stained for lymphatic identifying tumor subtypes. The total number of cases endothelial vessel marker LYVE-1 and positive cells in each category was tabulated, and percentages were counted in tumors and compared with normal calculated based on the total number of 468 examined skin. Gene set enrichment analysis and RT-PCR was cases. performed on SCC, adjacent non-tumor bearing skin Summary: In 52.4% of the cases, biopsy and and normal skin to determine differential expression of intraoperative examination of NMSCA showed lymphangiogenesis associated genes. Laser capture concordance in the diagnosis of an aggressive or a microdissection was performed to isolate tumor and non-aggressive tumor subtype. In 17.3% of the cases, tumor-associated inflammatory cells for further gene intraoperative examination revealed an aggressive tumor G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc Presenter: Hillary Johnson-Jahangir, MD, PhD Title: Modified Flap Design for Symmetric Reconstruction of the Apical Triangle of the Upper Lip Authors: Hillary Johnson-Jahangir, MD, PhD; Mary Stevenson, BA; Désirée Ratner, MD Institution: Dermatology, Columbia University, New York, NY, United States

Purpose: The apical triangle of the upper lip, described by Burget, is a subunit of the cutaneous upper lip located at the confluence of the nose, lip, and cheek (Figure 1a). Defects of the apical triangle present a reconstructive challenge in terms of proper placement of the upper nasolabial fold and preservation of facial symmetry. If the apical triangle is not taken into account when repairing such defects, the upper nasolabial fold may be displaced inferiorly with asymmetric loss of the apical triangle subunit, which may lead to visible facial asymmetry. We present a further modification of the cheek advancement flap for repair of apical triangle defects to address this concern.

Design: Twenty-seven patients with defects involving the apical triangle of the upper lip after Mohs micrographic surgery for BCC or SCC were followed between 2002 through 2008 (Table 1). Patients were reconstructed with or without modification of the cheek advancement flap. The modified cheek advancement flap was performed by making an incision extending from the alar crease onto the nasal sill in order to optimize facial symmetry. For larger defects extending onto the nose or including additional subunits of the upper lip, Burrow’s full thickness skin grafts were sometimes required to repair a portion of the defects. Photographs taken at the time of surgery were reviewed for evaluation of symmetry of the bilateral apical triangle.

Summary: Apical triangle defects were repaired utilizing a standard cheek advancement flap (Figure 1b) Research Abstract Session – Saturday,or a modifiedMay 1: cheek7:15 –advancement 8:45 am flap (Figure 1c) in which an additional incision was made inferiorly along the alar crease onto the nasal sill. The modification allowed for advancement of the upper subtype that was not diagnosed by biopsy. In 23.3% of cutaneousSummary: lip Apical to meet triangle the apex defects of the were hairless repaired triangl utilizinge with symmetrical placement of the nasolabial fold. the cases, intraoperative examination found no residual Fora standard larger defects cheek involvingadvancement significant flap portions(Figure 1b) of theor aupper lip or nasal sidewall, Burrow’s full thickness tumor in the biopsied site. skinmodified grafts werecheek required advancement to fully repairflap (Figure the defects. 1c) in which

Conclusion: In the majority of cases, there was an additional incision was made inferiorly along the alar concordance between the initial NMSCA diagnosis and Nocrease difference onto the in complicationsnasal sill. The modification was noted between allowed the for two reconstructive methods. Complications the final Mohs tumor layer diagnosis. The prevalence of includedadvancement hypertrophic of the upperscarring, cutaneous foreign bodylip to reactionmeet the to ingrown hair, suture granuloma, or pyogenic aggressive SCC and BCC subtypes underdiagnosed by granuloma.apex of the Hemorrhage, hairless triangle necrosis, with symmetrical and infection placement did not occur. biopsy in this study suggests that a significant proportion of the nasolabial fold. For larger defects involving of biopsied NMSCA may be treated sub-optimally in the Conclusion:significant portions Modification of the ofupper the lipcheek or nasal advancement sidewall, flap for reconstruction of perialar defects involving clinical settings. theBurrow’s apical full triangle thickness subunit skin graftsof the wereupper required lip is a simpleto fully and reliable technique for aesthetic preservation of facialrepair symmetry. the defects. Rotation flaps may be a useful alternative for recreating defects of the upper lip involving 8:21 – 8:29 am theNo lowerdifference portion in complicationsof the apical triangle. was noted Other between reconstructive the alternatives, including crescentic Presenter: Hillary Johnson-Jahangir, MD, PhD advancementtwo reconstructive flaps, methods. nasolabial Complications transposition includedflaps, or island pedicle flaps, may not be as effective in hypertrophic scarring, foreign body reaction to ingrown Title: Modified Flap Design for Symmetric recreating the apical subunit and may present additional aesthetic challenges. hair, suture granuloma, or pyogenic granuloma. Reconstruction of the Apical Triangle of the Upper Hemorrhage, necrosis, and infection did not occur. Lip Figure 1

Authors: HillaryG:\Mohs\Annual Johnson-Jahangir, Meeting\Publications\2010\Final MD, PhD; Program\201 Mary0 Draft Final program Copy.doc Stevenson,Presenter: Hillary BA; Johnson-Jahangir, Désirée Ratner, MD, PhD MD Title: Modified Flap Design for Symmetric Reconstruction of the Apical Triangle of the Upper Lip Institution:Authors: Hillary Johnson-Jahangir, Dermatology, MD, PhD; Columbia Mary Stevenson, University, BA; Désirée Ratner,New MD Institution: Dermatology, Columbia University, New York, NY, United States York, NY, United States Purpose: The apical triangle of the upper lip, described by Burget, is a subunit of the cutaneous upper lip Purpose:located at the confluenceThe apical of the nose,triangle lip, and ofcheek the (Figure upper 1a). Defects lip, described of the apical triangle present a byreconstructive Burget, challengeis a subunit in terms of proper the placement cutaneous of the upper upper nasolabial lip foldlocated and preservation of facial symmetry. If the apical triangle is not taken into account when repairing such defects, the upperTableFigure 1.1: Patient Characteristics atnasolabial the confluence fold may be displaced of inferiorlythe nose, with asymme lip, tricand loss cheekof the apical (Figure triangle subunit,1a). which may lead to visible facial asymmetry. We present a further modification of the cheek advancement flap for Modified Advancement Standard Advancement Defectsrepair of apical of trianglethe apical defects to triangle address this presentconcern. a reconstructive Conclusion:Characteristic Modification of the cheek advancement challenge in terms of proper placement of the upper flap for reconstruction of perialar defects Flapinvolving the Flap Design: Twenty-seven patients with defects involving the apical triangle of the upper lip after Mohs nasolabialmicrographic surgery fold for and BCC preservationor SCC were followed of bet facialween 2002 symmetry. through 2008 (Table If the 1). Patientsapical were triangle subunit of the upper lip is a simple17 and 10 reconstructed with or without modification of the cheek advancement flap. The modified cheek Patients, n apicaladvancement triangle flap was isperformed not taken by making into an incisionaccount extending when from the repairing alar crease onto the nasalreliable sill technique for aesthetic preservation of facial suchin order defects, to optimize facialthe symmetry. upper Fornasolabial larger defects extendingfold may onto bethe nose displaced or including additionalsymmetry. Sex, Rotation % male flaps may be a useful alternative6 for 40 subunits of the upper lip, Burrow’s full thickness skin grafts were sometimes required to repair a portion of inferiorlythe defects. withPhotographs asymmetric taken at the time loss of surgeryof the were apical reviewed triangle for evaluation of symmetry ofrecreating the Sex, defects% female of the upper lip involving94 the lower 60 subunit,bilateral apical which triangle. may lead to visible facial asymmetry. We portion of the apical triangle. Other reconstructive Age, range (mean, presentSummary: aApical further triangle modification defects were repaired utilizingof the a standardcheek cheek advancement advancement flap (Figurealternatives, 1b) including crescentic advancement53-95 (74,76) flaps, 51-81 (72,76) flapor a modified for repair cheek advancement of apical flap triangle (Figure 1c) indefects which an additional to address incision wasthis made inferiorlynasolabial median) transposition flaps, or island pedicle flaps, may along the alar crease onto the nasal sill. The modification allowed for advancement of the upper concern.cutaneous lip to meet the apex of the hairless triangle with symmetrical placement of the nasolabialnot fold. Defect be as effective size, cm2,% in recreating the apical subunit and For larger defects involving significant portions of the upper lip or nasal sidewall, Burrow’s full thicknessmay present additional aesthetic challenges. Design:skin grafts were Twenty-seven required to fully repair patients the defects. with defects involving the apical triangle of the upper lip after Mohs micrographic No difference in complications was noted between the two reconstructive methods. Complications 8:29 – 8:37 am Page 52 of 114 surgeryincluded hypertrophic for BCC scarring, or SCC foreign were body reactionfollowed to ingrown between hair, suture 2002granuloma, or pyogenic granuloma. Hemorrhage, necrosis, and infection did not occur. Presenter: Yang Xia, MD through 2008 (Table 1). Patients were reconstructed with orConclusion: without Modification modification of the cheek of advancement the cheek flap for advancement reconstruction of perialar flap. defects involving the apical triangle subunit of the upper lip is a simple and reliable technique for aesthetic preservationTitle: of Randomized Study to Assess the Wound Thefacial modified symmetry. Rotation cheek flaps mayadvancement be a useful alternative flap for recreating was defectsperformed of the upper lip involvingInfection Incidence Using Clean versus Sterile bythe making lower portion an of the incision apical triangle. extending Other reconstructive from thealternatives, alar includingcrease crescentic advancement flaps, nasolabial transposition flaps, or island pedicle flaps, may not be as effective inGloves for Mohs Micrographic Surgery (MMS) ontorecreating the the nasal apical subunit sill in and order may present to optimize additional aesthetic facial challenges. symmetry. Wound Repairs For larger defects extending onto the nose or including Figure 1 1 2 additional subunits of the upper lip, Burrow’s full thickness Authors: Yang Xia, MD ; Sunghun Cho, MD ; Daniel E. skin grafts were sometimes required to repair a portion Zelac, MD1; Hubert T. Greenway, Jr., MD1 of the defects. Photographs taken at the time of surgery Institutions: 1. Division of Mohs Surgery, Scripps Clinic, were reviewed for evaluation of symmetry of the bilateral La Jolla, CA, United States 2. Dermatology, Darnall Army apical triangle. Table 1: Patient Characteristics Medical Center, Ft. Hood, TX, United States Modified Advancement Standard Advancement Characteristic Flap Flap Purpose: The purpose of this study is to assess the Patients, n 17 10 difference in the wound infection rate when using clean, Sex, % male 6 40 non-sterile gloves versus sterile gloves for wound repairs in Sex, % female 94 60 Mohs micrographic surgery. Age, range (mean, 53-95 (74,76) 51-81 (72,76) median) Design: This is a prospective subject-blinded single G:\Mohs\Annual Meeting\P ublications\2010\Final Program\201 0 Draft Final program Copy.doc Defect size, cm2,% institution pilot study with plans to expand to a multi- <1.0 12 0 1.0-3.0 40 60 Page 52institutional of 114 study within one year. The study is designed 3.1-5.0 6 10 to investigate the difference in infection rate using clean, 5.1-7.0 18 10 non-sterile gloves versus sterile gloves when repairing 7.1-9.0 12 10 surgical defects during Mohs surgery. Enrollment for >9.0 12 10 this pilot study will include 60 patients. Patients who are Burrow’s FTSG, n 13 4 repaired by an outside physician, take antibiotics prior to

Table8:29 – 1:8:37 Patient am Characteristics Presenter: Yang Xia, MD Title: Randomized Study to Assess the Wound Infection Incidence Using Clean versus Sterile Gloves for Mohs Micrographic Surgery (MMS) Wound Repairs 1 2 1 1 Authors: Yang Xia, MD ; Sunghun Cho, MD ; Daniel E. Zelac, MD ; Hubert T. Greenway, Jr., MD Institutions: 1. Division of Mohs Surgery, Scripps Clinic, La Jolla, CA, United States 2. Dermatology, Darnall Army Medical Center, Ft. Hood, TX, United States

Purpose: The purpose of this study is to assess the difference in the wound infection rate when using clean, non-sterile gloves versus sterile gloves for wound repairs in Mohs micrographic surgery.

Design: This is a prospective subject-blinded single institution pilot study with plans to expand to a multi- institutional study within one year. The study is designed to investigate the difference in infection rate using clean, non-sterile gloves versus sterile gloves when repairing surgical defects during Mohs surgery. Enrollment for this pilot study will include 60 patients. Patients who are repaired by an outside physician, take antibiotics prior to the procedure, or have other serious medical conditions are excluded. Subjects will be stratified and randomized to have their repairs performed with either clean, non-sterile gloves or sterile gloves. The particular glove type will be used throughout the entire repair, even if the physician or surgical assistant requires multiple glove changes. Sterile patient prep and sterile surgical trays will still be used during all wound repairs. In addition to the glove type, data to include patient’s age, sex, anatomic location of skin cancer, number of Mohs stages, closure type, final surgical defect size, and total surgical time (from first cut to closure) will be collected. After wound repair, each patient will follow-up between 5 to 21 days for suture removal and wound assessment. Wound assessment is performed by a healthcare professional (i.e. a nurse or a medical assistant) outside of the study and the wound is scored based on the following scale. A score of 0 is given to wounds with zero or slight erythema. A score of 1 is given to wounds with erythema less than 1 cm from suture line. A score of 2 is given to wounds with erythema greater than 1 cm from suture line with or without edema. A score of 3 is given to wounds with exudates and purulent drainage.

Summary: Three months of data have been collected from the 29 patients enrolled in the study. Eighteen patients were repaired with clean gloves and 11 patients were repaired with sterile gloves. One patient from the clean glove arm of the study had clinical infection during follow-up and 2 patients from the sterile glove arm of the study had clinical infection during follow-up. Seven months of data, to include information on patient demographics and characteristics of the skin cancer excised, will be available at the time of the Mohs College meeting.

Conclusion: (Preliminary) the infection rate in MMS wound repairs between clean, non-sterile gloves versus sterile gloves is not statistically significant. From our pilot study, dermatologic surgeons can use clean, non-sterile gloves for simple uncomplicated wound repairs. The implication from this study may lead to significant cost savings when using clean, non-sterile gloves instead of sterile gloves for Mohs surgical repairs.

8:37 – 8:45 am Presenter: Daniel I. Wasserman, MD Title: A Prospective Pilot Study of the Alexandrite Laser on Basal Cell Carcinomas 1 2 1 Authors: Daniel I. Wasserman, MD ; Zeina S. Tannous, MD ; Gary D. Monheit, MD . Institutions: 1. Total Skin & Beauty Dermatology Center, Birmingham, AL, United States 2. Dermatology, Massachusetts General Hospital, Boston, MA, United States

Page 53 of 114 Research Abstract Session – Saturday, May 1: 7:15 – 8:45 am the procedure, or have other serious medical conditions Purpose: Skin cancer represents the most common form are excluded. Subjects will be stratified and randomized of human cancer. Basal cell carcinomas (BCC) are slow to have their repairs performed with either clean, non- growing tumors that comprise roughly 80% of all non- sterile gloves or sterile gloves. The particular glove type melanoma skin cancers (NMSCs). Due to the lack of its will be used throughout the entire repair, even if the emergent nature, several approaches have evolved for physician or surgical assistant requires multiple glove the treatment of this slow growing, locally destructive changes. Sterile patient prep and sterile surgical trays will cancer. They include Mohs micrographic surgery (MMS), still be used during all wound repairs. In addition to the excision, electrodessication and curettage (ED&C), glove type, data to include patient’s age, sex, anatomic cryosurgery, topical immunomodulators, photodynamic location of skin cancer, number of Mohs stages, closure therapy, and radiotherapy. Recently, the pulsed-dye laser type, final surgical defect size, and total surgical time (PDL) (595 nm) has demonstrated considerable efficacy (from first cut to closure) will be collected. After wound for superficial BCCs. The PDL for the use of BCCs is limited repair, each patient will follow-up between 5 to 21 days by its penetration of approximately 2 mm. Increasing for suture removal and wound assessment. Wound the penetration 50% to a depth of 3 mm, achieved by assessment is performed by a healthcare professional the 755-nm alexandrite laser, could potentially provide (i.e. a nurse or a medical assistant) outside of the study increased complete clearance rates for not only and the wound is scored based on the following scale. A superficial BCCs, but also perhaps nodular BCCs. Based score of 0 is given to wounds with zero or slight erythema. on the deep penetration of long wavelength visible A score of 1 is given to wounds with erythema less than and near infrared light, and a small peak of hemoglobin 1 cm from suture line. A score of 2 is given to wounds absorption in the 800–900 nm range, long-pulsed with erythema greater than 1 cm from suture line with millisecond-domain alexandrite lasers (755-nm) have or without edema. A score of 3 is given to wounds with been developed to treat moderately deep, larger caliber exudates and purulent drainage. spider and feeding reticular . Currently, there are no reports for the use of the 755-nm alexandrite laser for the Summary: Three months of data have been collected purpose of treating basal cell carcinomas. The goal of this from the 29 patients enrolled in the study. Eighteen pilot study is to determine whether superficial and nodular patients were repaired with clean gloves and 11 patients basal cell carcinomas can be successfully treated using were repaired with sterile gloves. One patient from the 755-nm alexandrite laser. the clean glove arm of the study had clinical infection during follow-up and 2 patients from the sterile glove Design: Approximately 12 patients with biopsy-proven arm of the study had clinical infection during follow-up. nodular or superficial basal cell carcinomas less than 2 Seven months of data, to include information on patient cm located on the trunk or extremities (chest, abdomen, demographics and characteristics of the skin cancer back, arms or legs), suitable for treatment by standard excised, will be available at the time of the Mohs College surgical excision were enrolled in this study. Following meeting. a standard baseline screening visit, each tumor was treated with the 755-nm alexandrite laser (GentleLASE®, Conclusion: (Preliminary) the infection rate in MMS Candela Corporation, Wayland, MA) either once or 4 wound repairs between clean, non-sterile gloves versus times at 2-4 week intervals. Two-to-four weeks following sterile gloves is not statistically significant. From our pilot the final treatment, all tumors were excised according study, dermatologic surgeons can use clean, non-sterile to standard of care. All excisional specimens were then gloves for simple uncomplicated wound repairs. The reviewed histologically for the complete clearance or implication from this study may lead to significant cost partial clearance of tumors. In addition to efficacy, pain, savings when using clean, non-sterile gloves instead of purpura, edema, and blistering following treatments were sterile gloves for Mohs surgical repairs. measured during the study. Photos were taken throughout 8:37 – 8:45 am the study. Presenter: Daniel I. Wasserman, MD Summary: This study is currently in progress and preliminary results will be discussed at the Annual Meeting. Title: A Prospective Pilot Study of the Alexandrite Laser on Basal Cell Carcinomas Conclusion: Conclusion will be discussed at the Mohs

1 College Annual Meeting pending analysis of all available Authors: Daniel I. Wasserman, MD ; Zeina S. Tannous, data. MD2; Gary D. Monheit, MD1. Institutions: 1. Total Skin & Beauty Dermatology Center, Birmingham, AL, United States 2. Dermatology, Massachusetts General Hospital, Boston, MA, United States G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc Conclusion: The one-stage nasolabial transposition flap is a reliable reconstruction option that results in reproducibly excellent cosmetic and functional outcomes for alar defects. This approach to the nasolabial transposition flap provides an excellent alternative to traditional multi-staged flaps. This technique offers advantages including single-stage procedure, suitable color and texture match, excellent vascular supply, abundant tissue laxity from the medial cheek, and well-concealed donor site scar along the melolabial fold.

Figure 1. Defect (A) and postoperative result (B) 2 months after reconstruction with NLT flap.

Figure 2. Defect (A) and postoperative result (B) 4 months after Clinical Pearls Abstract Session – Saturday, May 1: 12:30 – 2:30 pmreconstruction with NLT flap.

12:30 – 12:38 pm Presenter: Christopher J. Miller, MD Title: Revisiting the One-stage Nasolabial Figure 3. Defect (A) and postoperative result (B) 5 months after Transposition Flap reconstruction with NLT flap. Authors: Christopher J. Miller, MD2, 1; Aerlyn G. Dawn, MD, MBA1

Institutions: 1. Dermatology, University of Pennsylvania, Philadelphia, PA, United States 2. Division of Dermatologic Figure 3. Defect (A) and Surgery, University of Pennsylvania, Philadelphia, PA, postoperative12:38 – 12:46 result pm (B) 5 months after reconstruction United States Presenter: Theresa L. Ray, MD withTitle: NLT Retroauricular flap. Chondrocutaneous Interpolation Flap for Reconstruction of Large Helical Purpose: The small size of the alar subunit forces the Defects surgeon to recruit donor tissue from outside cosmetic 12:38Authors: – 12:46 Theresa pm L. Ray, MD; Rehana L. Ahmed, MD; Peter K. Lee, MD, PhD subunits to repair all but the smallest defects. One-stage Presenter:Institution: Dermatology, Theresa L. Ray, University MD of Minnesota, St. Louis Park, MN, United States reconstruction with local flaps risks deformity of the subtle contours of the convex ala, its free margin, and TPurpose:itle: Retroauricular Full thickness Chondrocutaneousdefects of the helical rim I nterpolationpresent a reconstructive challenge. If the defect is large, the concave transition to the neighboring cosmetic Flapthe ear for may Reconstruction be structurally compromised of Large Helical leading Defects to difficulty with use of hearing aids and eyeglasses. subunits. The one-staged nasolabial transposition flap Further, the loss of cartilage presents a challenge cosmetically, as a loss of helical contour is Autunacceptablehors: Theresa for many L. patients.Ray, MD; The Rehana classic L. retroauricular Ahmed, MD; interpolation flap can be used for large helical provides excellent color and texture match for alar Peterdefects K. andLee, can MD, provide PhD superior cosmetic results; however, if the helical cartilage is lost, a cartilage graft defects. However, the flap can succumb to trapdoor should be placed under the flap to maintain structural integrity. Harvesting a separate cartilage graft adds deformity and interrupt contour by blunting the Institution: Dermatology, University of Minnesota, St. Louistime toPark, reconstruction MN, United and States could leave an additional donor-site scar if taken from the contralateral ear. We concave boundaries of the ala. We present a simple, propose a retroauricular interpolation flap for reconstruction of large helical defects, which incorporates reliable approach to the nasolabial transposition flap Purpose:retroauricular Full cartilage thickness into defects the flap of itself. the Tohelical our knowledge, rim present this has not yet been described in the that minimizes these common complications, reliably aliterature. reconstructive Herein is challenge. our experience If the with defect 18 patients. is large, the ear produces a cosmetic outcome that rivals or surpasses may be structurally compromised leading to difficulty other reconstruction options, and offers patients the withDesign: use Allof hearingdefects resulted aids and from eyeglasses. Mohs micrographic Further, suthergery loss and were large enough to risk structural convenience of a one-stage flap that rarely requires ofcompromise cartilage topresents the ear. a A challenge traditional retroauricular cosmetically, in terpolationas a loss flap was outlined posterior to the defect. A secondary scar revision. ofportion helical of thecontour underlying is unacceptable cartilage just behindfor many the patients.leading edge The of the flap was taken as part of the flap and used to reconstruct the helix. The cartilage is attached to the flap, thereby maintaining its innate classic retroauricular interpolation flap can be used for Design: We present flap indications, design, execution, vascular supply. The flap is then sutured into place and the leading edge of the flap, anterior to the large helical defects and can provide superior cosmetic and tips for success in a step-by-step manner using clinical cartilage graft, wrapped around the front of the ear to recreate the anterior helical rim. Buried vertical photos. We report our experience in 21 patients using a results;mattress however, sutures using if the 5-0 helical polyglactin cartilage were is used lost, fora cartilagedeep closure followed by interrupted anchoring one-stage nasolabial transposition flap for reconstruction graftsutures should using be 5-0 placed polypropylene. under theThe flapremainder to maintain of the superficial closure was then achieved using a of alar defects. structuralrunning stitch integrity. with 5-0 Harvesting chromic gut. a separateA through cartilageand through basting stitch is then placed through the graftscapha adds to hold time the to cartilage reconstruction in place atand the could helix. Afterleave 3 anweeks the flap is divided and inset in the Summary: Twenty-one patients underwent Mohs additionalstandard fashion. donor-site The secondary scar if taken defect from continues the contralateral to heal by second intent. micrographic surgery for tumors of the ala. All patients ear. We propose a retroauricular interpolation flap Page 55 of 114 were successfully repaired with a nasolabial transpositionG:\Mohs\Annual for reconstruction Meeting\Publications\2010\Final of large helical defects, Program\201 which 0 Draft Final program Copy.doc flap. All patients had excellent cosmetic and functional incorporates retroauricular cartilage into the flap itself. outcomes with preservation ofConclusion: the subtle concavity The one-stage of the nasolabial transposition flap is a reliable reconstruction option that results in reproducibly excellent cosmeticTo and our functionalknowledge, outcomes this has not for yet alar been defects. described This approachin the to the nasolabial superior alar crease. Scar revision was rare and primarily literature. Herein is our experience with 18 patients. used to address focal inversiontransposition of the scar. flap provides an excellent alternative to traditional multi-staged flaps. This technique offers advantages including single-stageDesign: procedure, All defects suitable resulted color from and Mohs texture micrographic match, excellent vascular supply, Conclusion: The one-stage nasolabial transposition flap is abundant tissue laxity from thesurgery medial and cheek, were and large we enoughll-concealed to risk donor structural site scar along the melolabial a reliable reconstruction option that results in reproducibly fold. compromise to the ear. A traditional retroauricular excellent cosmetic andG:\Mohs\Annual functional outcomes Meeting\P forublications\2010\Final alar interpolation Program\201 flap 0 wasDraft outlined Final program posterior Copy.doc to the defect. A defects. This approach to the nasolabial transposition portion of the underlying cartilage just behind the leading The one-stage nasolabial transposition flap is a reliable reconstruction option that results in flapConclusion: provides an excellent alternative to traditional multi- edge of the flap was taken as part of the flap and used stagedreproducibly flaps. excellentThis technique cosmetic offers and advantages functional including outcomes forto alar reconstruct defects. This the helix.approach The cartilage to the nasolabial is attached to the single-stagetransposition procedure, flap provides suitable an excellent color and alternative texture match, to traditional flap, multi-staged thereby maintaining flaps. This its technique innate vascular offers supply. The excellentadvantages vascular including supply, single-stage abundant procedure, tissue laxity suitable from the color flapand textureis then suturedmatch, intoexcellent place vascular and the supply,leading edge of medialabundant cheek, tissue and laxity well-concealed from the medial donor cheek, site scar and alongwell-concealed the flap, donorFigure anterior site 1.scar to Defect the along cartilage (A) the and melolabial graft, postoperative wrapped around result (B) 2 months after the melolabial fold. fold. the frontreconstruction of the ear to recreate with NLTthe anterior flap. helical rim. Buried vertical mattress sutures using 5-0 polyglactin were used for deep closure followed by interrupted anchoring sutures using 5-0 polypropylene. The remainder of the

superficial closure was then achieved using a running stitch with 5-0 chromic gut. A through and through basting Figure 2. Defect (A) and postoperative result (B) 4 months after Figure 1. Defect (A) andstitch postoperative is then placed result through (B) the 2 monthsscapha toafter hold the reconstruction with NLT flap. reconstruction with NLTcartilage flap. in place at the helix. After 3 weeks the flap is divided and inset in the standard fashion. The secondary

Figure 1. Defect (A) and defect continues to heal by second intent. postoperative result (B) 2 Figure 2. Defect (A) and months after reconstruction postoperative result (B) 4 with NLT flap. months after reconstruction with NLT flap.Figure 2. Defect (A) and postoperative result (B) 4 months after reconstruction with NLTFigure flap. 3. Defect (A) and postoperative result (B) 5 months after reconstruction with NLT flap.

Figure 3. Defect (A) and postoperative result (B) 5 months after 12:38reconstruction – 12:46 pm with NLT flap. Presenter: Theresa L. Ray, MD Title: Retroauricular Chondrocutaneous Interpolation Flap for Reconstruction of Large Helical Defects Authors: Theresa L. Ray, MD; Rehana L. Ahmed, MD; Peter K. Lee, MD, PhD Institution: Dermatology, University of Minnesota, St. Louis Park, MN, United States 12:38 – 12:46 pm Presenter: Theresa L. Ray,Purpose: MD Full thickness defects of the helical rim present a reconstructive challenge. If the defect is large, Title: Retroauricular Chondrocutaneousthe ear may be Interpol structurallyation compromised Flap for Reconstruction leading to di offficulty Large with Helical use of hearing aids and eyeglasses. Defects Further, the loss of cartilage presents a challenge cosmetically, as a loss of helical contour is Authors: Theresa L. Ray, MD;unacceptable Rehana L. Ahmed,for many MD; patients. Peter K.The Lee, classic MD, PhDretroauricular interpolation flap can be used for large helical Institution: Dermatology, Universitydefects andof Minneso can provideta, St. superiorLouis Park, cosmetic MN, United results; States howeve r, if the helical cartilage is lost, a cartilage graft should be placed under the flap to maintain structural integrity. Harvesting a separate cartilage graft adds Full thickness defects of the helical rim present a reconstructive challenge. If the defect is large, Purpose: time to reconstruction and could leave an additional donor-site scar if taken from the contralateral ear. We the ear may be structurally compromised leading to difficulty with use of hearing aids and eyeglasses. Further, the loss of cartilage proposepresents aa retroauricularchallenge cosmetically, interpolation as a flap loss for of reconshelical tructioncontour ofis large helical defects, which incorporates unacceptable for many patients.retroauricular The classic cartilage retroauricular into the interpolation flap itself. Toflap our can knowledge, be used for thislarge has helical not yet been described in the defects and can provide superiorliterature. cosmetic Herein results; is our howeve experiencer, if the with helical 18 patients.cartilage is lost, a cartilage graft should be placed under the flap to maintain structural integrity. Harvesting a separate cartilage graft adds time to reconstruction and couldDesign: leave All an defects additional resulted donor-site from scar Mohs if takenmicrographic from the sucontralateralrgery and wereear. We large enough to risk structural propose a retroauricular interpolationcompromise flap forto the recons ear.truction A traditional of large retroauricular helical defects, interpolation which incorporates flap was outlined posterior to the defect. A retroauricular cartilage into theportion flap itself. of the To underlying our knowledge, cartilage this just has behind not yet thebeen leadi describedng edge in of the the flap was taken as part of the flap literature. Herein is our experienceand used with to 18 reconstruct patients. the helix. The cartilage is attached to the flap, thereby maintaining its innate vascular supply. The flap is then sutured into place and the leading edge of the flap, anterior to the Design: All defects resulted cartilagefrom Mohs graft, micrographic wrapped suaroundrgery theand frontwere of large the enoughear to recreate to risk structural the anterior helical rim. Buried vertical compromise to the ear. A traditionalmattress retroauricular sutures using interpolation 5-0 polyglactin flap was were outlined used forposterior deep closure to the defect. followed A by interrupted anchoring portion of the underlying cartilagesutures just using behind 5-0 the polypropylene. leading edge ofThe the remainder flap was taken of the as superficial part of the closure flap was then achieved using a and used to reconstruct the helix.running The stitch cartilage with is5-0 attached chromic to gut. the Aflap, through thereby and maintaining through basting its innate stitch is then placed through the vascular supply. The flap is thenscapha sutured to hold into the plac cartilagee and the in leading place at edge the helix.of the Afterflap, anterior3 weeks to the the flap is divided and inset in the cartilage graft, wrapped aroundstandard the front fashion. of the earThe to secondary recreate the defect anterior continues helical torim. heal Buried by second vertical intent. mattress sutures using 5-0 polyglactin were used for deep closure followed by interrupted anchoring sutures using 5-0 polypropylene. The remainder of the superficial closure was then achieved using a Page 55 of 114 running stitch with 5-0 chromic gut. A through and through basting stitch is then placed through the scapha to hold the cartilage in place at the helix. After 3 weeks the flap is divided and inset in the standard fashion. The secondary defect continues to heal by second intent. Page 55 of 114 G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc

Summary: All 18 patients had successful reconstruction with restoration of the auricle’s structural integrity and excellent cosmetic results. We experienced no cases of flap failure or necrosis. We had one case of postoperative infection, which resolved with oral antibiotics and no long term complications. Post- operative pain was minimal for all patients.

Conclusion: In our experience, the retroauricular chondrocutaneous interpolation flap is an excellent option to reliably restore auricular structure after large, full thickness helical defects. It offers a faster, more reliable alternative to the standard interpolation flap over a cartilage graft, with lack of an additional scar at the cartilage donor site. Since the cartilage’s innate blood supply is maintained, the potential for graft/flap failure is reduced as compared to the previous combination. As an additional benefit, it gives excellent cosmetic results with restoration of normal helical contour without shortening the ear.

G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc

Summary: All 18 patients had successful reconstruction with restoration of the auricle’s structural integrity and excellent cosmetic results. We experienced no cases of flap failure or necrosis. We had one case of postoperative infection, which resolved with oral antibiotics and no long term complications. Post- operative pain was minimal for all patients.

Conclusion: In our experience, the retroauricular chondrocutaneous interpolation flap is an excellent option to reliably restore auricular structure after large, full thickness helical defects. It offers a faster, more reliable alternative to the standard interpolation flap over a cartilage graft, with lack of an additional scar at the cartilage donor site. Since the cartilage’s innate blood supply is maintained, the potential for

Clinicalgraft/flap failure is reduced Pearls as comp aredAbstract toFlap the afterprevious elevation. combination. Session A large As full an thicknessadditional – Saturday, benefit,defect ofit givesthe May helix 1:is seen 12:30 on the – left. 2:30 The cartilagepm excellent cosmetic results with restorationportion of normal of helicalthe flap cont is ouroutlined without on shortening the right. the ear.

were numerous and included chronic tobacco use, anticoagulation with two anti-platelet agents, and chronic renal insufficiency. The patient experienced persistent perioperative bleeding during the Mohs resection and later that night requiring a trip to the ER. A delayed reconstruction had been planned the next day under monitored anesthesia care at the patient’s request. He underwent a cartilage graft with a cheek interpolation flap accompanied by extensive bleeding difficult to Flap after elevation. A large full thickness defect of the helix is seen on the left. The cartilage Flap after elevation. A large full Results immediately after flap placementcontrol. showing Becauseexcellent restoration of his bleeding, of auricular he contour was admittedand for 24 portion of the flap is outlined on the right.Resultsstructural immediately integrity. after flap thickness defect of the helix is placement showing excellent hour observation. Within 2 hours post-op he experienced seen on the left. The cartilage restoration12:46 – 12:54 of pm auricular contour profuse bleeding from G:\Mohs\Annualall operative sites. Meeting\P A presumptiveublications\2010\Final Program\2010 Draft Final program Copy.doc portion of the flap is outlined David E. Kent, MD andPresenter: structural integrity. diagnosis of platelet dysfunction of uncertain cause was on the right. Title: Massive Hemorrhage and Platelet Dysfunctionchronic tobaccoFollowing use,Mohs anticoagulationSurgery and Nasal with two anti-platelet agents, and chronic renal insufficiency. The Reconstruction with Cartilage Graft andmade. Interpolation Platelet Flap: Lessonsfunction Learned tests were drawn. The patient 1, 2 patient1 experienced persistent perioperative bleeding during the Mohs resection and later that night Authors: David E. Kent, MD ; Keith M. Harrigill,required MD a return to the OR with general anesthesia, All 18 patients had successful reconstruction requiring a trip to the ER. A delayed reconstruction had been planned the next day under monitored Summary: Institutions: 1. Medicine, Mercer Medical School,administration Macon, GA, ofUnited DDAVP States based2. Dermatology, on patient’s Medical body with restoration of the auricle’sCollege structural of Georgia, integrity Augusta, and GA, United States weight,anesthesia transfusion care at of the phoresed patient’s platelets, request. andHe underwent other a cartilage graft with a cheek interpolation flap excellent cosmetic results. We experienced no cases of accompanied by extensive bleeding difficult to control. Because of his bleeding, he was admitted for 24 Purpose: The purpose of this presentationblood is to highlight products the potential during results the of 24platelet hours dysfunction perioperatively. that His flap failure or necrosis. We had one case of postoperative occurred during Mohs surgery and a nasal plateletcompositehour observation. reconstruction.function studies TheWithin dysfunction returned 2 hours was grossly post-op caused abnormalby he use experie andnced profuse bleeding from all operative sites. A infection, which resolved with oralof two antibiotics platelet inhibitors and (aspirin no long and clopidogrel) and co-morbid conditions including renal insufficiency. hispresumptive hemoglobin diagnosis dropped of from platelet 10.6 dytosfunction 7.3. Hematologic of uncertain cause was made. Platelet function tests were termResults complications. immediately after Post-operativeflap placementWe showin will pain discussg excellent was the useminimal restoration and interpretation for of auricular of platel contouret function and studies, patient management protocol for structural integrity. platelet dysfunction and attempt to identify evaluationthosedrawn. patients The withrevealed patient specific co-morbidrequiredfindings conditions aconsistent return that to might thewith OR drug wi thinduced general anesthesia, administration of DDAVP based all patients. benefit from preoperative platelet function testing.plateleton patient’s dysfunction. body weight, Prior to transfusion an uneventful of phoresed division platandelets, and other blood products during the 24 hours 12:46 – 12:54 pm insetperioperatively. of the flap, repeatHis platelet platelet function function studies studies retu rnedwere grossly abnormal and his hemoglobin dropped from Conclusion:Presenter: David InE. Kent,our experience, MD Design: the retroauricular We present a case of a 73 y/o male that underwent Mohs surgery for a basal cell carcinoma of chondrocutaneousTitle: Massive Hemorrhage interpolation and Plateletthe Dysfunction flapleft nose is resultingan Following excellent in a Mohs3.8 x 3.0Surgery cm soft andnormal. tissue10.6 Nasal defect. to 7.3. The Hematologic defect involved the evaluation left nasal ala, revealed findings consistent with drug induced platelet dysfunction. Reconstruction with Cartilage Graft andunderlying Interpolation cartilage Flap: and Lessons portion Learnedof the side wall.Prior His co-morbidto an uneventful conditions were division numerous and and inset included of the flap, repeat platelet function studies were normal. option to reliably restore1, 2 auricular structure1 after large, full Authors: David E. Kent, MD ; Keith M. Harrigill, MD Conclusion: Platelet dysfunction due to antiplatelet thickness helical defects. It offers a faster, more reliable Institutions: 1. Medicine, Mercer Medical School, Macon, GA, United States 2. Dermatology,agents Medicalcan result in massive bleeding.Page Identification 56 of 114 of alternativeCollege of Georgia, to the Augusta, standard GA, United interpolation States flap over a Conclusion: Platelet dysfunction due to antiplatelet agents can result in massive bleeding. Identification these patients preoperatively is desirable. Management cartilage graft, with lack of an additional scar at the of these patients preoperatively is desirable. Management may require blood products as well as DDAVP. Purpose: The purpose of this presentation is to highlight the potential results of plateletmay dysfunction require that blood products as well as DDAVP. Recognition cartilage donor site. Since the cartilage’s innate blood Recognition of these patients preoperatively with platelet function testing may help to avoid such occurred during Mohs surgery and a nasal composite reconstruction. The dysfunctionof was these caused patients by use preoperatively with platelet function supplyof two platelet is maintained, inhibitors (aspirin the and potential clopidogrel) for and graft/flap co-morbid conditions failure including renalbleeding. insufficiency. Specific patient profiles may the physician identify these patients. testing may help to avoid such bleeding. Specific patient isWe reduced will discuss as the compared use and interpretation to the of previous platelet function combination. studies, patient management protocol for platelet dysfunction and attempt to identify those patients with specific co-morbid conditionsprofiles that mightmay help the physician identify these patients. Asbenefit an fromadditional preoperative benefit, platelet function it gives testing. excellent cosmetic results with restoration of normal helical contour without shorteningDesign: We present the ear. a case of a 73 y/o male that underwent Mohs surgery for a basal cell carcinoma of the left nose resulting in a 3.8 x 3.0 cm soft tissue defect. The defect involved the left nasal ala, underlying cartilage and portion of the side wall. His co-morbid conditions were numerous and included 12:46 – 12:54 pm Presenter: David E. Kent, MD Page 56 of 114 Title: Massive Hemorrhage and Platelet Dysfunction Following Mohs Surgery and Nasal Reconstruction with Cartilage Graft and Interpolation Flap: Lessons Learned Authors: David E. Kent, MD1, 2; Keith M. Harrigill, MD1 Post op hemorrhage due to platelet dysfunction. Post op hemorrhage due to platelet dysfunction. Institutions: 1. Medicine, Mercer Medical School, 12:54 – 1:02 pm Macon, GA, United States 2. Dermatology, Medical Presenter: Chris Kearney, MD College of Georgia, Augusta, GA, United States 12:54Title: – A1:02 Tunneled pm and Turned-over Nasolabial Flap for Reconstruction of Full Thickness Nasal ala Purpose: The purpose of this presentation is to highlight Presenter:Defects Christopher Kearney, MD Chris Kearney, MD; Adam T. Sheridan, MBBS, FACD; Carl Vinciullo, MD; Timothy G. Elliott, the potential results of platelet dysfunction that Title:Authors: A Tunneled and Turned-over Nasolabial Flap MD occurred during Mohs surgery and a nasal composite for Reconstruction of Full Thickness Nasal ala Defects reconstruction. The dysfunction was caused by use of two Institution: Skin and Cancer Foundation, Sydney, Australia, Bondi Junction, NSW, Australia platelet inhibitors (aspirin and clopidogrel) and co-morbid Aut hors: Christopher Kearney, MD; Adam T. Sheridan, conditions including renal insufficiency. We will discuss the MBBS,Purpose: FACD; We Carl describe, Vinciullo, with MD; illustrative Timothy G.cases, Elliott, a singleMD stage flap for repair of full thickness nasal alar rim where the lateral portion of the alar and the alar groove has been preserved during excisional surgery. use and interpretation of platelet function studies, patient Institution: Skin and Cancer Foundation, Sydney, management protocol for platelet dysfunction and Australia, Bondi Junction, NSW, Australia attempt to identify those patients with specific co-morbid Design: This utilized a nasolabial turnover flap as described by Spear and colleague with the additional conditions that might benefit from preoperative platelet Purpose:maneuver We of describe, tunneling withthe flapillustrative beneath cases, the alar a single groove to its recipient site at the alar rim. function testing. stage flap for repair of full thickness nasal alar rim where theSummary: lateral portion Before, of during,the alar immediately and the alar post-procedure, groove has and long term follow up of multiple cases are Design: We present a case of a 73 y/o male that beenshown. preserved during excisional surgery. underwent Mohs surgery for a basal cell carcinoma of the Design: This utilized a nasolabial turnover flap as left nose resulting in a 3.8 x 3.0 cm soft tissue defect. The This procedure has the advantages over alternative repairs of preserving the important describedConclusion: by Spear and colleague with the additional defect involved the left nasal ala, underlying cartilage lateral alar groove, having a reliable vascular supply, providing a single stage solution, and providing a and portion of the side wall. His co-morbid conditions maneuver of tunneling the flap beneath the alar groove togood its recipient cosmetic site outcome. at the alar rim.

Page 57 of 114 G:\Mohs\AnnualG:\Mohs\Annual Meeting\P Meeting\Publications\2010\Finalublications\2010\Final Program\201 Program\2010 0Draft Draft Final Final program program Copy.doc Copy.doc chronicchronic tobacco tobacco use, use, anticoagulation anticoagulation with with two two anti-platelet anti-platelet agents, agents, and and chronic chronic renal renal insufficiency. insufficiency. The The patientpatient experienced experienced persistent persistent perioperative perioperative bleedi bleedingng during during the the Mohs Mohs resection resection and and later later that that night night requiringrequiring a atrip trip to to the the ER. ER. A Adelayed delayed reconstruc reconstructiontion had had been been planned planned the the next next day day under under monitored monitored anesthesiaanesthesia care care at at the the patient’s patient’s request. request. He He underwent underwent a acartilage cartilage graft graft with with a acheek cheek interpolation interpolation flap flap accompaniedaccompanied by by extensive extensive bleeding bleeding difficult difficult to to control. control. Because Because of of his his bleeding, bleeding, he he was was admitted admitted for for 24 24 hourhour observation. observation. Within Within 2 2hours hours post-op post-op he he experie experiencednced profuse profuse bleeding bleeding from from all all operative operative sites. sites. A A presumptivepresumptive diagnosis diagnosis of of platelet platelet dy dysfunctionsfunction of of uncertain uncertain cause cause was was m made.ade. Platelet Platelet function function tests tests were were G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc drawn.drawn. The The patient patient required required a areturn return to to the the OR OR wi withth general general anesthesia, anesthesia, administration administration of of DDAVP DDAVP based based 1:02 – 1:10 pm onon patient’s patient’s body body weight, weight, transfusion transfusion of of phoresed phoresed plat platelets,elets, and and other other blood blood products products during during the the 24 24 hours hours Presenter: Tracy M. Campbell, MD perioperatively.perioperatively. His His platelet platelet function function studies studies retu returnedrned grossly grossly abnormal abnormal and and his his hemoglobin hemoglobin dropped dropped from from Title: Using Electrosurgery for Scar Revision 10.610.6 to to 7.3. 7.3. Hematologic Hematologic evaluation evaluation revealed revealed findings findings co consistentnsistent with with drug drug induce induced dplatelet platelet dysfunction. dysfunction. Authors: Tracy M. Campbell, MD; Daniel B. Eisen, MD Department of Dermatology, UC Davis Medical Center, Sacramento, CA, United States PriorPrior to to an an uneventful uneventful division division and and inset inset of of the the flap, flap, repeat repeat platelet platelet function function studies studies were were normal. normal. Institution:

Purpose: Many techniques have been advocated for scar revision over the years to improve both contour Conclusion:Conclusion: Platelet Platelet dysfunction dysfunction due due to to antiplatelet antiplatelet agents agents can can result result in in massive massive bleeding. bleeding. Identification Identification and color match between the surgery site or scar and that of the normal surrounding skin. Dermabrasion ofof these these patients patients pre preoperativelyoperatively is is desirable. desirable. Management Management may may re requirequire blood blood products products as as well well as as DDAVP. DDAVP. is one of the most utilized, however, the need for specialized equipment, inability to address redundant RecognitionRecognition of of these these patients patients preoperatively preoperatively with with platelet platelet function function testing testing may may help help to to avoid avoid such such G:\Mohs\Annual Meeting\Ptissue suchublications\2010\Final as surgery dog-ears, Program\201 and bleeding0 Draft after Final completion program Copy.doc of the procedure are disadvantages. We bleeding.bleeding. Specific Specific patient patient profiles profiles may may the the physician physician identify identify these these patients. patients. 1:02 – 1:10 pm describe two alternative scar revision methods using electrosurgery that address some of the Presenter: Tracy M. Campbell, MD shortcomings of dermabrasion. Electrosurgical instruments are readily available and settings are adjusted Title: Using Electrosurgery for Scarto Revision provide different depths of tissue ablation. Low power settings and short dwell time results in superficial Authors: Tracy M. Campbell, MD; Danieltissue B. ablation Eisen, MDwhere as higher power settings or longer dwell times cause deeper tissue ablation. The Institution: Department of Dermatology,distance UC Davis between Medi thecal electrode Center, Sacramento,tip and the tissue CA, canUnited be vaStatesried which also results in different levels of ablation. Using these various techniques the scar or surgery site can be quickly ablated to the desired Purpose: Many techniques have beenlevel advocated similar to for that scar of revidermabrasion.sion over the We years have toco improveined the bothterm contour“electroblation” for this technique. and color match between the surgery Alternatively,site or scar and when that presented of the normal with redundant surrounding tissue, skin. such Dermabrasion as a surgery dog-ear, a fine tipped is one of the most utilized, however, theelectrosurgery need for specialized epilating tipequipment, can be used inability to burn to addressinto the subcutaneous redundant tissue. When performed in a grid tissue such as surgery dog-ears, and likebleeding pattern after over completion the affected of areathe procedure it causes sign areificant disadvantages. dermal tissue We contraction while sparing the describe two alternative scar revision interveningmethods us overlyinging electrosurgery tissue. We that have address termed some this method of the “fractionated electroblation.” shortcomings of dermabrasion. Electrosurgical instruments are readily available and settings are adjusted to provide different depths of tissue ablation.Design: Low For powescarsr where settings better and color short or dwell contour time match results with in superficialsurrounding normal tissue is desired an electrosurgical device maybe used in lieu of dermabrasion. The site is identified, cleansed, numbed, and tissue ablation where as higher power settings or longer dwell times cause deeper tissue ablation. The PostPost op op hemorrhage hemorrhage due due to to platelet platelet dysfunction. dysfunction. distance between the electrode tip andablated the tissue with cana standard be varied hyfrecator which also needle results using in lowdifferent power levels on a settingof of 10. A sweeping motion is used

ablation. Using these various techniquesto paint the scarthe scar or surgery and several site can millimeters be quickly of adjacent ablated tosk inthe to desired the level of the superficial papillary dermis. Figure 1 illustrates this technique for scar revision on a forehead flap repair. For areas with cutaneous 12:5412:54 – –1:02 1:02 pm pm level similar to that of dermabrasion. We have coined the term “electroblation” for this technique. redundancies or bulky type of scars where the color match is already good and complete deep ablation of Presenter:Presenter: Chris Chris Kearney, Kearney, MD MD Alternatively, when presented with redundant tissue, such as a surgery dog-ear, a fine tipped the entire skin surface is likely to cause atrophic scars we use fractionated electroblation. A fine epilating Title:Title: A A Tunneled Tunneled and and Turned-over Turned-over Nasolabial Nasolabial Flap Flap for for Reconstruction Reconstruction of of Full Fullelectrosurgery Thickness Thickness Nasal epilatingNasal ala ala tip can be used to burn into the subcutaneous tissue. When performed in a grid needle is used on lower power on a setting of 5-10 and advanced into the deep dermis or subcutaneous DefectsDefects like pattern over the affected area it causes significant dermal tissue contraction while sparing the Authors:Authors: Chris Chris Kearney, Kearney, MD; MD; Adam Adam T. T. S heridan,Sheridan, MBBS, MBBS, FACD; FACD; Carl Carl Vinciullo, Vinciullo, MD; MD; Timothy Timothy G. G. Elliott, Elliott, plane depending on the size of the redundancy. Treatment is continued in a grid like pattern until the intervening overlying tissue. We havecontour termed ofthis the method treated “fractionated tissue is made electroblation.” to match that of the surrounding skin. Figure 2 illustrates this MDMD Skin Skin and and Cancer Cancer Foundation, Foundation, Sydney, Sydney, Aust Australia,ralia, Bondi Bondi Junction, Junction, NSW, NSW, Australia Australia technique on a graft which has pin cushioned with contour irregularities. Petroleum jelly is applied to the Institution:Institution: Design: For scars where better color treatmentor contour area match until with re-epithelialization. surrounding normal tissue is desired an electrosurgical device maybe used in lieu of dermabrasion. The site is identified, cleansed, numbed, and WeWe describe, describe, with with illustrative illustrative cases, cases, a asingle single st stageage flap flap for for repair repair of of full full thickness thickness nasal nasal alar alar rim rim Purpose:Purpose: ablated with a standard hyfrecator needleSummary: using low The power primary on advantages a setting of of 10. electroblation A sweeping are motion the ability is used to treat cutaneous redundancies or wherewhere the the lateral lateral portion portion of of the the alar alar and and the the alar alar gr grooveoove has has been been preserved preserved during during excisional excisional surgery. surgery. – Saturday,to paint the scar May and 1: several 12:30 millimeters – 2:30bulky of adjacentpmflaps, no needskin to for the specialized level of the equipment superficial that papillary is typically dermis. present on hand in most dermatologic Clinical Pearls Abstract Session Figure 1 illustrates this technique for scarsurgeon’s revision offices, on a greatlyforehead reduced flap repair. bleeding, For areasand faster with procedurecutaneous time. Design:Design: This This utilized utilized a anasolabial nasolabial turnover turnover flap flap as as described described by by Spear Spear and and colleague colleagueredundancies with with the the additional oradditional bulky type of scars where the color match is already good and complete deep ablation of maneuvermaneuverS ummary:of of tunneling tunneling Before,the the flap flap beneath during, beneath the immediatelythe alar alar groove groove to post-procedure, to its its recipient recipient site site at at the the alarthe ofalar scarsrim.entire rim. skinwhere surface the is color likely matchto causeConclusion: isatrophic already sc Electroblationars good we use and fractionated is a convenient electroblation. and easy metA finehod epilating for scar revision. Potential advantages of and long term follow up of multiple cases are shown. needlecomplete is used deep on lower ablation power onof athe settingelectroblation entire of 5-10 skin overand surface advanceddermabrasion into anthed deeplaser systemsdermis or include subcutaneous decreased expense, ease of use, diminished Summary:Summary: Before, Before, during, during, immediately immediately post-procedure, post-procedure, and and lo longng term term follow follow up up of planeisof multiple likelymultiple depending to cases casescause areon are theatrophic size of thescars redundancy.bleeding, we use and fractionatedTreatment ability to is treat continued cutaneous in a redundancies.grid like pattern until the shown.shown. Conclusion: This procedure has the advantages over contour of the treated tissue is made to match that of the surrounding skin. Figure 2 illustrates this techniqueelectroblation. on a graft A which fine hasepilating pin cushioned needle with is contourused onirregularities. lower Petroleum jelly is applied to the alternative repairs of preserving the important lateral power on a setting of 5-10 and advanced into the deep Conclusion:Conclusion:alar Thisgroove, This procedure procedure having has has a the thereliable advantages advantages vascular over over altesupply, alternativernative providing repairs repairs of of preserving preservingtreatment the the importantarea important until re-epithelialization. dermis or subcutaneous plane depending on the size laterallateral alar alara groove,single groove, stage having having solution,a areliable reliable andvascular vascular providing suppl supply,y, providinga providing good acosmetic asingle single stage stage solution, solution, and and providing providing a a goodgood cosmetic cosmetic outcome. outcome. Summary:of the redundancy. The primary advantagesTreatment of is electroblation continued are in athe grid ability like to treatFigure cutaneous 1. (A, redundanciesB) 10 wks s/p or forehead flap repair (C) outcome. bulkypattern flaps, until no need the contourfor specialized of the equipment treated that tissue is typically is made present on Electroblation.hand in most dermatologic (D) 6 wks s/p electroblation surgeon’s offices, greatly reduced bleeding, and faster procedure time. to match that of the surrounding skin. Figure 2 illustrates

this techniqueElectroblation on a graft is a which convenient has and pin easy cushioned method for with scar revision. Potential advantages of Conclusion: electroblationcontour irregularities. over dermabrasion Petroleum and laser jelly systems is applied include to decreased the expense, ease of use, diminished

bleeding,treatment and area ability untilto treat re-epithelialization. cutaneous redundancies.

Figure 2. (A, B) 6 wks s/p FTSG (C, D) 4 wks s/p fractionated electroblation PagePage 57 57 of of 114 114 Figure 1. (A, B) 10 wks s/p forehead flap repair (C) Electroblation. (D) 6 wks s/p electroblation 1:02 – 1:10 pm Page 58 of 114 Presenter: Tracy M. Campbell, MD

Title: Using Electrosurgery for Scar Revision

Authors: Tracy M. Campbell, MD; Daniel B. Eisen, MD Figure 1. (A, B) 10 wks s/p Figure 2. (A, B) 6 wks s/p FTSG

forehead flap repair (C) (C, D) 4 wks s/p fractionated Institution: Department of Dermatology, UC Davis Electroblation. (D) 6 wks s/p electroblation Figure 2. (A, B) 6 wks s/p FTSG (C, D) 4 wks s/p fractionated Medical Center, Sacramento, CA, United States electroblation electroblation Purpose: Many techniques have been advocated for scar revision over the years to improve both contour Summary: The primary advantages of electroblation and color match between the surgery site or scar and are the ability to treat cutaneous redundancies or bulky Page 58 of 114 that of the normal surrounding skin. Dermabrasion is one flaps, no need for specialized equipment that is typically of the most utilized, however, the need for specialized present on hand in most dermatologic surgeon’s offices, equipment, inability to address redundant tissue such greatly reduced bleeding, and faster procedure time. as surgery dog-ears, and bleeding after completion of Conclusion: Electroblation is a convenient and easy the procedure are disadvantages. We describe two method for scar revision. Potential advantages of alternative scar revision methods using electrosurgery electroblation over dermabrasion and laser systems that address some of the shortcomings of dermabrasion. include decreased expense, ease of use, diminished Electrosurgical instruments are readily available and bleeding, and ability to treat cutaneous redundancies. settings are adjusted to provide different depths of tissue ablation. Low power settings and short dwell 1:10 – 1:18 pm time results in superficial tissue ablation where as higher Presenter: John M. Strasswimmer, MD, PhD power settings or longer dwell times cause deeper tissue ablation. The distance between the electrode tip and the Title: Challenges to Marketing the Mohs College: A tissue can be varied which also results in different levels Florida Experience of ablation. Using these various techniques the scar or surgery site can be quickly ablated to the desired level Authors: John M. Strasswimmer, MD, PhD; Richard similar to that of dermabrasion. We have coined the term Krathen, MD “electroblation” for this technique. Alternatively, when Institution: www.MohsForSnowbirds.com, Palm Beach presented with redundant tissue, such as a surgery dog- County, Delray Beach, FL, United States ear, a fine tipped electrosurgery epilating tip can be used to burn into the subcutaneous tissue. When performed Purpose: We describe the challenges of growing an in a grid like pattern over the affected area it causes ACMS Mohs surgery practice in Florida and the creation significant dermal tissue contraction while sparing the of a cooperative marketing approach to promote local intervening overlying tissue. We have termed this method Mohs College members. “fractionated electroblation.” Design: We provide a description of the challenges Design: For scars where better color or contour match posed to ACMS members in a county in Florida. These with surrounding normal tissue is desired an electrosurgical include the practice of dermatologic surgery by non- device maybe used in lieu of dermabrasion. The site ACMS members, non-dermatologists, non ABD-certified is identified, cleansed, numbed, and ablated with dermatologists and non MD physicians. The public’s lack a standard hyfrecator needle using low power on a of knowledge about the ACMS fellowship program is a setting of 10. A sweeping motion is used to paint the limitation to growing a practice by ACMS members. In scar and several millimeters of adjacent skin to the level response, we describe genesis of an initial cooperative of the superficial papillary dermis. Figure 1 illustrates this marketing plan. The plan might serve for other grass-roots technique for scar revision on a forehead flap repair. Mohs Surgery ACMS marketing in other locations in the US. For areas with cutaneous redundancies or bulky type G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc 1:10 – 1:18 pm Author: John M. Strasswimmer, MD, PhD Title: Challenges to Marketing the Mohs College: A Florida Experience – Saturday, May 1: 12:30 – 2:30 pm Authors:Clinical John M. Strasswimmer, Pearls MD, PhD;Abstract Richard Krathen, MD Session Institution: www.MohsForSnowbirds.com, Palm Beach County, Delray Beach, FL, United States An informal review revealed that the vast outcomes and patient satisfaction. Readily applicable Purpose:Summary: We describe the challenges of growing an ACMS Mohs surgery practice in Florida and the creationmajority of a cooperativeof Mohs marketingsurgery approac providersh to promote in a localcounty Mohs Collegein Florida members. clinical pearls regarding the nasal valve will be reviewed are not ACMS certified. Moreover, the public did not in order to provide a practical understanding of nasal Design: We provide a description of the challenges posed to ACMS members in a county in Florida. Theseunderstand include the thepractice significance of dermatologic surgof eryACMS by non-ACMS training members, and thenon-dermatologists, valve non anatomy and physiology, a framework for ABD-certifiedpotential dermatologistsadvantages and nonthat MD provides. physicians. The We public's will describelack of knowledge an about theperioperative ACMS assessment, and recommendations for fellowship program is a limitation to growing a practice by ACMS members. In response, we surgicaldescribe management. genesisinitial ofcooperative an initial cooperative advertising marketing plan. approach The plan might which serve fo hasr other met grass-roots Mohs Surgery ACMSwith marketinggreat satisfaction in other locations from in the theUS. participants. Design: Anatomy and physiology pearl: Soft tissue is a key Summary:Conclusion: An informal A reviewcost-effective revealed that theadvertising vast majority ofapproach Mohs surgery providers in astructural county in component of the nasal valve. Florida are not ACMS certified. Moreover, the public did not understand the significance of ACMS training andpromoting the potential theadvantages ACMS that resulted provides. We in willconversion describe an initial of patientscooperative advertisingThe approach nasal valve is a dynamic structure that may move whichfrom has dermatologists met with great satisfaction who fromdid the not participants. participate in this plan. physiologically with sufficiently deep inspiration. It imparts Patient feedback was positive and the ACMS member Conclusion: A cost-effective advertising approach promoting the ACMS resulted in conversionthe of locus of highest resistance in the respiratory system. patientsexpressed from dermatologists universal who satisfaction did not participate with in this plan. program. Patient feedback We was positiveAlthough and the the precise boundaries and components of ACMShope member this approach expressed universal will be satisfaction used withelsewhere this program. in We the hope US this to approach will be used elsewhere in the US to promote the "branding" of the ACMS. the valve have been debated from a physiologic and promote the “branding” of the ACMS. a surgical perspective, a reasonably practical view may

consider the entire valve as being composed of an internal and external valve. The internal valve is formed by the anterior caudal edge of the upper lateral cartilage

the septum while the external valve is formed by the fibrofatty tissues of the alar lobule and overlying skin, the

lateral crus of the alar cartilage, the caudal septum, and the piriform aperture. The corresponding surface landmarks of the valve may be approximated by the

distal lateral nasal sidewall, the alar groove, and the alar lobule.

Initial advertisement used for print Preoperative assessment pearl: A thorough preoperative

evaluation may facilitate identification of patients at high-risk of NVI. At a minimum the surgeon should take

into careful consideration the native structure and rigidity of the nose, any baseline nasal valve dysfunction, and the precise anatomic location of the tumor. Several methods

have been described to assess nasal valve function, including the Cottle test and Adamson nasal patency

test. Patients at high risk for nasal valve impingement include those with long, thin noses, a deviated septum,

atrophy of the intrinsic nasal muscles, and tip ptosis. Specific tumoral characteristic that impart an increased risk of nasal valve collapse include: 1.) lesions or defects

that cross the alar crease; 2.) lesions greater than 1 cm in Page 59 of 114 diameter on the ala or lateral sidewall and within 1 mm of the alar crease.

Initial advertisement used for print Surgical management pearl: NVI may develop despite complete preservation of native cartilage. Though surgical loss of nasal cartilage is likely the most 1:18 – 1:26 pm obvious risk for NVI, other, more subtle factors may occur Presenter: Christian L. Baum, MD intraoperatively. In our practice, we have identified Title: Detection and Treatment of Nasal Valve at least two settings in which NVI may develop even Insufficiency Despite Complete Preservation though native cartilage may be preserved. First, tumor of Cartilage Following Mohs Surgery and extirpation may lead to sufficient loss of fibrofatty, soft tissue, and intrinsic nasal muscle to compromise the Reconstruction structural integrity of the nasal valve, resulting in NVI. Authors: Christian L. Baum, MD; Christopher J. Arpey, In such cases we have found the application of a MD polypropylene suspension suture to the medial cheek to be useful in mitigating NVI. This technique decreases Institution: Department of Dermatology, University of the morbidity associated with harvesting a cartilaginous Iowa Hospitals and Clinics, Iowa City, IA, United States graft while affording more predictable results. In another Purpose: The nasal valve is often altered during Mohs setting, NVI may develop as a result of sub-optimally surgery and reconstruction. As a result of nasal valve placed tension vectors during reconstruction, rather insufficiency (NVI), patient morbidity may be limited than as a direct consequent of tumor extirpation. In such at best to a sensation of nasal fullness and, at worst, cases, re-orientation of the tension vector or, perhaps, to a physiologically significant diminution of airflow. consideration of another reconstructive option may be Therefore, a working knowledge of the nasal valve and necessary. Thus, we recommend careful and periodic management of NVI may facilitate optimal clinical assessment of nasal valve patency during all phases of Mohs surgery and reconstruction. G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc Authors: David E. Geist, MD; Dori Goldberg, MD; Jason D. Givan, MD; Mary E. Maloney, MD Institution: Dermatology, UMass Medical School, Worcester, MA, United States

Purpose: Large medial cheek and combined nasal sidewall-cheek defects can be challenging to repair. A classic approach is to use a laterally based advancement or rotation flap with a horizontal infraorbital incision. A disadvantage of this approach is long-lasting residual eyelid edema and a large flap. When the defect extends onto the nasal sidewall, an additional challenge is effectively tacking the flap down to prevent tenting over the melonasal junction.

Design: An alternate approach to these defects is a modified check advancement flap in which an inferior redundancy is designed and immediately removed as the first step. The flap and wound are then undermined without releasing the superior pole of the flap. The closure is then performed from “the bottom up” placing deep and superficial sutures from the inferior pole upwards gradually closing the defect. Tacking sutures can be placed along the melonasal junction either to maxillary periosteum, if it can be reached, or simply to subcutaneous tissue and/or SMAS and tightened variably to recreate the appropriate contour and avoid tenting. With this contour recreated, nasal sidewall portions of the defects can be closed as well.

During the closure, the relatively elastic skin of the superior cheek and lower eyelid tends to stretch allowing closure of the superior pole, again without a releasing incision. A small burrows wedge or M- plasty can be performed at the medial lower eyelid, healing almost imperceptibly. There is minimal residual eyelid edema and the overall suture lines are shorter. In a short case series there have been several excellent cosmetic and functional outcomes. In one case under high tension, hypertrophic scarring was seen along the suture line.

Conclusion: The bottom-up cheek advancement flap offers an alternative approach for repairing large cheek and cheek-nasal sidewall defects. Advantages include shorter scar lines and limited eyelid edema Clinical Pearls Abstract Session – Saturday,versus traditional May 1: approaches.12:30 – 2:30 pm

Conclusion: The nasal valve may be compromised during Mohs surgery solely due to sufficient soft tissue loss, or as a direct result of reconstruction. Awareness of the nasal valve at all times, even when native cartilage has been preserved, may facilitate avoidance of NVI, Bottom-up cheek advancement flap: A large inferior cone minimize postoperative morbidity, and improve patient is taken initially. Then deep sutures are placed from satisfaction. bottom to top. Only a small superior cone is needed on the eyelid to complete the closure. 1:26 – 1:34 pm Presenter: David E. Geist, MD Title: A Reconstructive Pearl: The “Bottom-Up” Cheek Advancement Flap

Authors: David E. Geist, MD; Dori Goldberg, MD; Jason

D. Givan, MD; Mary E. Maloney, MD “Bottom-up” cheek advancement flap: A 1:34large inferior– 1:42 cone pm is taken initially. Then deep Institution: Dermatology, UMass Medical School, Presenter:sutures are placed Jeremy from Cook, bottom MD to top. Only a Worcester, MA, United States small superior cone is needed on the eyelid to Title:complete Use the of closure. the Temporary Suspension Suture in Melolabial Interpolation Flap Nasal Purpose: Large medial cheek and combined nasal Reconstruction: A Tool to Prevent Distal Flap Necrosis and Dehiscence Jeremy Cook, MD; Sarah Schram, MD; Peter K. Lee, MD, PhD sidewall-cheek defects can be challenging to repair. A 1:34Authors: – 1:42 pm Dermatology, University of Minnesota, Minneapolis, MN, United States classic approach is to use a laterally based advancement Presenter:Institution: Jeremy Cook, MD or rotation flap with a horizontal infraorbital incision. A disadvantage of this approach is long-lasting residual TPurpose:itle: Use ofNasal the Tdefectsemporary involving Suspension the inferior Suture third in of the nose can be challenging to repair. For extensive eyelid edema and a large flap. When the defect extends Melolabialor complex Idefects,nterpolation recons Flaptruction Nasal utilizing Reconstruction: distant flaps is often necessary. The melolabial interpolation onto the nasal sidewall, an additional challenge is Aflap, Tool and to variationsPrevent Distal thereof, Flap has Necrosis been reported and to provide adequate tissue match in terms of color, texture, effectively tacking the flap down to prevent tenting over Dehiscenceand thickness, while preserving nasal architecture. Necrosis of the distal flap may complicate this repair, the melonasal junction. Authowever,hors: and Jeremy in the Cook, authors’ MD; Sarahexperience, Schram, often MD; results Peter K. fr om tension at the distal margin. Here we present Design: An alternate approach to these defects is a Lee,a series MD, ofPhD 6 cases of melolabial interpolation flap repairs of nasal defects in which temporary suspension modified cheek advancement flap in which an inferior sutures were placed to reduce tension and thereby prevent distal flap necrosis and dehiscence. Institution: Dermatology, University of Minnesota, redundancy is designed and immediately removed as the first step. The flap and wound are then undermined Minneapolis, MN, United States Design: We used the melolabial interpolation flap with placement of a temporary suspension suture for without releasing the superior pole of the flap. The Purpose:closure of Nasal 6 medium defects to involvinglarge nasal the tip inferior and alarthird defeof cts generated after Mohs micrographic surgery. After closure is then performed from the “bottom-up” placing theproper nose positioning can be challenging of the flap, to a repair. single For 3-0 extensive polypro pyleneor suture was passed through the skin into the deep and superficial sutures from the inferior pole complex defects, reconstruction utilizing distant flaps upwards gradually closing the defect. Tacking sutures is often necessary. The melolabial interpolation flap, Page 61 of 114 can be placed along the melonasal junction either to and variations thereof, has been reported to provide maxillary periosteum, if it can be reached, or simply to adequate tissue match in terms of color, texture, and subcutaneous tissue and/or SMAS and tightened variably thickness, while preserving nasal architecture. Necrosis to recreate the appropriate contour and avoid tenting. of the distal flap may complicate this repair, however, With this contour recreated, nasal sidewall portions of the and in the authors’ experience, often results from tension defects can be closed as well. at the distal margin. Here we present a series of 6 cases During the closure, the relatively elastic skin of the superior of melolabial interpolation flap repairs of nasal defects cheek and lower eyelid tends to stretch allowing closure in which temporary suspension sutures were placed to of the superior pole, again without a releasing incision. A reduce tension and thereby prevent distal flap necrosis small burrows wedge or M-plasty can be performed at the and dehiscence. medial lower eyelid, healing almost imperceptibly. There is Design: We used the melolabial interpolation flap minimal residual eyelid edema and the overall suture lines with placement of a temporary suspension suture for are shorter. In a short case series there have been several closure of 6 medium to large nasal tip and alar defects excellent cosmetic and functional outcomes. In one case generated after Mohs micrographic surgery. After proper under high tension, hypertrophic scarring was seen along positioning of the flap, a single 3-0 polypropylene suture the suture line. was passed through the skin into the subcutaneous tissue Conclusion: The “bottom-up” cheek advancement lateral to the flap donor site and then again over the flap offers an alternative approach for repairing large nasal dorsum, where a knot was tied to secure it. In this cheek and cheek-nasal sidewall defects. Advantages manner, tension was displaced from the distal flap margin include shorter scar lines and limited eyelid edema versus to the temporary suspension suture. After three weeks, traditional approaches. the suspension suture was removed and takedown of the melolabial interpolation flap was performed in the typical fashion. Summary: All patients in our series had successful reconstructions. Restoration of nasal architecture and good cosmetic outcomes were obtained in all cases. There were no cases in which necrosis or dehiscence G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc subcutaneous tissue lateral to the flap donor site and then again over the nasal dorsum, where a knot was tied to secure it. In this manner, tension was displaced from the distal flap margin to the temporary suspension suture. After three weeks, the suspension suture was removed and takedown of the melolabial interpolation flap was performed in the typical fashion.

Summary: All patients in our series had successful reconstructions. Restoration of nasal architecture and good cosmetic outcomes were obtained in all cases. There were no cases in which necrosis or dehiscence of the distal flap occurred. No complications related to placement or removal of the temporary Clinical Pearls Abstractsuspension sutures Session was observed. – Saturday, May 1: 12:30 – 2:30 pm G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.docG:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc subcutaneousof the distal tissue flap lateral occurred. to the Conclusion: flapNo complicationsdonor site Previously and thenrelated describedagain over as the a nasalmethod dorsum, to prevent where ectropion a knot in oculoplastic procedures, the wasto tied placement to secure orit. Inremoval this manner, oftemporary the tension temporary suspensionwas di splacedsuspension suture from was the useddistal in flap our margin series toto thereduce temporary tension across melolabial interpolation suspensionsutures was suture. observed. After three weeks,flaps theused suspension in nasal reconstruction. suture was removed In contrast and totakedown the axial of blood the supply of the paramedian forehead flap, melolabial interpolation flap was performedthe melolabial in the interpolation typical fashion. flap is a random-based flap and has a more tenuous blood supply. The Conclusion: Previously described as a method to additional effect of gravity on the flap may further compromise blood flow to the distal margin, resulting in Summary:prevent Allectropion patients inin ouroculoplastic seriesan hadincreased procedures,successful susceptibility recons the tructions. to excess Restoration tension. We of nasalfound architecturethe temporary and suspension suture to be an goodtemporary cosmetic suspensionoutcomes were suture obtainedeffective was usedin toolall cases.in for our reducing Thereseries tensionwereto no across cases thein which distal necrosis flap margin or and preventing associated necrosis and dehiscencereduce tensionof the distal across flap melolabialoccurred.dehiscence. No interpolation complication sflaps related used to placement or removal of the temporary suspensionin nasal reconstruction.sutures was observed. In contrast to the axial blood supply of the paramedian forehead flap, the melolabial Conclusion:interpolation Previously flap is describeda random-based as a method flap to prevent and has ectropion a more in oculoplastic procedures, the temporarytenuous suspension blood supply. suture The was additional used in our effect series of to gravityreduce tensionon across melolabial interpolation flapsthe used flap in nasalmay further reconstruction. compromise In contrast blood to theflow axial to bloodthe distal supply Temporary of the paramedian suspension forehead suture flap, placement at time of flap repair. themargin, melolabial resulting interpolation in an flapincreased is a random-based susceptibility flap to and excess has a more tenuous blood supply. The additionaltension. effect We foundof gravity the on temporary the flap may suspension further compro suturemise to blood be flow to the distal margin, resulting in an increased susceptibility to excess tension. We found the temporary suspension suture to be an an effective tool for reducing tension across the distal effective tool for reducing tension across the distal flap margin and preventing associated necrosis and flap margin and preventing associated necrosis and dehiscence. dehiscence.

Temporary suspension suture placementFour weeks at status/post time of flap flap repair. takedown and removal of temporary suspension1:50 – 1:58 suture. pm 1:50 – 1:58 pm Presenter:Presenter: Yaohui Yaohui G. Xu,G. MD,Xu, PhDMD, PhD

Title:Title: Bilateral Transposition Transposition Flap for Flap Reconstruction for Reconstruction of Circular Mohs Surgery Defects Yaohui G. Xu, MD, PhD; Stephen N. Snow, MD Authors:of Circular Mohs Surgery Defects Temporary suspension suture 1:42 Four – 1:50weeks pm status/post flap Dermatology, University of Wisconsin, Madison, Madison, WI, United States placement at time of flap Institution:Authors: Yaohui G. Xu, MD, PhD; Stephen N. Snow, MD Presenter: takedown Juan and Vasquez,removal of MD repair. Title: temporary Curvilinear suspension Advancement suture. FlapI nstitution:for Infraorbital Dermatology, Defects: A Case University Series of Wisconsin, Authors:Four weeks Juan status/post Vasquez, MD; flap Oliver takedown Purpose:PereMadison,z, and MD; removal HakeemMadison, Bilateral of Sam, WI,temporary MD,transpositionUnited PhD States flap, also described as a double opposing semicircular flap, a modified Institution:suspension Dermatology, suture. University opposingof Pittsburgh, Z-plasty,Pittsburgh, PA, has United been States proven reliable and elegant in the reconstruction of circular defects in 1:42 – 1:50 pm Purpose: Bilateral transposition flap, also described as a Presenter: Juan Vasquez, Purpose:MD Infraorbital defects from surgicalvariousdouble excisions opposing body arise parts. semicircularcommonly We andpropose flap, numerous a modifiedthat methods it is opposing forlikely closure unde rutilized in daily practice due to the relatively of these lesions exist. However, many Z-plasty,befitting repairs has been for this proven area resultreliable in less-than-ideal and elegant geometricin the Title: Curvilinear Advancement Flap for Infraorbital complicated preoperative planning and the lack of experience in comparing to other more commonly scars, while others are rather tediousconducted toreconstruction execute. We closures. describe of circular an alteWe defectsrnative report in flap various ourfor closure successfulbody which parts. is experience using symmetric or asymmetric bilateral Defects: A Case Series aesthetically pleasing, functional, and avoidsWe propose either ec thattropion it is orlikely lower underutilized eyelid traction. in dailyOur closure practice is also less involved than others flaps. 1:42Aut – 1:50hors: pm Juan Vasquez, MD; Oliver Perez, MD; Hakeem transpositiondue to the relatively flap complicatedfor closure preoperative of large circular planning defects on the face and neck in 12 patients. Presenter: Juan Vasquez, MD and the lack of experience in comparing to other more Sam, MD, PhD We present a case series of 5 patients with defects in the infraorbital region repaired by the Title: Curvilinear Advancement Design:Flap for Infraorbital Defects: A Casecommonly Series conducted closures. We report our successful Juan Vasquez, MD; Olivercurvilinear Perez, MD;advanc Hakeemement Sam, flap. MD, PhD All defects were the result of Mohs micrographic surgery. The defects were located on the Authors:Institution: Dermatology, University of Pittsburgh, Design:experience using symmetric or asymmetric bilateral Dermatology, University of Pittsburgh, Pittsburgh, PA, United States Institution:Pittsburgh, PA, United States forehead,transposition brow, flap for nose, closure chin, of large cheek, circular ear defects lobe, ontemple, and neck, ranging from 1 to 4 cm in size. Bilateral Summary: Functional and aesthetic outcomes were excellent. No serious complications were transpositionthe face and neck flaps in 12were patients. designed to orientate opposing parallel straight lines in the junction of cosmetic Purpose:Purpose: Infraorbital Infraorbital defects defects fromencountered. surgical from surgical excisions excisions arise commonly arise and numerous methods for closure of thesecommonly lesions and exist. numerous However, methodsmany befitting for closure repairs forof thesethis area resultsubunitsDesign: in less-than-ideal All and defects relaxed geometric were theskin result tension of Mohs lines. micrographic Flaps were transposed to the circular defect and then sutured. scars,lesions while exist. others However, are rather many tediousConclusion: befitting to execute. repairs This We flap describefor enhances this areaan alte thernative dermatologicsurgery. flap Thefor surgeon’closure defects whichs repertoirewere is located and should on the be forehead, considered brow, for appropriately located lesions found in the infraorbital cheek, close to the lower eyelid. aestheticallyresult in less-than-ideal pleasing, functional, geometric and avoids scars, either while ec tropionothers orare lower eyelidnose, traction. chin, cheek, Our closure ear lobe,is also temple, and neck, ranging less involved than others flaps. All 12 patients had successful reconstruction with good cosmetic outcome assessed rather tedious to execute. We describe an alternative Summary:from 1 to 4 cm in size. Bilateral transposition flaps were flap for closure which is aesthetically pleasing, functional, immediatelydesigned to orientate and long-term opposing parallelup to onestraight to Page linesthree 62in of years. 114 There were no flap failures, infection, dehiscence, or Design:and avoids We present either a ectropioncase series orof lower5 patients eyelid with traction. defects in Our the infraorbital region repaired by the curvilinear advancement flap. necrosis.the junction There of cosmetic was subunitsonly one and patient relaxed whoskin tension was not entirely pleased with her scar on the nasal dorsum due closure is also less involved than others flaps. lines. Flaps were transposed to the circular defect and to mildly asymmetric elevation of the alar rim. Design:Functional We present and a aesthetic case series outcomes of 5 patients were excellent. with No seriousthen complications sutured. were Summary: encountered.defects in the infraorbital region repaired by the Summary: All 12 patients had successful reconstruction curvilinear advancement flap. Conclusion:with good cosmetic In our outcome experience, assessed theimmediately bilateral and transposition flap is a valuable option providing a functionally This flap enhances the dermatologic surgeon’s repertoire and should be considered for Conclusion: andlong-term aesthetically up to one pleasingto three years. reconstruction There were no flapof circular defects on the face and neck. It is particularly useful appropriatelySummary: located Functional lesions and found aesthetic in the infr outcomesaorbital cheek, were close to the lower eyelid. excellent. No serious complications were encountered. whenfailures, there infection, is insufficient dehiscence, unilateralor necrosis. Theredonor was skin. only Having techniques that use bilateral donor skin increases theone options patient who for wasclosure not entirely of large pleased def ects.with her Additionally, scar on a utilization of modified Z-plasty principles permits Conclusion: This flap enhances the dermatologic the nasal dorsum duePage to62 mildlyof 114 asymmetric elevation of surgeon’s repertoire and should be considered for reliablethe alar rim.cosmesis by minimizing the later contracture of the scar. appropriately located lesions found in the infraorbital cheek, close to the lower eyelid. Conclusion: In our experience, the bilateral transposition 1:58flap is– 2:06a valuable pm option providing a functionally and Presenter:aesthetically pleasingGalen H.reconstruction Fisher, MD of circular defects on the face and neck. It is particularly useful when there Title:is insufficient Interpolated unilateral Paranasaldonor skin. Having Flap: techniques an Advantag that eous Alar Reconstructive Option for Selected Defects 1 2 Authors: Galen H. Fisher, MD ; Joel Cook, MD Institutions: 1. Galen Fisher, Laser & Skin Surgery Center of Richmond, Richmond, VA, United States 2. Dermatologic Surgery, Medical University of South Carolina, Charleston, SC, United States

Purpose: Alar reconstruction is often accomplished with superiorly based melolabial interpolation flaps. In men this can be problematic due to transfer terminal to the nose. To circumvent this problem we have used an inferiorly based paranasal interpolation flap that sidesteps the issue of terminal hair transfer and has fewer tendencies towards medial cheek distortion when compared to the traditional interpolated melolabial flap.

Design: Presentation of two representative cases where this flap was used to fix a partial and total alar Page 63 of 114 Clinical Pearls Abstract Session – Saturday, May 1: 12:30 – 2:30 pm use bilateral donor skin increases the options for closure Purpose: Accurate mapping is crucial to the Mohs surgeon of large defects. Additionally, a utilization of modified to orient removed tissue and to identify residual neoplasm Z-plasty principles permits reliable cosmesis by minimizing for subsequent stages. While the majority of Mohs the later contracture of the scar. surgeons use a pen and paper for Mohs mapping, digital photography Mohs mapping is an effective alternative, 1:58 – 2:06 pm particularly in the age of electronic health records. Presenter: Galen H. Fisher, MD Design: We describe our six-year experience with digital Title: Interpolated Paranasal Flap: An Advantageous photography Mohs mapping. After the first stage is excised, Alar Reconstructive Option for Selected Defects the tissue is placed on non-stick gauze (with a notch at

1 2 12 o’clock for anatomic orientation) and photographed Authors: Galen H. Fisher, MD ; Joel Cook, MD adjacent to the Mohs surgical defect. Using the pre- Institutions: 1. Galen Fisher, Laser & Skin Surgery installed Microsoft Windows Paint program and computer Center of Richmond, Richmond, VA, United States mouse, the histologist marks on the same photograph 2. Dermatologic Surgery, Medical University of South where the tissue was stained. After the slides are processed, Carolina, Charleston, SC, United States G:\Mohs\Annual Meeting\Pthe Mohsublications\2010\Final surgeon uses the Paint Program\201 program0 and Draft computer Final program Copy.doc skin subunit loss. mouse to mark any remaining neoplasm on the same Purpose: Alar reconstruction is often accomplished photograph. All digital photographs can be opened, with superiorly based melolabial interpolation flaps. In To date the presenting authormodified, has used and thisimported flap in into well the over electronic 50 patients health and record has had no men this can be problematicSummary: due to transfer terminal on any computer desktop in the practice using a shared significant complications such as infection, hemorrhage, necrosis or pin cushioning. It is a fast hairs to the nose. To circumvent this problem we have external hard drive. used an inferiorly based paranasalreconstruction interpolation to execute, flap reliable vascularity and can be used for a variety of defects with a high degree that sidesteps the issue ofof terminal predictability. hair transfer and has Summary: Advantages of digital photography Mohs fewer tendencies towards medial cheek distortion when mapping include superior tissue orientation, easy storage compared to the traditionalConclusion: interpolated A superiorly melolabial based flap. paranasalof images, interpolation quick retrieval flap adds and a interpretation versatile and of reliable Mohs maps,option to the reconstructive repertoire of the contempoandrary low-cost Mohs of and equipment. reconstructive Disadvantages surgeon. include a Design: Presentation of two representative cases where this reliance of an operating computer and the learning curve flap was used to fix a partial and total alar skin subunit loss. G:\Mohs\Annual Meeting\Publications\2010\Final of training Program\201 your staff.0 Draft Final program Copy.doc Sskinummary: subunit To loss. date the presenting author has used this Conclusion: Digital photography Mohs mapping is an flap in well over 50 patients and has had no significant easy, accurate, cost-effective means of providing tissue complications such as infection, hemorrhage, necrosis Summary: To date the presenting author has usedAlar this defect flap orientationin well over and 50 assessingpatients andsurgical has marginshad no for the Mohs orsignificant pin cushioning. complications It is a fast such reconstruction as infection, to hemo execute, rrhage, necrosissurgeon. or pin cushioning. It is a fast reliable vascularity and can be used for a variety of reconstruction to execute, reliable vascularity and can be used for a variety of defects with a high degree defects with a high degree of predictability. of predictability. 2:14 – 2:22 pm Presenter: Paul J.M. Salmon, MD Conclusion: A superiorly based paranasal interpolation flapConclusion: adds a versatile A superiorly and reliable based paranasaloption to the interpolation flapT itle:adds Tahe versatile Nasal Sandidewall reliable Rotation option Flap:to the A Workhorse reconstructive repertoire of the contemporary Mohs and reconstructive repertoire of the contemporary Mohs and reconstructiveFlap for Small surgeon. Defects of the Distal Nose reconstructive surgeon. 1 2 Authors: Paul J.M. Salmon, MD ; Eugene Tan, MD ; Neil J. Mortimer, MBChB1; Syed W. Hussain, MD1

Institutions: 1. Dermatologic Surgery Unit, Skin Cancer

Alar defect Institute, Tauranga, New Zealand. 2. Dermatology Department, Waikato Hospital, Hamilton, New Zealand Interpolated paranasal flap in place Purpose: Skin cancers of the nasal tip present a challenge for the dermatologic surgeon. The bilobed flap has widely been utilized as the ‘workhorse’ flap for such defects but requires meticulous design and may be complicated by a tendency for pin-cushioning. We describe the use of the nasal sidewall rotation flap for Alar defect Interpolated paranasal reconstructing defects on the nasal tip. flap in place 2:06 – 2:14 pm Design: A retrospective analysis of the Mohs 2:06 – 2:14 pm Presenter: Justin J. Vujevich, MD micrographic surgery database over a 4 year period was Title: Digital Photography Mohs Mapping for the Electronic Health Record Presenter: Justin J. Vujevich, MD 1 performed. All cases where2 the nasal sidewall rotation2 Authors: Justin J. Vujevich, MD ; Arashflap Kimyai-Asadi, was used were MD identified.; Leonard H.Defect Goldberg, location, MD size and Title: Digital PhotographyInstitutions:Interpolated Mohs Mapping 1. paranasalVujevich for the Dermatology flap in placeany Associates, post-operative PC, Pi complicationsttsburgh, PA, United were noted. States All2. patientsDermSurgery Electronic Health RecordAssociates, PC, Houston, TX, United wereStates reviewed at the time of suture removal and at Authors: Justin J. Vujevich, MD1; Arash Kimyai-Asadi, MD2; 6-weeks. Leonard H. Goldberg, MDPurpose:2 Accurate mapping is crucial to the Mohs surgeon to orient removed tissue and to identify residual neoplasm for subsequent stages.Summary: While theThere ma werejority 65of Mohscases surgeonsin total (19 use men a penand and 46 paper for women). Their age ranged from 39-86 years old with a Institutions: 1. VujevichMohs Dermatology mapping, Associates, digital photography PC, Mohs mapping is an effective alternative, particularly in the age of mean of 60.5 years (median age 59 years old). Defect size Pittsburgh, PA, United Stateselectronic 2. DermSurgery health records. Associates, PC, Houston, TX, United States varied from 0.4 cm to 2.0 cm in diameter with the majority (63%) measuring 1.0-1.4 cm. Good to excellent results 2:06 – 2:14 pm Design: We describe our six-year experience with digital photography Mohs mapping. After the first stage Presenter: Justin J. Vujevich,is excised, MD the tissue is placed on non-stick gauze (with a notch at 12 o'clock for anatomic orientation) Title: Digital Photographyand photographedMohs Mapping adjacent for the to Electronic the Mohs surgical Health defecRecordt. Using the pre-installed Microsoft Windows Paint program 1and computer mouse, the histologist2 marks on the same2 photograph where the tissue was Authors: Justin J. Vujevich, MD ; Arash Kimyai-Asadi, MD ; Leonard H. Goldberg, MD stained. After the slides are processed, the Mohs surgeon uses the Paint program and computer mouse Institutions: 1. Vujevich Dermatology Associates, PC, Pittsburgh, PA, United States 2. DermSurgery Associates, PC, Houston,to markTX, United any remaining States neoplasm on the same photograph. All digital photographs can be opened, modified, and imported into the electronic health record on any computer desktop in the practice using a shared external hard drive. Purpose: Accurate mapping is crucial to the Mohs surgeon to orient removed tissue and to identify residual neoplasm for subsequent stages. While the majority of Mohs surgeons use a pen and paper for Advantages of digital photography Mohs mapping include superior tissue orientation, easy Mohs mapping, digital photographySummary: Mohs mapping is an effective alternative, particularly in the age of storage of images, quick retrieval and interpretation of Mohs maps, and low-cost of equipment. electronic health records. Disadvantages include a reliance of an operating computer and the learning curve of training your staff.

Design: We describe our six-year experience with digital photography Mohs mapping. After the first stage is excised, the tissue is placed on non-stick gauze (with a notch at 12 o'clock for anatomic orientation) and photographed adjacent to the Mohs surgical defect. Using the pre-installed Microsoft Windows Paint Page 64 of 114 program and computer mouse, the histologist marks on the same photograph where the tissue was stained. After the slides are processed, the Mohs surgeon uses the Paint program and computer mouse to mark any remaining neoplasm on the same photograph. All digital photographs can be opened, modified, and imported into the electronic health record on any computer desktop in the practice using a shared external hard drive.

Summary: Advantages of digital photography Mohs mapping include superior tissue orientation, easy storage of images, quick retrieval and interpretation of Mohs maps, and low-cost of equipment. Disadvantages include a reliance of an operating computer and the learning curve of training your staff.

Page 64 of 114 Clinical Pearls Abstract Session – Saturday, May 1: 12:30 – 2:30 pm were seen in all patients and postoperative complications revealed intracranial extension of both subcutaneous were uncommon and minor. masses, erosion through the calvarium with parenchymalG:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc compression and, in the gentleman, involvement of Conclusion: The nasal sidewall rotation flap is a versatile the superior sagittal sinus with associated non-occlusive and useful alternative for reconstructing surgical defects clot, warranting urgent surgical decompression due of the nasal tip. to high stroke risk. Repeat biopsies were performed 2:22 – 2:30 pm in both patients and histology was compared with Non-occlusive clot in the posterior aspect of the superior sagittal the original biopsy results. Both confirmed infiltrative Presenter: Lorraine Jennings, MD sinus (arrow) - Surgical emergency due to stroke risk. squamous carcinoma, consistent with metastasis from a Title: Metastatic Nasopharyngeal Carcinoma nasopharyngeal primary. Presenting as a Soft Tissue Scalp Tumor: Cautionary Conclusion: These cases demonstrate that rapidly Tales in Two Patients growing soft tissue tumors of the scalp may represent secondary metastatic spread from an ENT source. Authors: Lorraine Jennings, MD; Chrysalyne D. Schmults, MD One should consider repeat biopsy and appropriate radiological imagingG:\Mohs\Annual in the management Meeting\P of ublications\2010\Finalthese tumors Program\2010 Draft Final program Copy.doc Institution: Mohs micrographic surgery center, Brigham and Women’s Hospital, Harvard Medical School, Jamaica

Plain, MA, United States

Purpose: Metastatic carcinoma of nasopharyngeal origin Non-occlusive clot in the posterior aspect of the superior sagittal should be considered in patients presenting with rapidly sinus (arrow) - Surgical emergencyRapidly duegrowing to stroke tumor risk. of the scalp over 3 months. growing soft tissue tumors of the scalp. Design: Two patients present with a similar history of rapidly growing tumors of the scalp over three months. A 50-year old gentleman with a past history significant for right tonsillar squamous cell carcinoma (SCC) two years ago and a 70-year old lady with a history of nasopharyngeal SCC nine years ago, both treated with chemoradiation. Initial histology of the scalp Non-occlusive clot in the Rapidly growing tumor of the tumors reported basal cell carcinoma (BCC) and SCC posterior aspect of the scalp over 3 months. respectively and patients were referred for Mohs surgery. superior sagittal sinus (arrow) Tromovitch Award Abstract Session – Sunday, May 2: 11:00 am – 12:00 pm 11:04 – 11:12 am On review, the gentleman mentioned severe headaches, - Surgical emergency due to while the lady was asymptomatic. Imaging work-up stroke risk. Presenter: Larisa Ravitskiy, MD Title:Rapidly Cost growing Analysis: tumor Mohs of Micrographic the scalp over Surgery 3 months. 1 2 2 Authors: Larisa Ravitskiy, MD ; David G. Brodland, MD ; John A. Zitelli, MD Institutions: 1. Dermatology, OSU Medical Center, Columbus, OH, United States 2. Dermatology and ENT, University of Pittsburgh, Pittsburgh, PA, United States

Purpose: As the incidence of skin cancer continues to increase following the trend of our aging population, delivery of cost efficient skin cancer treatment is a top priority. As with any therapeutic intervention, the intent is to achieve high cure rates, with minimal morbidity and cost effectiveness. Attempts to control costs have resulted in repeated re-examinations of relative values for physician’s work Tromovitch Award Abstractand practice Session expenses – Sunday, as well asMay policy 2: changes11:00 am such – as12:00 the loss pm of exemption of Mohs micrographic 11:04 – 11:12 am surgery (MMS) from the multiple surgery reduction rule (MSRR). Presenter: Larisa Ravitskiy, MD Title: Cost Analysis: Mohs MicrographicDesign: We compared Surgery the costs associated with removal of skin cancers using each of four methods: (1) 1 2 2 Authors: Larisa Ravitskiy, MDMMS,; David (2) G.Office-based Brodland, MDstandard; John surgical A. Zitelli, excision MD (SSE) with permanent margin control, (3) Office-based Institutions: 1. Dermatology, SSEOSU with Medical frozen Center, margin Colu controlmbus, follo OH,wed United by permanent States 2. marginDermatology examinat andion, and (4) Ambulatory surgical ENT, University of Pittsburgh,center Pittsburgh, (ASC)-based PA, United SSE States with frozen margin control followed by permanent margin examination. SSE margins were based on current recommendations of National Comprehensive Cancer Network. Purpose: As the incidence of Subsequently,skin cancer continues the simplest to increase and most following functionally the trend and ofco oursmetically aging pleasing reconstruction of the resulting population, delivery of cost efficientSSE defect skin cancer was designed. treatment An is assumptiona top priority. was As madewith any that therapeutic all SSE defects would be reconstructed. The intervention, the intent is to achieveplan was high recorded cure rates, and with coded minimal based morbidity on preoperative and cost determination effectiveness. of clinical tumor and excision Attempts to control costs havemargins. resulted Next, in repeated MMS was re-examinations performed on of all relative tumors values and codes for physician’s for MMS and work reconstruction, if performed, and practice expenses as wellwere as policy recorded. changes Costs such for asactual the lossMMS of and exemption calculat edof Mohscosts micrographicfor all SSE were calculated based on 2009 surgery (MMS) from the multipleCPT surgery and, when reduction applicable, rule (MSRR). CMS ASC fees. For patients with multiple tumors, the MSRR was applied. Based on historical estimates, 11% of tumors treated with SSE and permanent sections margin control Design: We compared the costswould associated be expected with toremoval have positive of skin cancersmargin(s). using The each cost of foursubsequent methods: re-excision (1) and reconstruction for MMS, (2) Office-based standardtumors surgical with excisionpositive (SSE)margins with was permanent added to marginthe total c ontrol,cost of (3)treatment. Office-based Based on prior studies, 21% of SSE with frozen margin controltumors followed treated by permanent with SSE andmargin frozen examinat sectionsion, marg and in(4) control Ambulatory would surgicalhave pos itive margin(s) thus center (ASC)-based SSE withtranslating frozen margin into control1.21 stages followed to clear. by per It manentwas presumed margin thatexamination. the final marginSSE would be evaluated with margins were based on currentpermanent recommendations sections toof confirmNational tumor Comprehensive clearance. TumoCancerr recurrence Network. was included in the calculations as Subsequently, the simplest andwell: most 10.1% functionally of SSE tumorsand cosmetically and 1.0% pleasingof tumors reconstruction treated with MMS of the would resulting recur. The cost of treating SSE defect was designed. Anrecurrences assumption withwas MMSmade (equal that all to SSE the averagedefects would cost of be Mohs reconstructed. surgery calculated The herein) was added to the plan was recorded and coded based on preoperative determination of clinical tumor and excision margins. Next, MMS was performed on all tumors and codes for MMS and reconstruction, if performed, Page 66 of 114 were recorded. Costs for actual MMS and calculated costs for all SSE were calculated based on 2009 CPT and, when applicable, CMS ASC fees. For patients with multiple tumors, the MSRR was applied. Based on historical estimates, 11% of tumors treated with SSE and permanent sections margin control would be expected to have positive margin(s). The cost of subsequent re-excision and reconstruction for tumors with positive margins was added to the total cost of treatment. Based on prior studies, 21% of tumors treated with SSE and frozen sections margin control would have positive margin(s) thus translating into 1.21 stages to clear. It was presumed that the final margin would be evaluated with permanent sections to confirm tumor clearance. Tumor recurrence was included in the calculations as well: 10.1% of SSE tumors and 1.0% of tumors treated with MMS would recur. The cost of treating recurrences with MMS (equal to the average cost of Mohs surgery calculated herein) was added to the

Page 66 of 114 G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc final estimate.

Summary: A total of 344 patients with 406 tumors were included in the study. Of 344 patients, 12.5% had multiple tumors. Data on previous treatment were available on 379 tumors: 341 (90%) were primary and 38 (10%) – Sunday, were recurrent. May An average 2: 11:00 tumor wasam clea – red12:00 in 1.6 stagespm (median 1.0; range 1-8), with Tromovitch Award Abstract Sessionnearly 60% of patients cleared in one stage. Of tumors treated with MMS, 37.9% were allowed to heal by secondary intention, while another 37.5% were closed primarily (complex or intermediate linear closures). 11:04 – 11:12 am 37.9%Only 13.8%were andallowed 8.9% of to MMS heal defects by secondary required a flap intention, or graft, respec tively. Conversely, due to larger G:\Mohs\Annual Meeting\Publications\2010\Final Program\2010 Draft Final program Copy.doc whileexpected another size of 37.5% defects, were tumors closed treated primarily with SSE neces(complexsitated ornearly 3 times as many flaps and grafts. Presenter: Larisa Ravitskiy, MD final estimate. intermediate Complicated repairs, linear such closures). as two- Onlyand more 13.8% staged and procedures, 8.9% of MMScompound and cartilage grafts, were Title: Cost Analysis: Mohs Micrographic Surgery defectsSummary:twice as required Alikely total ofto 344occur apatients flap in the with orSSE 406 graft, tumorsgroups. respectively. were Of included surgical in the procedures study.Conversely, Of 344 evaluated, patients, 12.5% MMS had was the least multipleexpensive tumors. at Data $805 on perprevious tumor. treatment Office-based were available SSEs on 379with tumors: permanent 341 (90%) margins were primary were and more expensive than Authors: Larisa Ravitskiy, MD1; David G. Brodland, MD2; due38MMS, (10%) to but largerwere less recurrent. expectedthan Anoffice-based average size tumor SSEof was defects, withcleared frozen in 1.6tumors stagesmargins (median treated ($1026 1.0; rangevs.with $1200, 1-8), with respectively) and ASC- nearly 60% of patients cleared in one stage. Of tumors treated with MMS, 37.9% were allowed to heal by 2 SSE necessitated nearly 3 times as many flaps and grafts. John A. Zitelli, MD secondarybased SSE intention, with whilefrozen another margins 37.5% ($2507). were closed primarily (complex or intermediate linear closures). ComplicatedOnly 13.8% and 8.9% repairs, of MMS defects such required as two- a flap and or graft, more respec tively.staged Conversely, due to larger Institutions: 1. Dermatology, OSU Medical Center, procedures,expectedConclusion: size of defects, Whencompound tumorsadjusted treated and for with inflation, cartilage SSE neces thesitated cost grafts, nearlyof MMS, were 3 times inclusive astwice many of flaps initial and grafts.work up, biopsy, and 5 year Complicatedfollow up, repairs,in 2009 such is inas facttwo- andlower more than staged in 1998procedures, ($1376 compound vs. $1635, and cartilage respectively). grafts, were Based on previously Columbus, OH, United States 2. Dermatology and ENT, astwice likely as likely to tooccur occur in inthe the SSE groups.SSE groups. Of surgical Of procedures surgical evaluated, procedures MMS was the least University of Pittsburgh, Pittsburgh, PA, United States expensivepublished at $805costs per of tumor. non-surgical Office-based modalities, SSEs with permanentMMS ($80 margins5) is lesswere moreexpensive expensive option than (radiation ($2559 to evaluated,MMS,4558), but imiquimod less than MMS office-based ($959), was the SSEall SSEs) withleast frozen andexpensive ma onlyrgins more ($1026 at expensive vs. $805 $1200, per respectively) than electrodessication and ASC- and curettage ($471 Purpose: As the incidence of skin cancer continues to tumor.basedto $652). SSE Office-based withLow frozen recurrence margins ($2507). SSEsrates, withsmaller permanent defects result marginsing in simpler, were less costly repairs or secondary more intention expensive healing, and than the MMS, demonstrated but less cost than effect office-basediveness confirm SSEMohs surgery as the cornerstone of increase following the trend of our aging population, Conclusion: When adjusted for inflation, the cost of MMS, inclusive of initial work up, biopsy, and 5 year efficacious and cost effective treatment when compared to standard surgical excision, regardless of place delivery of cost efficient skin cancer treatment is a top withfollow frozen up, in 2009 margins is in fact lower ($1026 than in vs.1998 $1200, ($1376 vs. respectively) $1635, respectively). and Based on previously ASC-basedpublishedof service costs (office ofSSE non-surgical orwith ASC) frozen modalities, or type margins ofMMS margin ($80 5)($2507). control is less expensive pathology. option (radiation ($2559 to priority. As with any therapeutic intervention, the intent 4558), imiquimod ($959), all SSEs) and only more expensive than electrodessication and curettage ($471 to $652). Low recurrence rates, smaller defects resulting in simpler, less costly repairs or secondary is to achieve high cure rates, with minimal morbidity intentionCosts healing,for treatment and the demonstrated per tumor: cost MMS effect (actual),iveness confirm SSE Mohs (calculated). surgery as the cornerstone of and cost effectiveness. Attempts to control costs have efficacious and cost effective treatment whenCost compared ($) to standard Range surgical ($) excision, regardless of place of service (office or ASC) or type of margin control pathology. resulted in repeated re-examinations of relative values MMS 805 545 — 8398 for physician’s work and practice expenses as well as CostsOffice for excision/permanent treatment per tumor: MMS (actual),1026 SSE (calculated). 438 — 13459 policy changes such as the loss of exemption of Mohs Cost ($) Range ($) Office excision/frozen 1200 693 — 13702 micrographic surgery (MMS) from the multiple surgery MMS 805 545 — 8398 1026 2507 438 — 13459 1142 — 16761 reduction rule (MSRR). OfficeASC excision/permanent excision/frozen Office excision/frozen 1200 693 — 13702 2507 1142 — 16761 Design: We compared the costs associated with Costs ASC for excision/frozen treatment per tumor: MMS (actual), SSE (calculated). Cost for treatment per tumor: MMS (actual), Traditional Excision (calculated). removal of skin cancers using each of four methods: Scalp/ Trunk/ Hands/ (1) MMS, (2) Office-based standard surgical excision Cost for treatment per tumor: Nose MMS Ear (actual), Eyelid Traditional Face Excision (calculated). Genitalia Scalp/ Trunk/Neck Hands/ Extremity Feet (SSE) with permanent margin control, (3) Office-based Nose Ear Eyelid Face Genitalia Neck Extremity Feet SSE with frozen margin control followed by permanent MMS 996 803 1043 876 783 828 652 596 MMS 996 803 1043 876 783 828 652 596 margin examination, and (4) Ambulatory surgical center Office Office 1219 12191347 13301347 1143 1330 922 1143 863 922 1036 863 886 1036 886 (ASC)-based SSE with frozen margin control followed by SSE/permanentSSE/permanent permanent margin examination. SSE margins were based OfficeOffice SSE/frozen SSE/frozen 1323 13231451 14341451 1247 1434 1026 1247 967 1026 1140 967 990 1140 990 on current recommendations of National Comprehensive ASCASC SSE/frozen SSE/frozen 3853 38534004 40604004 2983 4060 2686 2983 2310 2686 3179 2310 2641 3179 2641

Cancer Network. Subsequently, the simplest and most 11:12 – 11:20 am functionally and cosmetically pleasing reconstruction of CostPresenter:11:12 for – treatment 11:20 Tina I. Tarantola,am per MD tumor: MMS (actual), Traditional Excision Title: Prognostic Factors in Merkel Cell Carcinoma (calculated).Presenter: Tina I. Tarantola,1,3 MD 2 4 1 the resulting SSE defect was designed. An assumption was Authors: Tina I. Tarantola, MD ; Laura A. Vallow, MD ; Michele Y. Halyard, MD ; Roger Weenig, MD ; Title: Prognostic Factors4 in Merkel Cell1 Carcinoma 1 1 made that all SSE defects would be reconstructed. The Karen E. Warschaw, MD ; Randall K. Roenigk,1,3 MD ; Jerry D. Brewer, 2MD ; Clark C. Otley, MD 4 1 Authors: Tina1. Dermatology, I. Tarantola, Mayo MD Clinic, ;Rochester, Laura A. MN Vallow,, United MD States; Michele 2. Radiation Y. Oncology,Halyard, Mayo MD ; Roger Weenig, MD ; Institutions: 4 1 1 1 plan was recorded and coded based on preoperative Conclusion:Clinic,Karen Jacksonville, E. Warschaw, WhenFL, United MD adjusted States ; Randall 3. Dermatology, forK. Roenigk, inflation, Mayo Clinic,MD the; Scottsdale,Jerry cost D. Brewer,AZ,of United MD States; Clark 4. C. Otley, MD determination of clinical tumor and excision margins. MMS,RadiationInstitutions: inclusive Oncology, 1. Dermatology,Mayoof initial Clinic, Scottsdale,work Mayo up, AZ,Clinic, biopsy,United Rochester, States and 5MN year, United States 2. Radiation Oncology, Mayo Clinic, Jacksonville, FL, United States 3. Dermatology, Mayo Clinic, Scottsdale, AZ, United States 4. Next, MMS was performed on all tumors and codes for followPurpose: up, To determinein 2009 factors is in thatfact impact lower prognosis than in patients in 1998 with a($1376 known primary vs. Merkel cell $1635,carcinoma.Radiation respectively). Oncology, Mayo Based Clinic, on Scottsdale, previously AZ, Unitedpublished States costs MMS and reconstruction, if performed, were recorded. of non-surgical modalities, MMS ($805) is less expensive Costs for actual MMS and calculated costs for all SSE were Design:Purpose: A multi-center, To determine retrospective, factors consecutive that impact study prognosis reviewing 240 in subjectspatients diagnosed with a known with known primary Merkel cell optionprimary Merkel (radiation cell carcinoma ($2559 (MCC) to between 4558), 1981 imiquimod and 2008 was completed. ($959), Data all from three academic calculated based on 2009 CPT and, when applicable, medicalcarcinoma. centers was collected and combined for analysis. Each diagnosis was confirmed histologically at SSEs) and only more expensive than electrodessication CMS ASC fees. For patients with multiple tumors, the MSRR Page 67 of 114 was applied. Based on historical estimates, 11% of tumors andDesign: curettage A multi-center, ($471 retrospective,to $652). Low consecutive recurrence study reviewingrates, 240 subjects diagnosed with known smallerprimary defects Merkel cell resulting carcinoma in (MCC) simpler, between less costly1981 and repairs 2008 was or completed. Data from three academic treated with SSE and permanent sections margin control medical centers was collected and combined for analysis. Each diagnosis was confirmed histologically at would be expected to have positive margin(s). The cost of secondary intention healing, and the demonstrated cost subsequent re-excision and reconstruction for tumors with effectiveness confirm Mohs surgery as the cornerstone Page 67 of 114 positive margins was added to the total cost of treatment. of efficacious and cost effective treatment when Based on prior studies, 21% of tumors treated with SSE compared to standard surgical excision, regardless of and frozen sections margin control would have positive place of service (office or ASC) or type of margin control margin(s) thus translating into 1.21 stages to clear. It was pathology. presumed that the final margin would be evaluated with permanent sections to confirm tumor clearance. Tumor 11:12 – 11:20 am recurrence was included in the calculations as well: 10.1% Presenter: Tina I. Tarantola, MD of SSE tumors and 1.0% of tumors treated with MMS would Title: Prognostic Factors in Merkel Cell Carcinoma recur. The cost of treating recurrences with MMS (equal to the average cost of Mohs surgery calculated herein) was Authors: Tina I. Tarantola, MD1,3; Laura A. Vallow, MD2; added to the final estimate. Michele Y. Halyard, MD4; Roger Weenig, MD1; Karen E. Warschaw, MD 4; Randall K. Roenigk, MD1; Jerry D. Brewer, Summary: A total of 344 patients with 406 tumors were MD1; Clark C. Otley, MD1 included in the study. Of 344 patients, 12.5% had multiple tumors. Data on previous treatment were available on Institutions: 1. Dermatology, Mayo Clinic, Rochester, 379 tumors: 341 (90%) were primary and 38 (10%) were MN, United States 2. Radiation Oncology, Mayo recurrent. An average tumor was cleared in 1.6 stages Clinic, Jacksonville, FL, United States 3. Dermatology, (median 1.0; range 1-8), with nearly 60% of patients Mayo Clinic, Scottsdale, AZ, United States 4. Radiation cleared in one stage. Of tumors treated with MMS, Oncology, Mayo Clinic, Scottsdale, AZ, United States Tromovitch Award Abstract Session – Sunday, May 2: 11:00 am – 12:00 pm

Purpose: To determine factors that impact prognosis in from appearance of the lesion; timely treatment versus patients with a known primary Merkel cell carcinoma. delayed treatment – greater than 30 days from diagnosis; SLNB versus no SLNB; or ELND versus no ELND. In this same Design: A multi-center, retrospective, consecutive study group, those with a history of other cancer demonstrated a reviewing 240 subjects diagnosed with known primary statistically significant decrease in overall survival (p<0.001), Merkel cell carcinoma (MCC) between 1981 and 2008 and those with age beyond 70 years demonstrated a was completed. Data from three academic medical statistical trend toward decreased survival (p=0.064). centers was collected and combined for analysis. Each Additionally, though there was no significant difference diagnosis was confirmed histologically at one of the three in overall survival between patients treated with local or institutions. locoregional radiation therapy versus untreated patients Summary: The average age at diagnosis was 69.6 in this group, there was a statistical trend demonstrating years, and the majority of subjects were male (70%) and improved survival free of local recurrence when Caucasian (98.3% of those reported). Immunosuppressed locoregional radiation therapy was used versus none or subjects - those with solid organ transplant, on local only (p=0.089). immunosuppressive medication, or with a diagnosis of CLL Conclusion: The data presented represents one of or HIV - comprised 13.8% of the patients. The majority of the largest collections of data on primary MCC in the tumors occurred on the head and neck (46.3%), followed literature. Our data confirm the findings of other studies by the extremities (37.9%) and the buttock (8.8%). The that suggest that MCC of all sizes has metastatic potential, most common clinical impression was cyst or non- supporting the NCCN recommendations to consider SLNB melanoma skin cancer, 11.7% and 10% respectively. The for all primary MCC. The trend toward survival free of average size at diagnosis was 1.7 cm on the head and local recurrence demonstrated by stage I and II patients neck, and 2.6 cm below the head and neck. At diagnosis, treated with adjuvant locoregional radiation supports 31.3% were Stage I, 17.1% Stage II, 22.9% Stage III, 2.5% recommendations to strongly consider adjuvant radiation Stage IV, and 26.3% could not be staged based on the for MCC in this group. Because immunosuppressed patients current AJCC staging system as no initial tumor size was had a worse prognosis, we recommend aggressive recorded. Diameter on biopsy histology was available in treatment of this population, with timely surgical excision 46 subjects with stage I or II disease, with median diameter and adjuvant radiation. Due to the unpredictable natural being 7 mm. history of MCC, we recommend individualization of care Wide local excision was the most common primary based on the details of each patient’s tumor and clinical intervention, followed by Mohs micrographic surgery. presentation. When wide local excision was used, and surgical margins recorded, 1 cm and 2 cm margins were used equally at 11:20 – 11:28 am 39.4%. Histologic nodal evaluation was completed in 120 Presenter: Tracy M. Campbell, MD subjects, 72 with sentinel lymph node biopsy (SLNB), 29 with elective lymph node dissection (ELND), and 40 with Title: A Case Controlled Study of Mohs Recurrences therapeutic lymph node dissection (TLND). Of the 120 and the Role of Surgeon Error and Tissue Processing subjects, 41.7% had positive nodes at diagnosis. Tumor size Authors: Tracy M. Campbell, MD; Daniel B. Eisen, MD did not predict nodal involvement. The positive predictive value of a clinical lymph node exam was 79.2% (19/24), Institution: Department of Dermatology, UC Davis with SLNB and TLND used for histologic nodal evaluation. Medical Center, Sacramento, CA, United States The negative predictive value of a clinical lymph node Purpose: To determine the role of surgeon error vs. exam was 75.3% (58/77), with SLNB and ELND used for adequate tissue processing in Mohs recurrences. histologic nodal evaluation. Adjuvant radiation therapy was administered in 107 subjects, 52% of stage I patients Design: Our study is a case controlled study looking and 51.2% of stage II patients. Adjuvant chemotherapy at Mohs recurrences at an academic center involving was administered in 30 patients, 19 of which were stage III 2 Mohs surgeons ranging from 2002-2009. The Mohs or IV. Among the 116 stage I and II patients, there were a recurrences were identified, tallied, and an extensive total of 17 local recurrences all of which occurred within chart review was done for demographic information. For 1.5 years of the primary diagnosis. all 18 recurrences the original slides and Mohs maps were pulled, compared, and analyzed by 2 Mohs surgeons and A log rank test revealed no statistically significant a dermatopathologist. Parameters were outlined and set difference in survival between stage I and II patients. Stage for various histotechnician errors, surgeon error, and slide III patients had a statistically significant decrease in survival quality. A random sampling of slides without recurrences compared with stage I and II patients. Immunosuppressed from 2002-2009 were also analyzed by same physicians patients had a significant decrease in survival with an and parameters. Each recurrence could fill more than 1 overall two year survival of 47.9% compared with 74.3% in parameter. the immunocompetent. When combining stage I and II patients for analysis, no Summary: Of the 18 recurrences: 7 were aggressive statistically significant difference in overall survival or survival subtypes, 6 were due to tissue drop out, 5 were free of local recurrence was demonstrated with: histologic inadequate tissue staining, 5 dense lymphoid like diameter less than 7 mm versus greater than 7 mm; male inflammation, 4 of them were due to surgeon error, versus female gender; location on head and neck, versus 4 had a large number of stages (>3) (surgeon stage extremities, versus all other locations combined; timely averages 1.78 and 1.64), 3 had less than 100% visibility diagnosis versus delayed diagnosis – greater than 90 days of the epidermal border, 3 had large specimen size (>4 Tromovitch Award Abstract Session – Sunday, May 2: 11:00 am – 12:00 pm pieces per stage), 2 had indeterminate cell types, 1 was or an average rate of 0.1 per month. (The range in rate inadequate tissue processing, 1 was too superficial of a reduction was between 2 to 15-fold, with 2 patients not layer (above a scar), and 1 the tissue was folded on all developing any tumors while on the study.) This rate would cuts. extrapolate to the development of just over 1 tumor per year for each individual. A general trend was seen where None had PNIV, inconsistent staining, too thick of tissue the higher the rate of tumor development prior to study cut, a busy adenexal slide, a residual floater not removed, enrollment, the greater the response to capecitabine. tumor present deep in the block, or fibrosis without obvious tumor. The random sampling slide analysis is There are common serious side effects reported pending. The final data analysis is pending but will be in approximately 30% of the patients who have presented at the ACMS meeting. used capecitabine, most of which can be treated symptomatically, with dose reduction, or delay of dose Conclusion: In this case control study will hope to administration. Some form of side effects was noted highlight the role of surgeon error in Mohs recurrences and in all patients on capecitabine. Fatigue was the most the importance of adequate tissue processing. commonG:\Mohs\Annual side effect Meeting\P seen inublications\2010\Final the study patients. Program\201 This side 0 Draft Final program Copy.doc effect ranged from mild to rate-limiting. A few patients 11:28 – 11:36 am range in rate reduction was between 2 to 15-fold, with 2 patients not developing any tumors while on the study.) This rate wouldalso developed extrapolate neutropeniato the development which of necessitated just over 1 tumor a dose per year for each individual. A Bart T. Endrizzi, MD, PhD Presenter: general trend wasreduction seen where or thedelay higher in treatment. the rate of Renaltumor developmentfunction was prior to study enrollment, the Title: A Two-year Perspective on the Efficacygreater of the responseclosely to capecitabine. monitored, and 2 patients developed elevation Capecitabine in Tumor Reduction for Transplant Patients in creatinine. After reducing the capecitabine dose, their There are commoncreatinine serious side level effects resolved reported to baseline in approximately and the patients30% of the patients who have used Authors: Bart T. Endrizzi, MD, PhD; Theresa L.capecitabine, Ray, MD; mostwere of which able canto continue be treated with sympto the matically,study. Other with common dose reduction, side or delay of dose Peter K. Lee, MD, PhD administration. Someeffects form included of side effects hand wasand notedfoot syndrome, in all patients mild on diarrhea, capecitabine. Fatigue was the most common side effectand seen abdominal in the study pain. patients. This side effect ranged from mild to rate-limiting. A few Institution: Dermatology, University of Minnesota,patients also developed neutropenia which necessitated a dose reduction or delay in treatment. Renal Minneapolis, MN, United States function was closelyConclusion: monitored, Theand use2 patients of capecitabine developed elevation in our study in creatinine. showed After reducing the capecitabine dose,a significanttheir creatinine reduction level resolved in the todevelopment baseline and ofthe CSCC patients were able to continue with Purpose: This study was initiated to evaluate the in transplant patients. This drug does have common efficacy and tolerance of capecitabine in reducingthe study. the Other common side effects included hand and foot syndrome, mild diarrhea and abdominal pain. side effects. Patients need close monitoring of fatigue, development of cutaneous squamous cell carcinomas of neutropenia, and renal function, and a reduction in dose the skin in transplant patients. Conclusion: Themay use ofneed capecitabine to be performed. in our study A tendencyshowed a significantto delay biopsyreduction in the development of Design: Screening was performed during regularCSCC skin in transplantof patients.inflamed This lesions drug doeswhile haveon capecitabine common side effects.was evident Patients in need close monitoring of checks of a transplant patient population. Patentsfatigue, were neutropenia, a review and renal of clinical function, visits, and which a reducti mayon havein dose an may impact need on to be performed. A tendency identified who had a high level of actinic damageto delay biopsy ofthe inflamed study lesionsresults. whileWhile on the capecitabi results arene verywas evidentexciting, in aa futurereview of clinical visits, which and a rate of cutaneous squamous cell carcinomamay have an impactstudy on needsthe study to occurresults. where While the repatientssults are and very the exciting, physician a future study needs to (CSCC) development that was refractory to standardoccur where the patientsare blinded and the to thephysician treatment are blinde to determined to the treatment conclusively to determine the conclusively the therapy. Upon induction into the study other skinlevel cancer of response leveland the of responsetrue level ofand tumor the reduction.true level of tumor reduction. adjunctive treatment modalities were halted, and patients were initiated on oral capecitabine. Cryotherapy for precancerous lesions was continued at monthly visits. Initiation on capecitabine was performed in conjunction with the Hematology and Oncology department in a protocol that was previously designed for treatment of colorectal cancer, but with a lower dose of capecitabine. Capecitabine was administered on a 14 days-on/7 days- off schedule for a total of 1000-1500 mg/m2/day, with cycles repeated every three weeks. Monthly follow up to assess side effects of the medication and impact on transplant were performed, including repeat laboratory assessments. The rate of CSCC development was assessed following capecitabine induction with monthly full body skin checks.

Summary: To date, 15 patients have undergone treatment with capecitabine for an average of 11 months (range 4-22 months). Prior to the study the average rate CSCC development was just above 0.6 per month, that represents a rate of greater than 7 tumors per year. (Range of 0.25 to 1.15 per month) This high rate of tumor development reflected the selection11:44 process – 11:52 am and could be roughly correlated with a high levelPresenter: of Sheri A. Nemeth, MD Title: The Risk of Wrong Site Surgery and the Mohs Surgeon immunosuppression and multiple solid organ transplants. 1 2 Authors: Shari A. Nemeth, MD ; Naomi Lawrence, MD Following initiation on capecitabine the rate ofInstitutions: tumor 1. Dermatology, Mayo Clinic Arizona, Scottsdale, AZ, United States 2. Center for development for all patients was reduced. TheDermasurgery, overall Cooper University Hospital, Marlton, NJ, United States reduction in the rate of CSCC development was 6-fold, Purpose: Patients presenting for Mohs micrographic surgery in our practice were noted to have significant difficulty in identifying their surgical site on the day of surgery. Unfortunately, records from the referring physician are often inadequate to allow the Mohs surgeon to identify the site based on biopsy records, pathology reports, diagrams, or photographs. Lack of accurate or inaccurate documentation of biopsy sites at a minimum can result in a significant inconvenience for the patients who may need to cancel or delay their surgery until they can return to the referring physician to help identify the biopsy site. The most severe consequence of poor biopsy site documentation is wrong site surgery and eventual tumor recurrence.

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11:36 – 11:44 am to identify their site on the day or surgery, it would be Presenter: Sheri A. Nemeth, MD greatly beneficial for referring physicians to provide the Mohs surgeon with accurate and detailed site identifying Title: The Risk of Wrong Site Surgery and the Mohs information to minimize the risk of wrong site surgery which Surgeon is one reason for “recurrence” after Mohs surgery. Authors: Shari A. Nemeth, MD1; Naomi Lawrence, MD2 11:44 – 11:52 am Institutions: 1. Dermatology, Mayo Clinic Arizona, Presenter: Emily P. Tierney, MD Scottsdale, AZ, United States 2. Center for Dermasurgery, Cooper University Hospital, Marlton, NJ, United States Title: Mohs Surgery Workforce: Trends in Career Paths, Job Satisfaction and Academic Productivity Purpose: Patients presenting for Mohs micrographic 1, 2 2 surgery in our practice were noted to have significant Authors: Emily P. Tierney, MD ; C. William Hanke, MD ; 3 difficulty in identifying their surgical site on the day of Alexa B. Kimball, MD, MPH surgery. Unfortunately, records from the referring physician Institutions: 1. Dermatology, Boston University, Boston, are often inadequate to allow the Mohs surgeon to identify MA, United States 2. Dermatologic Surgery, Laser and the site based on biopsy records, pathology reports, Skin Surgery Center of Indiana, Carmel, IN, United States diagrams, or photographs. Lack of accurate or inaccurate 3. Dermatology, Harvard University School of Medicine, documentation of biopsy sites at a minimum can result in a Boston, MA, United States significant inconvenience for the patients who may need to cancel or delay their surgery until they can return to the Purpose: While many residents and fellows in Mohs referring physician to help identify the biopsy site. The most surgery express an interest in academics early in their severe consequence of poor biopsy site documentation is career, departure from academics occurs at the level wrong site surgery and eventual tumor recurrence. of many trainees or junior faculty, with an adverse effect on the training and recruitment of the next generation Design: A retrospective chart review of 996 Mohs cases of dermatologic surgeons. We designed a survey in a single physician academic surgical practice was to specifically criteria affecting initial selection and performed. IRB approval was obtained. For each Mohs subsequent changes in practice setting for Mohs surgeons. surgery, the presence of a photograph, measurement from anatomic landmarks, diagram, and location as listed Design: The survey was issued to all members of the ACMS on the pathology report were recorded. The quality of in 2009. A response rate of 58.3% (315/540) was obtained. the diagrams was assessed as being of good quality if it Summary: A total of 315 Mohs surgeons completed the allowed easy localization of the cancer based on day of survey with a total of 84 female surgeons (26.7%) and 231 surgery photographs. Poor quality diagrams were assessed male surgeons (73.3%). A total of 52 surgeons (16.4%) were as such because they did not provide specific enough in full time academics, 238 (75.6%) were in full time private anatomic detail to enable localization of the biopsy site. practice and 28 were in partial private/academic practice The location listed on the pathology report was compared (8.8%). Of those in private practice, 116 (48.7%) had a to the actual anatomic location of the tumor and clinical appointment in academics. considered concordant if it accurately identified the site of the lesion versus providing a generalized location (i.e. right In terms of fellowship training setting, the largest majority ear vs. right tragus). of surgeons, 179 (56.9%), trained in Mohs fellowships in academics. A total of 137 Mohs surgeons (53.1%) trained in Summary: In our study, 2.3% patient referrals for Mohs had fellowships in private practice. A total of 72 Mohs surgeons a photo. A measurement from an anatomic landmark (40.2%) who trained in fellowships in academic practices was provided in 0.6%. Diagrams were provided for 16.8% entered academics whereas, 107 Mohs surgeons (59.8%) of referred patients. Of these, 49.1% were classified as high who trained in academics entered into private practice. quality (i.e. 8.2% of referred patients had diagram of good In contrast, Mohs surgeons who trained in private practice quality). Overall, 29.1% of biopsy sites on the pathology settings were significantly less likely to enter academia. For report specifically and correctly identified the anatomic the Mohs surgeons who trained in private practice, 107 location of the tumor. Locations on the nose were correctly (78.1%) entered into careers in private practice and 30 named on the pathology report 45.3% of the time, 49.1% of (29.9%) entered into careers in academia (p<.01). ear tumors were correctly named, 18.7% of tumors on the trunk were correctly named, 14.5% of extremity lesions were For Mohs surgeons entering into academics after correctly identified, 0% of genital tumors were correctly fellowship, the strongest factors influencing job selection labeled. were an interest in teaching (3.82, on a scale of 0-5, where 0=not important and 5=very important), referral base (3.29), Conclusion: Few patient referrals to the Mohs practice professional ties to institution (3.03). The least important were accompanied by adequate documentation of factors were salary (2.25) and opportunities in cosmetics the biopsy site. As all lesions must be biopsied prior to (1.39). For Mohs surgeons entering into private practice Mohs surgery, the pathology report always accompanies after fellowship, the strongest factors influencing job the patient referral. Unfortunately, the location on the selection were the referral base (3.88), geographic location pathology report only corresponds to the anatomic (3.797), excellent facilities (3.107) and competitive salary location of the tumor in 29.1% of cases. The most useful (2.89). The least important factors were opportunities in form of documentation is in the form of a photograph research (.6), teaching (1.099), and cosmetics (1.244). which provides detailed skin topography and anatomic landmarks to enable site identification despite patient The survey data also analyzed reasons for departure of confusion. Given that the number of patients who struggle surgeons from each practice setting. The most common Tromovitch Award Abstract Session – Sunday, May 2: 11:00 am – 12:00 pm reason for departure from academic Mohs surgery to (an unexpected occurrence involving death or serious private practice was lack of support from the academic physical or psychological injury) by the Joint Commission chair (4.00), potential for increased salary (3.47), and have been identified by the American Academy inadequate support staff (2.57) and facilities (2.03). For of Dermatology Association (AADA) Ad Hoc Task Force Mohs surgeons who left one private practice setting for as major patient safety issues in dermatology. The true another, the most common reasons were increased salary incidence of wrong site surgery is difficult to determine (3.3), geographic move (2.28), greater referral base (2.20) as the medical literature on the subject mostly limited to and lack of support from colleagues (2.03). operating room situations. A recent survey of 300 Mohs Mohs surgeons were asked to evaluate their overall job surgeons revealed that 14% of malpractice cases were satisfaction in each practice setting. The practice settings due to wrong site surgery. We sought to determine the with the highest satisfaction were solo practice (1.29, 1-5 incidence of wrong site, wrong procedure, and wrong scale where 1=excellent, 5=poor) and dermatology group person surgery following implementation of a preoperative practice (1.66), both of which were significantly higher than protocol in patients presenting for treatment of skin cancer academics (2.72) (p<.01). at a high-volume, Joint Commission accredited, tertiary referral center for dermatologic surgery. In terms of academic productivity, the practice setting with the highest productivity was academics, where the mean Design: Over six years we prospectively collected a number of publications was 24.8, lectures 92.8, clinical series of 7983 cases of Mohs micrographic surgery (MMS) trials 2.9 and research grants 1.3 (p<.01). However, Mohs performed on patients presenting for treatment of skin surgeons in private practice were also highly academically cancer. The three components of the Joint Commission productive. In private solo practices the mean number Universal Protocol (i.e. pre-procedure verification of of publications was 6.1, lectures 23.5, clinical trials 4.2 and patient identity, site identification, and performance of a research grants .2. In dermatology group practices the “time-out”), were applied to daily patient care. Patient mean number of publications was 5.8, lectures 23.5, clinical identity was established during consultation prior to the trials 1.9 and research grants .7. Interestingly, the same procedure by confirming patient name and date of individuals who were highly academically productive birth on office provided disposable wristbands placed in academics were often more productive later in their on patients’ left wrists at registration. Patients personally careers upon moving to private practice. confirmed operative sites in the presence of the operating physician via use of a mirror, and the sites were then Conclusion: Our study demonstrates that similar to both clearly circled and initialed with surgical marker by previous studies in dermatology, pursuit of an academic the dermatologic surgeon performing the procedure. career is most highly correlated with interest in the Digital photos of each marked surgical site were taken academic pursuits of teaching, research and scientific and printed for inclusion in the medical record. A “time- writing. One novel finding uncovered by this study is the out” confirming correct patient, correct site, and correct reasons for departure from academic Mohs surgery, procedure was taken prior to performing all procedures, including lack of support from the academic chair, and recorded with doctor’s initials on the reverse side of potential for increased salary in private practice and the patient’s micrographic surgery map. Numbers of wrong inadequate support staff and facilities. The majority of Mohs site office skin surgery were then obtained from prospective fellowships remain in academic practices or academically mandatory adverse reporting data from the last ten years affiliated private practices. Training and recruitment of the in the state of Florida and the last six years in the state of next generation of leaders and teachers in Mohs surgery is Alabama. essential to the continued success of the specialty. Novel efforts to recruit and retain academic Mohs surgeons are Summary: Analysis of 7983 cases of MMS for treatment highly needed. Interestingly, the most senior and tenured of skin cancer revealed no cases of wrong site, wrong Mohs surgeons today are primarily in private practice; procedure, or wrong person surgery in a dermatologic however, their early exposure to academics may have surgery practice. Detailed study of mandatory adverse ensured their continued pursuit of academic interests reporting data from ten years in the state of Florida and six throughout their career. years in the state of Alabama revealed one account of wrong site skin surgery performed by a dermatologist. 11:52 am – 12:00 pm Conclusion: Wrong site office surgery is a rare but Presenter: John Starling, III, MD unacceptable event. It is one of the major causes of Title: Outcome of Six Years of Protocol Use for medical lawsuits in the United States, and was the most Preventing Wrong Site Office Surgery frequently reported event in the Joint Commission sentinel event statistics database in 2008. The incidence of wrong Authors: John Starling, III, MD; Brett M. Coldiron, MD, site surgery is unknown in the outpatient clinic setting, and FACP there are no universal mandatory reporting guidelines in most states. Integration of a correct surgery site protocol Institution: The Skin Cancer Center, Cincinnati, OH, into a daily patient care model is a vital step in preventing United States occurrences of wrong site dermatologic surgery. Our Purpose: As future medical legislation brings increased experiences with integration of a correct surgery site emphasis on both patient outcomes and measures protocol into an everyday patient care model are of quality, patient safety is emerging as an integral presented so that hopefully more dermatologic surgeons part of the overall strategy to improve healthcare in will include this protocol when adopting a zero-tolerance the United States. Wrong site, wrong procedure, and policy for wrong site cutaneous surgery. wrong person surgery are considered sentinel events