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Predicting success: What medical student measures predict resident performance in neurology?
1540
1359
Outcomes of contoured staged excision for lentigo maligna of the head and neck: A pilot study with survey of current practices Annie Liu, The University of Toronto, Toronto, Ontario, Canada; Alexis Botkin, MD, The University of Toronto, Division of Dermatology, Toronto, Ontario, Canada; An-Wen Chan, MD, PhD, Division of Dermatology, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
Randomized clinical trial assessing patient satisfaction after Mohs micrographic surgery, depending on whether the patient sees or does not see the final defect in the mirror prior to closure Ganary Dabiri, MD, PhD, Roger Williams Medical Center, Providence, RI, United States; Jeffrey Tiger, MD, Roger Williams Medical Center, Providence, RI, United States; Heidi Anderson-Dockter, MD, South Coast Dermatology, Weymouth, MA, United States; Satori Iwamoto, MD, PhD, Roger Williams Medical Center, Providence, RI, United States
Introduction: Treatment of lentigo maligna on the head and neck remains challenging due to subclinical tumor extension and the potential for adverse functional and cosmetic outcomes postoperatively. Standard wide excision with a 0.5-cm margin remains the standard of care. However, no clinical trials exist to guide practice; case series suggest that most patients require a larger surgical margin for complete tumor clearance. Objectives: To determine the current treatment practices for lentigo maligna of the head and neck in Ontario by practicing physicians who commonly treat lentigo maligna. Methods: We conducted a cross-sectional survey of all dermatologists, plastic surgeons, and otolaryngologists practicing in Ontario, examining their current treatment practices for lentigo maligna of the head and neck. Results: Wide excision with immediate reconstruction was most commonly recommended overall (86%) and staged excision with margin control was the majority recommendation (60%) for sensitive anatomic sites. Five millimeters was the most frequently recommended (69%) margin, and few respondents routinely recommended a margin \0.5 cm (4.9%). Discussion: Although standard wide excision with immediate reconstruction is the most common treatment utilized for lentigo maligna of the head and neck, surgical practice varies in terms of excision technique and margin size across Ontario. Despite consensus guidelines recommending a 0.5-cm margin, there is variability in the margin size used in practice on the head and neck. Additional evidence from robust studies is needed to inform optimal treatment for this challenging tumor.
Background: Optimizing patient satisfaction and wound care compliance is important for the practicing Mohs surgeon. Objective: To evaluate whether showing or not showing patients their postsurgical defect in the mirror has any influence on scar satisfaction, wound care compliance, and complication rate. Also to determine other factors that influence scar satisfaction. Materials and methods: 50 patients with a nonmelanoma skin cancer on their head or neck requiring Mohs micrographic surgery were randomized to either see (mirror) or not see (nonmirror) their postsurgical defect in the mirror prior to wound closure. Patients evaluated their scar at week 1 and week 4 using the patient scar assessment questionnaire. Results: Patients in the mirror group had a significant change in scar satisfaction from week 1 to week 4 compared to the nonmirror group from week 1 to week 4. There was no difference in wound care compliance and complication rate between the two treatment groups. In addition, men and older patients were more satisfied with their scar at week 1 compared to women and younger patients. Conclusions: There is an advantage to showing patients their postoperative defect in the mirror prior to closure to improve patient perceived scar satisfaction, but not in wound care compliance or complication rates. Commercial support: None identified.
Commercial support: None identified.
664
A 26-year-old Trinidadian male presented with an exquisitely tender 5-cm tumor involving his penile shaft and median raphe, which rapidly evolved over the course of 3 weeks. He presented with inability to urinate, attain an erection, or ambulate without tenderness. One year prior, he presented to the urologist with a 1-cm nodule involving the median raphe, which was surgically resected and required circumcision. Dermatopathology revealed foreign body giant cell reaction with surrounding empty spaces in the dermis resembling ‘‘Swiss cheese,’’ consistent with a paraffinoma. The recurrent tumor, 5 times the size of the initial nodule, was biopsied and consistent with a paraffinoma yet again, with extensive dermal fibrosis and absence of polarizable material. The patient underwent extensive reconstructive surgery requiring skin grafting to the penile shaft. Given the size and location of this recurrent tumor, with the ability to destroy vital urologic and reproductive function, consideration for prevention of recurrent episodes includes suppression of inflammation and fibrosis with doxycycline and nicotinamide. In many countries, paraffin is injected into various parts of the body, most commonly the breast and buttock, in an effort to augment or enhance one’s appearance. However, paraffin is a mineral oil not hydrolyzed by tissue lipases and instead is treated as a foreign body substance with subsequent granuloma formation, which can occur many years after injection. Currently, surgical resection is the only definitive treatment. However, nonsurgical goals aim to spare vital tissue resection while reducing inflammation and fibrosis.
Rim Mohs technique for removing large skin tumors Hamza Bhatti, DO, Rutgers-Robert Wood Johnson Medical School, Somerset, NJ, United States; Aisha Masud, Rao Dermatology, New York, NY, United States; Babar Rao, MD, Rutgers-Robert Wood Johnson Medical School, Somerset, NJ, United States Large skin cancers can take may MOHS stages to be clear. This also may also cause bleeding and other difficulties during procedure. We present an alternate MOHS procedure for these lesions. An 82-year-old male farmer with PMHx of hypertension, end stage renal disease on hemodialysis with a BP of 70/49 presented with a large 6.5 cm 3 5.0 cm protuberant nodule on mid-forehead that was untreated and continued to worsen over years. Based off the biopsy report, it was proven to be a squamous cell carcinoma (SCC). The patient traveled at length to come have the lesion examined. Due to the language barrier and distance, we were afraid that the patient would fail to follow-up. Though the BP was low, the patient appeared to be stable otherwise. At that point, we decided to remove the lesion via Mohs using a rim technique, which we consider a quick procedure with minimal blood loss. In this technique, possible peripheral clinical edges were marked using erasable ink. Then another circle was drawn 2 mm away, around these initial markings all around the lesion. A rim of tissue between these two circles was removed and processed for Mohs. All peripheral and deep margins were negative for this rim of tissue, which included the clinical margins. In the next step, the whole protuberant tissue was removed along with subcutaneous fat. Then the entire circular base of tissue was processed for Mohs. This deeper section, which included the periosteum, was negative for SCC. The wound was then closed using a bilateral advancement flap. This method shortened the number of Mohs stages, duration for the surgery, and bleeding. In conclusion, this rim Mohs technique is another option for removing large skin tumors. This in turn allows for a shorter surgical period with decreased blood loss as well as compared to conventional Mohs procedure.
Commercial support: None identified.
Commercial support: None identified.
480 Penile paraffinoma: Dramatic recurrence after surgical resection Kelli Danowski, DO, St Joseph Mercy Department of Dermatology, Ypsilanti, MI, United States; Jessica Ghaferi, MD, St Joseph Mercy Department of Dermatopathology, Ann Arbor, MI, United States
MAY 2015
J AM ACAD DERMATOL
AB263
1359
Outcomes of contoured staged excision for lentigo maligna of the head and neck: A pilot study with survey of current practices Annie Liu, The University of Toronto, Toronto, Ontario, Canada; Alexis Botkin, MD, The University of Toronto, Division of Dermatology, Toronto, Ontario, Canada; An-Wen Chan, MD, PhD, Division of Dermatology, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
Randomized clinical trial assessing patient satisfaction after Mohs micrographic surgery, depending on whether the patient sees or does not see the final defect in the mirror prior to closure Ganary Dabiri, MD, PhD, Roger Williams Medical Center, Providence, RI, United States; Jeffrey Tiger, MD, Roger Williams Medical Center, Providence, RI, United States; Heidi Anderson-Dockter, MD, South Coast Dermatology, Weymouth, MA, United States; Satori Iwamoto, MD, PhD, Roger Williams Medical Center, Providence, RI, United States
Introduction: Treatment of lentigo maligna on the head and neck remains challenging due to subclinical tumor extension and the potential for adverse functional and cosmetic outcomes postoperatively. Standard wide excision with a 0.5-cm margin remains the standard of care. However, no clinical trials exist to guide practice; case series suggest that most patients require a larger surgical margin for complete tumor clearance. Objectives: To determine the current treatment practices for lentigo maligna of the head and neck in Ontario by practicing physicians who commonly treat lentigo maligna. Methods: We conducted a cross-sectional survey of all dermatologists, plastic surgeons, and otolaryngologists practicing in Ontario, examining their current treatment practices for lentigo maligna of the head and neck. Results: Wide excision with immediate reconstruction was most commonly recommended overall (86%) and staged excision with margin control was the majority recommendation (60%) for sensitive anatomic sites. Five millimeters was the most frequently recommended (69%) margin, and few respondents routinely recommended a margin \0.5 cm (4.9%). Discussion: Although standard wide excision with immediate reconstruction is the most common treatment utilized for lentigo maligna of the head and neck, surgical practice varies in terms of excision technique and margin size across Ontario. Despite consensus guidelines recommending a 0.5-cm margin, there is variability in the margin size used in practice on the head and neck. Additional evidence from robust studies is needed to inform optimal treatment for this challenging tumor.
Background: Optimizing patient satisfaction and wound care compliance is important for the practicing Mohs surgeon. Objective: To evaluate whether showing or not showing patients their postsurgical defect in the mirror has any influence on scar satisfaction, wound care compliance, and complication rate. Also to determine other factors that influence scar satisfaction. Materials and methods: 50 patients with a nonmelanoma skin cancer on their head or neck requiring Mohs micrographic surgery were randomized to either see (mirror) or not see (nonmirror) their postsurgical defect in the mirror prior to wound closure. Patients evaluated their scar at week 1 and week 4 using the patient scar assessment questionnaire. Results: Patients in the mirror group had a significant change in scar satisfaction from week 1 to week 4 compared to the nonmirror group from week 1 to week 4. There was no difference in wound care compliance and complication rate between the two treatment groups. In addition, men and older patients were more satisfied with their scar at week 1 compared to women and younger patients. Conclusions: There is an advantage to showing patients their postoperative defect in the mirror prior to closure to improve patient perceived scar satisfaction, but not in wound care compliance or complication rates. Commercial support: None identified.
Commercial support: None identified.
664
A 26-year-old Trinidadian male presented with an exquisitely tender 5-cm tumor involving his penile shaft and median raphe, which rapidly evolved over the course of 3 weeks. He presented with inability to urinate, attain an erection, or ambulate without tenderness. One year prior, he presented to the urologist with a 1-cm nodule involving the median raphe, which was surgically resected and required circumcision. Dermatopathology revealed foreign body giant cell reaction with surrounding empty spaces in the dermis resembling ‘‘Swiss cheese,’’ consistent with a paraffinoma. The recurrent tumor, 5 times the size of the initial nodule, was biopsied and consistent with a paraffinoma yet again, with extensive dermal fibrosis and absence of polarizable material. The patient underwent extensive reconstructive surgery requiring skin grafting to the penile shaft. Given the size and location of this recurrent tumor, with the ability to destroy vital urologic and reproductive function, consideration for prevention of recurrent episodes includes suppression of inflammation and fibrosis with doxycycline and nicotinamide. In many countries, paraffin is injected into various parts of the body, most commonly the breast and buttock, in an effort to augment or enhance one’s appearance. However, paraffin is a mineral oil not hydrolyzed by tissue lipases and instead is treated as a foreign body substance with subsequent granuloma formation, which can occur many years after injection. Currently, surgical resection is the only definitive treatment. However, nonsurgical goals aim to spare vital tissue resection while reducing inflammation and fibrosis.
Rim Mohs technique for removing large skin tumors Hamza Bhatti, DO, Rutgers-Robert Wood Johnson Medical School, Somerset, NJ, United States; Aisha Masud, Rao Dermatology, New York, NY, United States; Babar Rao, MD, Rutgers-Robert Wood Johnson Medical School, Somerset, NJ, United States Large skin cancers can take may MOHS stages to be clear. This also may also cause bleeding and other difficulties during procedure. We present an alternate MOHS procedure for these lesions. An 82-year-old male farmer with PMHx of hypertension, end stage renal disease on hemodialysis with a BP of 70/49 presented with a large 6.5 cm 3 5.0 cm protuberant nodule on mid-forehead that was untreated and continued to worsen over years. Based off the biopsy report, it was proven to be a squamous cell carcinoma (SCC). The patient traveled at length to come have the lesion examined. Due to the language barrier and distance, we were afraid that the patient would fail to follow-up. Though the BP was low, the patient appeared to be stable otherwise. At that point, we decided to remove the lesion via Mohs using a rim technique, which we consider a quick procedure with minimal blood loss. In this technique, possible peripheral clinical edges were marked using erasable ink. Then another circle was drawn 2 mm away, around these initial markings all around the lesion. A rim of tissue between these two circles was removed and processed for Mohs. All peripheral and deep margins were negative for this rim of tissue, which included the clinical margins. In the next step, the whole protuberant tissue was removed along with subcutaneous fat. Then the entire circular base of tissue was processed for Mohs. This deeper section, which included the periosteum, was negative for SCC. The wound was then closed using a bilateral advancement flap. This method shortened the number of Mohs stages, duration for the surgery, and bleeding. In conclusion, this rim Mohs technique is another option for removing large skin tumors. This in turn allows for a shorter surgical period with decreased blood loss as well as compared to conventional Mohs procedure.
Commercial support: None identified.
Commercial support: None identified.
480 Penile paraffinoma: Dramatic recurrence after surgical resection Kelli Danowski, DO, St Joseph Mercy Department of Dermatology, Ypsilanti, MI, United States; Jessica Ghaferi, MD, St Joseph Mercy Department of Dermatopathology, Ann Arbor, MI, United States
MAY 2015
J AM ACAD DERMATOL
AB263