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2020 Journal Club Archive

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2020

December 2020

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  • Article 1 take home points:
    • Mohs surgeons are experts in treatment of high-risk BCC/SCC
      • Highest adherence to NCCN treatment guidelines
    • Opportunities:
      • Additional efforts to educate treating physicians on rationale and evidence for CCPDMA
      • Further well-designed studies evaluating long-term comparative efficacy
      • Education for histotechnicians and pathologists on the utilization and comparative efficacy of CCPDMA vs. standard bread-loafing
  • Article 2 take home points:
    • Some patients do not want a 2-stage repair
    • It's always good to have options
    • Wrinkle with this is the preservation of the dorsal nasal skin
    • My caveats
      • Smokers
      • Very sebaceous skin
  • Article 3 take home points:
    • Largest reported cohort low-intermediate risk penile cancer with urethral involvement treated with MMS
    • MSS largely successful in clearing tumor (4/6)
    • Some requiring distal urethrectomy (2/6) for complete clearance
    • Allowed for preservation of form and function
  • Article 4 take home points:
    • Important for cutaneous surgeons to understand anatomy of the head and neck region
    • Inherent variety in human anatomy
    • Appropriately counsel patients regarding risks/benefits
    • Many other important "danger zones" not discussed

Dr. Ian Maher (University of Minnesota), Dr. Daniel Knabel (University of Minnesota Fellow), and Dr. Addison Demer (Mayo Clinic Hospital) present the best dermatologic surgery relevant literature from the December Journals.

November 2020

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  • Article 1 take home points:
    • Perforator based flaps are a useful tool for reconstruction of deep finger defects
    • Reverse metacarpal artery perforator flaps work very well for proximal finger defects (check out Penn articles)
    • The variants discussed here work well for more distal defects
    • Adipose layer is key to successful reconstruction of pulp defects
    • Digital/hand reconstruction is a field where derm surgeons can and should develop more facility
  • Article 2 take home points:
    • Rapidly absorbable polyglactin 910 and non-absorbable nylon sutures had equivalent photographic appearance at 6 month follow up
    • Suture choice should be based on physician and patient preference and scheduling logistics
  • Article 3 take home points:
    • More cases of filler granulomas are being reported
    • Self injection/injection with filler of uncertain provenance do happen
    • Biopsy +/- tissue culture provides important information on type of reaction and filler type
    • If conservative measures fail excision may be necessary
  • Article 4 take home points:
    • Preoperative imaging may identify histologic bony involvement, but not reliably
      • Consider X-ray, then MRI if findings are suspicious for bony involvement
    • Imaging does not decrease the rate of disarticulation
    • Treatment modality may be influenced more by treating specialty
    • Further investigation is needed to help guide preoperative planning for SCC of the NU
  • Article 5 take home points:
    • Ectropion repair will cause some predictable changes in eyelid shape and position
    • Eyelid will sit higher=decrease MRD2 (which is desirable)
    • Lid will flatten somewhat (maybe not desirable)
    • When performing unilateral cicatricial ectropion repairs the normal contralateral is your target.

Dr. Ian Maher (University of Minnesota) and Dr. Daniel Knabel (University of Minnesota Fellow), present the best dermatologic surgery relevant literature from the November Journals.

October 2020

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  • Article 1 take home points:
    • Capecitabine can be effective for prevention/treatment of SCCs
    • High rate of AE, 44%+ d/c'd due to AE
    • Goldilocks effect. Patients who need to most may not be able to tolerate it.
  • Article 2 take home points:
    • Small study that was not quite double blinded, so I will keep my conclusions soft:
      • Both microneedling and TA have potentially additive benefit when combined with standard of care first line treatment for melasma
      • When TA is used alone, there may be rebound flare upon discontinuing
      • Combining microneedling with TA may reduce risk of rebound flare upon discontinuing therapy
  • Article 3 take home points:
    • Significant variations in practice patterns
    • Largest cross-sectional survey examining practice patterns of MMS for melanoma
    • Contributing towards development of best practice guidelines
  • Article 4 take home points:
    • Multiple effective treatments for AK
    • Ingenol is less effective than others
    • Factors other than cost need to be considered
      • Patient factors
      • Compliance
    • Look at assumptions in analysis
      • 38% overhead added to MAL
      • Separate billing for curretage
  • Article 5 take home points:
    • N/A

Dr. Ian Maher (University of Minnesota), Dr. Daniel Knabel (University of Minnesota Fellow), and Dr. Lori Fiessinger (University of Minnesota) present the best dermatologic surgery relevant literature from the October Journals.

August 2020

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  • Article 1 take home points:
    • Need to enter into shared decision making with patients of advanced age
    • LLE can be predicted in multiple ways
    • Making it to a dermatologist's office is probably already a selector for functional status as seen by the high KPS and Katz index in this population
  • Article 2 take home points:
    • Outstanding clinical design, all aspects of methods rational and well-specified
    • Consider 86% effectiveness of C+I versus EDC or I alone in future
    • Surgery is clearly superior to C+I for nodular BCC, but the study was not powered for this comparison, which is a technical point.
  • Article 3 take home points:
    • So we should do radiation on all tumors with PNI, right?
      • No
    • May be factors about patients that chose not to do radiation that were not captured in staging data
    • Does suggest that a true trial would be helpful
    • Radiation is resource intensive, but so is salvage surgery
    • Correct application that improves outcomes would be a meaningful value add
  • Article 4 take home points:
    • Design flaws but few US studies of cosmetic treatment are randomized with larger numbers, hence the interest.
    • Problems
      • Are laser parameters really comparable?
      • How did they decide how many treatments per side (up to 6)?
      • The 5-point scale is skewed and not really validated as a measure
    • Biggest problem in terms of credibility: If PSAL worked better, how did it also hurt less and cause less pigmentary change? The stronger treatment hurts less? This is not consistent with clinical experience.

Dr. Ian Maher (University of Minnesota) and Dr. Murad Alam (Northwestern University) present the best dermatologic surgery relevant literature from the August Journals.

July 2020

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  • Article 1 take home points:
    • Both AJCC8 and BWH systems are both good at stratifying the likelihood of a (+) SNL biospy
    • cSCC of the trunk/extremities showed similar trends as those located on the head/neck with both systems
    • It may be reasonable to recommend SNL biopsy for patients with AJCC8 T3 or BWH stage T2b/T3 disease
  • Article 2 take home points:
    • The inferiorly based rhombic transposition flap may be considered as a reliable and cosmetically successful reconstructive option for (lower) medial canthal defects.
  • Article 3 take home points:
    • Complications rate related to the extent of the surgery
    • Removal of diseased tissue leads to a lower recurrence rate
      • Overall theme: recurrence rate increases when repaired with a closure
        • Primary closure: 39.9% recurrence rate
        • Secondary healing: 5.4% recurrence rate
      • No associated comorbidities and recurrence rates or complications
      • Review highlights a lack of overall data
  • Article 4 take home points:
    • N/A

Dr. Misha Miller (University of Colorado), Dr. June Park (University of Colorado), and Daniel Knabel (University of Minnesota Fellow) present the best dermatologic surgery relevant literature from the July Journals.

June 2020

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  • Article 1 take home points:
    • No "one size fits all for reconstruction"
    • Nasalis sling flap is a versatile tool
      • Bigger flap = more movement
      • Rotational component to lateral pedicle well compensated for in their design
      • My "get out of jail" flap
    • No reconstruction is perfect
      • High % of surgical revisions = expected when "pushing" local repair
      • Hard to compare reconstructive outcomes because we don't use standard scar scales
  • Article 2 take home points:
    • Successful relining of nose is critical for full thickness defect
    • Big bad defects occur in patients that generally have a higher cancer burden
    • Need a tumor free donor site, especially if it's going inside the nose!!
    • Cheek interp allows placement of cartilage in 1st stage therefore 2 stage solution
    • Graft for lining makes placement of cartilage in 1st stage more risky
      • 3 stages probably a good idea especially in smokers
    • Good to have options
  • Article 3 take home points:
    • No difference in improvement across two study arms
    • Possibly more pain and redness in AFL arm
    • Patients saw more improvement than blinded raters who noted little or none
  • Article 4 take home points:
    • High rate of MH in sBCC of the head/neck region (Zone H/M) in healthy and immunocompromised patients
    • Current AUC guidelines appropriate for treatment of sBCC
    • Biopsies offer limited information on tumor characteristics
    • Biologic behavior of pure sBCC and treatment strategies
    • 247 of 3,523 (7%) sBCC were treated with MMS

Dr. Murad Alam (Northwestern Medicine), Dr. Ian Maher (University of Minnesota), and Dr. Daniel Knabel  (Fellow, University of Minnesota) present the best dermatologic surgery relevant literature from the June Journals.

May 2020

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  • Article 1 take home points:
    • Epi reactions are rare
    • Probably depend heavily on patient factors
      • Patients make more epi than we give them
      • Some are more sensitive than others
    • Where the epi goes matters more than how much you give
    • Could have higher rates with less experienced injectors or younger cohort
    • Maintaining your differential diagnosis with anesthesia related AE is a core competency of dermatology
  • Article 2 take home points:
    • Study consistent with prior literature showing no difference in scar scores between top closure methods
    • Acrylates (even octylacrylates) have a "non-0" risk of allergy which may account for pigmentation difference
    • Once again a very high rate of dehiscence in this study (almost 10% of scar halves)
    • We as surgeons hold tightly to sutures despite lack of evidence
    • So even if we pretend to be evidence based we're not totally nihilistic
  • Article 3 take home points:
    • Pretreatment with Erbium:glass reduced scarring measured by POSAS at 12 months in setting of incisional surgery
    • Some differences with extrapolating to excisional surgery
    • Certainly an interesting idea.
    • Could be an ancillary service to add for demanding patients.
    • Would be interesting to study in an excisional setting.
  • Article 4 take home points:
    • MMS is well suited for treatment of nail unit SCC and may be considered the "standard of care"
      • Tissue sparing (100% margin assessment), high cure rates (>92%)
    • Despite surgical clearance with MMS, our hand surgery/plastics colleagues may recommend amputation...Consider reconstructing
    • Amputation has not been shown to have superior cure rates; increased morbidity
    • HPV associated with higher recurrence rates; likely due to "field" disease
  • Article 5 take home points:
    • HA fillers are now most commonly associated with filler-associated blindness
    • Most common injection locations: Nose (55%), glabella (35%), forehead (18.3)
    • Cannula complication less frequently reported; ?less frequently used
    • Approach to treatment is quite heterogeneous, although hyaluronidase (intraarterial + subq injection) seems most promising
      • I was a bit disappointed in retrobulbar success
    • Nearly 20% of patients will present with concomitant ischemic stroke

Dr. Ian Maher (University of Minnesota) and Dr.  Addison Demer (Fellow, University of Minnesota) present the best dermatologic surgery relevant literature from the May Journals.

April 2020

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  • Article 1 take home points:
    • Short term follow up - may not be totally comparable to 1 year follow up of many clinical trials
    • AK clearance rate ~ between incubated and immediate irradiation groups
    • Another option for providing low pain PDT
    • Potentially good for very sun damaged patients who may experience intense PDT-associated pain.
  • Article 2 take home points:
    • Utah has a really interesting approach to LM
    • Confirmed significant rate of occult invasion in LM (30%)
    • Response rates they cite for imiquimod are quite high
      • Maybe these vary with population or environmental factors?
    • Staged excision with purse string closure effective at reducing defect size
      • May likely decrease morbidity
      • No direct comparison
    • Caveats for purse strings
      • Lots of LM occur in places where doing a purse string may be tough
      • (Back to population) They're most useful in SUPER sun damaged skin
      • Going back early normally results in re-expansion of the wound.
  • Article 3 take home points:
    • Overall complication rate of 14%
    • Functional complication rate of 3%
    • No cases of lagophtalmos, keratitis or visual loss
    • Lower complication rate than reporter in the Oculoplastics literature
    • Limitations
      • Cases may have been referred to Oculoplastics
      • Cases performed by fellowship-trained Mohs surgeons in an academic setting
    • We can do this!
  • Article 4 take home points:
    • N/A
  • Article 5 take home points:
    • DAXI significantly more effective than placebo
    • Duration median 24w

Dr. Ian Maher (University of Minnesota), Dr. Mariah Brown (University of Colorado), and Dr. M. Laurin Council (Washington University) present the best dermatologic surgery relevant literature from the April Journals.

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