- •Foreword
- •Preface
- •Acknowledgements
- •Contents
- •Contributors
- •Summary: An Introduction to Mohs Micrographic Surgery
- •1.1 Introduction
- •Summary: Conclusion
- •1.2 Conclusion
- •References
- •Summary: Introduction
- •2.1 Introduction
- •Summary: Common Indications
- •2.2 Common Indications
- •2.2.1 Basal Cell Carcinoma (BCC)
- •2.2.2 Squamous Cell Carcinoma (SCC)
- •Summary: Uncommon Indications
- •2.3 Uncommon Indications
- •2.3.2 Microcystic Adnexal Carcinoma (MAC)
- •2.3.3 Atypical Fibroxanthoma (AFX)
- •2.3.5 Malignant Fibrous Histiocytoma (MFH)
- •2.3.6 Sebaceous Carcinoma (SC)
- •2.3.7 Melanoma
- •2.3.8 Merkel Cell Carcinoma (MCC)
- •Summary: Conclusion
- •2.4 Conclusion
- •References
- •3: Preoperative Evaluation
- •Summary: Introduction
- •3.1 Introduction
- •3.3 History of Present Illness and Physical Examination
- •Summary: Past Medical History
- •3.4 Past Medical History
- •Summary: Medications and Allergies
- •3.5 Medications and Allergies
- •Summary: Assessing the Need for Infection Prophylaxis
- •Summary: Discussion of Postoperative Care
- •3.7 Discussion of Postoperative Care
- •Summary: Conclusion
- •3.8 Conclusion
- •References
- •Summary: Introduction
- •4.1 Introduction
- •Summary: Mohs Surgery Waiting Room
- •4.2 Mohs Surgery Waiting Room
- •4.3 Mohs Surgery Operative Room Planning
- •4.3.1 Photography
- •4.3.2 Laser Safety
- •4.4 Mohs Surgery Operative Room Equipment
- •4.4.1 Surgical Table
- •4.4.3 Surgical Lights
- •4.4.4 Surgical Sink
- •4.4.5 Electrosurgical Equipment
- •4.4.6 Suction
- •4.4.7 Mayo Stand/Kick Bucket
- •4.4.8 Waste Disposal
- •Summary: Personal Protective Equipment
- •4.5 Personal Protective Equipment
- •4.5.1 Masks and Eye Protection
- •4.5.2 Gowns
- •4.5.3 Scrubs
- •4.5.4 Gloves
- •Summary: Instrumentation and Setup
- •4.6 Instrumentation and Setup
- •4.6.1 Scalpels
- •4.6.2 Blades
- •4.6.3 Standard Mohs Surgery Setup
- •4.6.4 Mohs Surgery Eye Tray
- •4.6.5 Excision/Closure Tray for Face
- •4.6.6 Excision/Closure Tray for Trunk
- •4.6.7 Nail Surgery Instruments
- •Summary: Wound Care Dressing Materials
- •4.7 Wound Care Dressing Materials
- •Summary: Equipment Sterilization
- •4.8 Equipment Sterilization
- •Summary: Monitoring and Emergency Equipment
- •4.9 Monitoring and Emergency Equipment
- •Summary: Conclusion
- •4.10 Conclusion
- •References
- •Summary: Introduction
- •5.1 Introduction
- •Summary: History
- •5.2 History
- •Summary: Pharmacology
- •5.3 Pharmacology
- •Summary: Pharmacokinetics
- •5.4 Pharmacokinetics
- •Summary: Regional Anesthesia
- •5.5 Regional Anesthesia
- •Summary: Peripheral Nerve Fibers
- •5.6 Peripheral Nerve Fibers
- •Summary: Metabolism
- •5.7 Metabolism
- •Summary: Toxicity
- •5.8 Toxicity
- •Summary: Method of Injection
- •5.9 Method of Injection
- •Summary: Amino-Esters
- •5.10 Amino-Esters
- •Summary: Amino-Amides
- •5.11 Amino-Amides
- •5.11.1 Topical Anesthesia
- •Summary: Conclusion
- •5.12 Conclusion
- •References
- •Summary: Introduction
- •6.1 Introduction
- •Summary: Scalp and Forehead
- •6.2 Scalp and Forehead
- •6.2.1 Vasculature
- •6.2.2 Nerves
- •6.2.3 Lymphatic Drainage
- •Summary: Midface
- •6.3 Midface
- •6.3.1 Nasal Subunit
- •6.3.1.1 Vasculature
- •6.3.1.2 Nerves
- •6.3.1.3 Lymphatic Drainage
- •6.3.2 Perioral
- •6.3.2.1 Vasculature
- •6.3.2.2 Nerves
- •6.3.2.3 Lymphatic Drainage
- •6.3.3 Chin
- •6.3.3.1 Vasculature
- •6.3.3.2 Nerves
- •6.3.3.3 Lymphatic Drainage
- •Summary: Periorbital
- •6.4 Periorbital
- •6.4.1 Vasculature
- •6.4.2 Nerves
- •6.4.3 Lymphatic Drainage
- •Summary: Cheeks
- •6.5 Cheeks
- •6.5.1 Vasculature
- •6.5.2 Nerves
- •6.5.3 Lymphatic Drainage
- •Summary: Auricular
- •6.6 Auricular
- •6.6.1 Vasculature
- •6.6.2 Nerves
- •6.6.3 Lymphatic Drainage
- •Summary: Neck
- •6.7 Neck
- •6.7.1 Nerves
- •6.7.2 Lymphatic Drainage
- •6.8 Special Anatomic Considerations in Mohs Micrographic Surgery
- •6.8.1 Danger Zones
- •6.8.2 Other Considerations
- •References
- •7: Mohs Surgery: Fixed Tissue Technique
- •Summary
- •Summary: Conclusion
- •7.2 Conclusion
- •References
- •8: Fresh Tissue Technique
- •Summary: Introduction
- •8.1 Introduction
- •Summary: The Technique
- •8.2 The Technique
- •Summary: Histologic Preparation of the Tissue
- •8.3 Histologic Preparation of the Tissue
- •Summary: Conclusion
- •8.4 Conclusion
- •References
- •Summary: Introduction
- •9.1 Introduction
- •Summary: Solid Organ Transplant Recipients
- •9.2 Solid Organ Transplant Recipients
- •Summary: HIV/AIDS
- •9.3 HIV/AIDS
- •Summary: Cutaneous Neoplasms
- •9.4 Cutaneous Neoplasms
- •9.4.1 Actinic Keratoses and Squamous Cell Carcinoma
- •9.4.2 Basal Cell Carcinoma
- •9.4.3 Melanoma
- •9.4.4 Merkel Cell Carcinoma
- •9.4.5 Kaposi Sarcoma
- •9.5.1 Preoperative Evaluation
- •9.5.2 Antibiotic Prophylaxis
- •9.5.3 Wound Healing
- •9.5.4 Selection of Therapeutic Modality
- •9.5.5 Follow-Up
- •Summary: Conclusion
- •9.6 Conclusion
- •References
- •10: Mohs Micrographic Surgery in Ethnic Skin
- •10.1 Introduction
- •Summary: Histologic Differences in Skin of Color
- •Summary: Basal Cell Carcinoma (BCC)
- •10.3 Basal Cell Carcinoma (BCC)
- •Summary: Squamous Cell Carcinoma (SCC)
- •10.4 Squamous Cell Carcinoma (SCC)
- •Summary: Malignant Melanoma (MM)
- •10.5 Malignant Melanoma (MM)
- •Summary: Conclusion
- •10.7 Conclusion
- •References
- •Summary: The Operating Room (OR)
- •11.2 The Operating Room (OR)
- •Summary: Surgical Waiting Room
- •11.3 Surgical Waiting Room
- •Summary: The Histopathology Laboratory
- •11.4 The Histopathology Laboratory
- •Summary: Grossing and Inking
- •11.5 Grossing and Inking
- •11.6 Embedding and Mounting Tissue and the Cryostat
- •Summary: Staining Frozen Sections
- •11.7 Staining Frozen Sections
- •Summary: Slide Reading
- •11.8 Slide Reading
- •Summary: Conclusion
- •11.10 Conclusion
- •References
- •Summary: Tissue Transport
- •12.1 Tissue Transport
- •Summary: Initial Processing
- •12.2 Initial Processing
- •Summary: Conclusion
- •12.3 Conclusion
- •Reference
- •Summary: Introduction
- •13.1 Introduction
- •13.2 Histopathologic Scanning of Mohs Slides
- •13.3 Histopathologic Recognition of Cutaneous Structures
- •13.3.1 Recognition of Epidermal and Epithelial Components and Their Neoplasia
- •13.3.1.1 The Epidermis
- •13.3.1.2 Melanocytes and the Melanocytic Lesions
- •13.3.1.4 The Pilosebaceous Unit
- •13.3.1.5 The Bulge
- •13.3.1.6 The Mantle and Sebaceous Glands
- •13.3.1.7 The Folliculocentric Basaloid Proliferations (FBP)
- •13.3.2 Histopathologic Recognition of Dermal Components
- •13.3.2.1 Fibrous Tissue, Desmoplasia, and Nerves
- •13.3.2.2 The Dermal Microvascular Unit
- •13.3.2.3 Dermal Muscles, Cartilage, and Subcutaneous Adipose Tissue
- •Summary: Conclusion
- •13.4 Conclusion
- •References
- •Summary: History
- •14.1 History
- •Summary: Preexamination Process
- •14.4 Preexamination Process
- •Summary: Examination Process
- •14.5 Examination Process
- •Summary: Postexamination Process
- •14.6 Postexamination Process
- •Summary: Conclusion
- •14.7 Conclusion
- •References
- •15: Immunostains
- •Summary: Introduction
- •15.1 Introduction
- •Summary: Melanoma
- •15.3 Melanoma
- •15.4 Basal Cell and Squamous Cell Carcinoma
- •Summary: Other Rare Tumors
- •15.7 Other Rare Tumors
- •15.7.1 Granular Cell Tumor
- •15.7.2 Primary Mucinous Carcinoma
- •15.7.3 Trichilemmal Carcinoma
- •Summary: Conclusions
- •15.8 Conclusions
- •References
- •16: Basal Cell Carcinoma
- •Summary: Introduction
- •16.1 Introduction
- •Summary: Etiology
- •16.2 Etiology
- •16.3 Histological Findings Using Horizontal Frozen Sections
- •Summary: Non-cancerous Conditions That May Be Histologically Similar to BCC
- •Summary: Cancerous Conditions That May Be Histologically Similar to BCC
- •16.6 Adnexal Differentiation Observed in BCC
- •Summary: Basosquamous Differentiation
- •16.7 Basosquamous Differentiation
- •Summary: Therapeutic Options
- •16.8 Therapeutic Options
- •Summary: Mohs Micrographic Surgery
- •16.9 Mohs Micrographic Surgery
- •Summary: Conclusions
- •16.10 Conclusion
- •References
- •17: Squamous Cell Carcinoma
- •Summary: Introduction
- •17.1 Introduction
- •Summary: Pathophysiology (Risk Factors for SCC Development)
- •17.2 Pathophysiology (Risk Factors for SCC Development)
- •17.2.1 Ultraviolet Light
- •17.2.2 Human Papilloma Virus
- •17.2.3 Molecular and Genetic Factors Impacting SCC Development
- •Summary: Clinical Disease Spectrum
- •17.3 Clinical Disease Spectrum
- •17.3.1 Actinic Keratosis
- •17.3.2 Squamous Cell Carcinoma In Situ
- •17.3.3 Invasive Squamous Cell Carcinoma
- •17.3.4 Differential Diagnosis
- •17.4 Management of Invasive Cutaneous SCC
- •17.4.1 Surgical Options
- •17.4.2 Radiation Therapy as Primary Therapy
- •17.5.4 Surgical Management
- •17.5.5 Radiation as Primary Therapy
- •17.5.6 Adjuvant Therapy
- •17.5.7 Assessment of Immune Status
- •17.5.8 Follow-Up for High-Risk SCC Patients
- •Summary: Treatment of Field Cancerization
- •17.6 Treatment of Field Cancerization
- •Summary: Conclusions
- •17.7 Conclusions
- •References
- •Summary: Introduction
- •18.1 Introduction
- •Summary: Surgical Treatment of Melanoma
- •18.2 Surgical Treatment of Melanoma
- •Summary: MMS for Cutaneous Melanoma
- •18.3 MMS for Cutaneous Melanoma
- •Summary: Application of MMS for the Treatment of Cutaneous Melanoma: IHC Stains
- •18.4 Application of MMS for the Treatment of Cutaneous Melanoma
- •18.4.1 IHC Stains
- •18.4.2 Technical Application of MMS and Interpretation of IHC Stains
- •Summary: Conclusion
- •18.5 Conclusion
- •References
- •19.1 Introduction
- •Summary: Epidemiology
- •19.2 Epidemiology
- •Summary: Pathogenesis
- •19.3 Pathogenesis
- •Summary: Clinical Features
- •19.4 Clinical Features
- •Summary: Pathology
- •19.5 Pathology
- •Summary: Differential Diagnose
- •19.6 Differential Diagnoses
- •Summary: Management
- •19.7 Management
- •19.7.1 Surgery
- •19.7.1.1 Wide Local Excision
- •19.7.1.2 Mohs Micrographic Surgery
- •19.7.2 Radiotherapy
- •19.7.3 Molecularly Targeted Therapy
- •19.7.4 Imaging Studies
- •Summary: Prognosis
- •19.8 Prognosis
- •Summary: Conclusion
- •19.9 Conclusion
- •20: Microcystic Adnexal Carcinoma
- •Summary: Introduction
- •20.1 Introduction
- •Summary: Epidemiology
- •20.2 Epidemiology
- •Summary: Pathogenesis
- •20.3 Pathogenesis
- •Summary: Clinical Features and Diagnosis
- •20.4 Clinical Features and Diagnosis
- •Summary: Histopathological Features
- •20.5 Histopathological Features
- •Summary: Treatment
- •20.6 Treatment
- •Summary: Prognosis and Follow-Up
- •References
- •21: Atypical Fibroxanthoma
- •Summary: History
- •21.1 History
- •Summary: Pathogenesis
- •21.2 Pathogenesis
- •Summary: Clinical Features
- •21.3 Clinical Features
- •Summary: Pathology
- •21.4 Pathology
- •Summary: Treatment
- •21.5 Treatment
- •Summary: Conclusion
- •21.6 Conclusion
- •References
- •22: Extramammary Paget Disease
- •Summary: Introduction
- •22.1 Introduction
- •Summary: History of EMPD and Epidemiology
- •22.2 History of EMPD and Epidemiology
- •22.2.1 History of EMPD
- •22.2.2 Epidemiology
- •22.2.3 Associated Malignancies
- •22.2.4 Affected Areas: Sites with Apocrine Glands
- •22.3 Clinical Presentation and Natural History
- •22.3.1 Clinical Presentation
- •22.3.2 Prognosis
- •Summary: Clinical Subtypes
- •22.4 Clinical Subtypes
- •22.4.1 Vulvar EMPD
- •22.4.2 Perianal EMPD
- •22.4.3 Penoscrotal EMPD
- •22.4.4 Triple EMPD
- •22.4.5 Unifocal or Multifocal Disease?
- •22.5 Diagnosing EMPD/Disease Pathophysiology
- •22.5.1 Histology
- •22.5.2 Histologic Differential Diagnosis
- •22.5.3 Evaluation for Internal Malignancy
- •22.5.4 Sentinel Lymph Node Biopsy
- •22.5.5 Pathophysiology
- •22.5.6 Cell of Origin
- •Summary: EMPD Treatment
- •22.6 EMPD Treatment
- •22.6.1 Wide Local Excision and Recommended Margin
- •22.6.2 Time to Recurrence
- •22.6.2.1 Mohs Surgery for EMPD
- •22.6.3 Mohs Surgery with CK7 Immunostaining
- •22.6.4 Peripheral Mohs Surgery
- •22.6.5 Scouting Biopsies
- •Summary: Alternative Treatment Options
- •22.7 Alternative Treatment Options
- •22.7.2 Photodynamic Therapy
- •22.7.3 Laser Vaporization
- •22.7.4 Radiation Therapy
- •22.7.5 Chemotherapy for EMPD: Local and Systemic
- •Summary: Conclusion
- •22.8 Conclusion
- •References
- •23: Leiomyosarcoma
- •Summary: Introduction
- •23.1 Introduction
- •Summary: Clinical Features
- •23.2 Clinical Features
- •Summary: Histologic Features
- •23.3 Histologic Features
- •Summary: Prognosis
- •23.4 Prognosis
- •23.4.1 Treatment
- •23.4.2 Mohs Micrographic Surgery (MMS)
- •Summary: Conclusion
- •23.5 Conclusion
- •References
- •24: Merkel Cell Carcinoma
- •Summary: Overview of Merkel Cell Carcinoma
- •24.1 Overview of Merkel Cell Carcinoma
- •Summary: Diagnosis of Merkel Cell Carcinoma
- •24.2 Diagnosis of Merkel Cell Carcinoma
- •24.2.1 Clinical Features
- •24.2.2 Pathology
- •24.2.3 Differential Diagnosis
- •Summary: Management of Merkel Cell Carcinoma
- •24.3 Management of Merkel Cell Carcinoma
- •24.3.1 Patient Evaluation and Staging
- •24.3.1.1 No Clinical Nodal Involvement
- •24.3.1.2 Clinical Nodal Involvement
- •24.3.1.3 Metastatic Disease
- •24.3.2 Treatment
- •24.3.3 Prognosis
- •24.4 Mohs Micrographic Surgery and Merkel Cell Carcinoma
- •Summary: Conclusion
- •24.5 Conclusion
- •References
- •25: Selected Sweat Gland Carcinomas
- •Summary: Porocarcinoma
- •25.1 Porocarcinoma
- •Summary: Hidradenocarcinoma
- •25.2 Hidradenocarcinoma
- •Summary: Cutaneous Adenoid Cystic Carcinoma
- •25.3 Cutaneous Adenoid Cystic Carcinoma
- •Summary: Malignant Cylindroma
- •25.5 Malignant Cylindroma
- •Summary: Mucinous Carcinoma of the Skin
- •25.6 Mucinous Carcinoma of the Skin
- •Summary: Conclusion
- •25.7 Conclusion
- •References
- •Porocarcinoma
- •Hidradenocarcinoma
- •Cutaneous Adenoid Cystic Carcinoma
- •Spiradenocarcinoma
- •Malignant Cylindroma
- •Mucinous Carcinoma of the Skin
- •26: Sebaceous Carcinoma
- •Summary: Introduction
- •26.1 Introduction
- •26.1.1 Origin
- •26.1.2 History
- •26.1.3 Extraorbital Sites
- •26.1.4 Incidence
- •Summary: Demographics
- •26.2 Demographics
- •26.2.1 Age, Sex, Irradiation, Race
- •26.2.3 Human Papillomavirus (HPV)
- •26.2.4 Other Risk Factors
- •Summary: Clinical Presentation
- •26.3 Clinical Presentation
- •Summary: Histopathology
- •26.4 Histopathology
- •26.4.1 Pattern of Differentiation
- •26.4.2 Degree of Differentiation
- •26.4.3 Mechanisms of Invasion
- •26.4.3.1 Direct Invasion
- •26.4.3.2 Pagetoid Spread
- •26.4.3.3 Multicentric Origin
- •26.4.4 Clinicopathologic Features of Poor Outcomes
- •Summary: Treatment
- •26.5 Treatment
- •26.5.1 Biopsy Procedure
- •26.5.2 Conjunctiva Mapped Biopsies
- •26.5.3 Oil Red O and Sudan Black Stains
- •26.5.4 Traditional Wide Local Excision (WLE)
- •26.5.5 Mohs Micrographic Surgery
- •26.5.6 Surgical and Tissue Processing Issues
- •26.5.7 Frozen Sections
- •26.5.9 Exenteration
- •26.5.10 Mohs Surgery, Practical Points
- •26.5.11 Corneal Protection Measures
- •Summary: Follow-Up Considerations
- •26.6.1 Local Recurrence
- •26.6.2 Metastasis
- •26.6.3 Distant Metastasis
- •26.6.4 Sentinel Lymph Node (SLN)
- •Summary: Conclusion
- •26.7 Conclusion
- •References
- •Summary: Introduction
- •27.1 Introduction
- •Summary: Review of the Relevant Anatomy
- •27.2 Review of the Relevant Anatomy
- •27.3 Anatomical Considerations When Using Mohs Micrographic Surgery in the Periorbital Region
- •Summary: Periorbital BCC
- •27.4 Periorbital BCC
- •Summary: Periorbital SCC
- •27.5 Periorbital SCC
- •Summary: Other Tumors
- •27.6 Other Tumors
- •Summary: Conclusion
- •27.7 Conclusion
- •References
- •28.1 Introduction
- •Summary: Introduction
- •Summary: Anatomy
- •28.2 Anatomy
- •28.2.1 Nail Matrix
- •28.2.2 Nail Plate
- •28.2.3 Supporting Portion: Nail Bed and Phalangeal Bone
- •28.2.4 Nail Folds
- •28.2.5 Cuticle
- •28.2.6 Hyponychium
- •28.2.7 Arteries and Nerves of the Digit
- •28.2.8 Extensor Tendon
- •Summary: Tumors
- •28.3 Tumors
- •28.3.1 Squamous Cell Carcinoma
- •28.3.3 Melanoma
- •28.3.4 Basal Cell Carcinoma
- •28.3.5 Warts
- •Summary: Mohs Technique
- •28.4 Mohs Technique
- •28.4.1 Preoperative Evaluation
- •28.4.2 Anesthesia
- •28.4.3 Instruments
- •28.4.4 Preoperative Preparation
- •28.4.5 Mohs Technique
- •28.4.6 Dressings and Postoperative Care
- •Summary: Complications
- •28.5 Complications
- •Summary: Conclusions
- •28.6 Conclusions
- •References
- •29: Genitalia
- •Summary: Introduction
- •29.1 Introduction
- •Summary: Surgical Technique
- •29.2 Surgical Technique
- •Summary: Reconstruction
- •29.3 Reconstruction
- •Summary: Common Genital Lesions Treated with Mohs Micrographic Surgery
- •29.4.1 Basal Cell Carcinoma
- •29.4.3 In Situ and Invasive Malignant Melanomas
- •29.4.6 Granular Cell Tumor
- •29.4.8 Leukemias and Lymphoblastomas
- •29.4.9 Langerhans Cell Histiocytosis
- •29.4.10 Haemolymphangioma
- •Summary: Conclusions
- •29.5 Conclusions
- •References
- •Summary: Introduction
- •30.1 Introduction
- •Summary: Innervation of the Face and Scalp
- •30.2 Innervation of the Face and Scalp
- •30.2.2 Sensory Innervation of the Face and Scalp
- •30.2.3 Innervation of the Ear
- •Summary: Muscles of Facial Expression
- •30.3 Muscles of Facial Expression
- •30.3.1 Muscles of the Forehead
- •30.3.2 Muscles of the Periorbital Region
- •30.3.3 Muscles of the Nose
- •30.3.4 Muscles of the Cheek and Perioral Region
- •30.4 Soft Tissue Components of the Scalp and Face
- •30.4.1 Scalp
- •30.4.2 Face
- •30.5 Bony and Cartilaginous Structures of the Face and Scalp
- •30.5.1 Bony Landmarks
- •30.5.2 Cartilaginous Structures
- •30.6 Muscosa of the Lip, Nose, and Conjunctiva
- •Summary: Conclusion
- •30.8 Conclusion
- •References
- •Summary: Bleeding Complications
- •31.1 Bleeding Complications
- •Summary: Infectious Complications
- •31.2 Infectious Complications
- •Summary: Nerve Injury
- •31.3 Nerve Injury
- •Summary: Tumor Recurrence
- •31.4 Tumor Recurrence
- •Summary: Medication Complications
- •31.5 Medication Complications
- •Summary: Recently Described Complications
- •31.6 Recently Described Complications
- •Summary: Conclusion
- •31.7 Conclusion
- •References
- •32.1.1 Upper Eyelid
- •32.1.1.1 Primary Closure
- •32.1.1.2 Myocutaneous Advancement Flap
- •32.1.1.3 Full-Thickness Skin Graft
- •32.1.2 Lower Eyelid
- •32.1.2.1 Primary Closure
- •32.1.2.2 Myocutaneous Advancement Flap
- •32.1.2.3 Ellipse Sliding Flap
- •32.1.2.4 Unipedicle Flap
- •32.1.2.5 Skin Graft
- •Summary: Full-Thickness Eyelid Defects
- •32.2.1 Upper Eyelid
- •32.2.1.1 Primary Closure
- •32.2.2 Lower Eyelid
- •32.2.2.1 Primary Closure
- •Summary: Special Circumstances
- •32.3 Special Circumstances
- •32.3.1 Medial Canthal Defect
- •32.3.1.1 Glabellar Flap
- •Summary: Postoperative Care and Follow-up
- •Summary: Conclusion
- •32.5 Conclusion
- •References
- •33: Flaps
- •Summary: Introduction
- •33.1 Introduction
- •Summary: Risks and Precautions
- •33.2 Risks and Precautions
- •Summary: Flap Design and Execution
- •33.3 Flap Design and Execution
- •Summary: Advancement Flaps
- •33.4 Advancement Flaps
- •33.4.1 Single Advancement
- •33.4.2 Bilateral Advancement
- •33.4.3 Crescentic Advancement
- •33.4.4 Island Pedicle
- •Summary: Rotation Flaps
- •33.5 Rotation Flaps
- •33.5.1 Dorsal Nasal Rotation
- •33.5.2 Bilateral Rotation
- •Summary: Transposition Flaps
- •33.6 Transposition Flaps
- •33.6.1 Rhombic
- •33.6.1.1 Dufourmental
- •33.6.1.2 Thirty-Degree Angle Webster Flap
- •33.6.2 The Banner Flap
- •33.6.3 Bilobed Flap
- •Summary: Interpolation Flaps
- •33.7 Interpolation Flaps
- •33.7.1 Paramedian Forehead
- •33.7.2 Nasolabial Interpolation
- •33.7.4 Retroauricular
- •Summary: Postoperative Care
- •33.8 Postoperative Care
- •Summary: Complications
- •33.9 Complications
- •Summary: Monitoring and Follow-Up
- •33.10 Monitoring and Follow-Up
- •Summary: Conclusion
- •33.11 Conclusion
- •References
- •34: Skin Grafting
- •Summary: Introduction
- •34.1 Introduction
- •Summary: Physiology
- •34.2 Physiology
- •Summary: Indications
- •34.3 Indications
- •Summary: Preoperative Assessment
- •34.4 Preoperative Assessment
- •Summary: Site Selection
- •34.5 Site Selection
- •Summary: Full-Thickness Skin Grafts
- •34.6.1 Graft Harvesting
- •34.6.2 Graft Fixation
- •Summary: Split-Thickness Skin Grafts
- •34.7.1 Graft Harvest
- •34.7.2 Graft Fixation
- •Summary: Composite Grafts
- •34.8 Composite Grafts
- •Summary: Postoperative Instructions
- •34.9 Postoperative Instructions
- •34.9.1 FTSG
- •34.9.2 STSG
- •Summary: Cultured Skin Substitutes
- •34.10 Cultured Skin Substitutes
- •34.10.1 Epidermal
- •34.10.2 Dermal
- •34.10.3 Bilayered
- •34.10.4 Graft Fixation
- •34.10.5 Postoperative Instructions
- •Summary: Graft Failure
- •34.11 Graft Failure
- •Summary: Conclusion
- •34.12 Conclusion
- •References
- •Summary: Introduction
- •35.1 Introduction
- •Summary: Side to Side Closures
- •35.2 Side to Side Closures
- •Summary: Suturing of the Wounds
- •35.3 Suturing of the Wounds
- •Summary: Cosmetic Subunits
- •35.4 Cosmetic Subunits
- •Summary: Complex Facial Defects
- •35.5 Complex Facial Defects
- •Summary: General Considerations
- •35.6 General Considerations
- •Summary: Complications
- •35.7 Complications
- •Summary: Conclusion
- •35.8 Conclusion
- •References
- •36: Prosthetic Rehabilitation
- •Summary: Introduction
- •36.1 Introduction
- •Summary: Moulage Impression Procedure
- •36.2 Moulage Impression Procedure
- •Summary: Adhesive Retained Nasal Prosthesis
- •36.3 Adhesive Retained Nasal Prosthesis
- •Summary: Adhesive Retained Auricular Prosthesis
- •36.4 Adhesive Retained Auricular Prosthesis
- •Summary: Adhesive and/or Mechanically Retained Orbital Prosthesis
- •36.5 Adhesive and/or Mechanically Retained Orbital Prosthesis
- •36.6 Midface/Multisite Craniofacial Prosthesis
- •36.7 Considerations Regarding Implant Retained Craniofacial Prosthesis
- •Summary: Implant Retained Nasal Prosthesis
- •36.8 Implant Retained Nasal Prosthesis
- •Summary: Implant Retained Auricular Prosthesis
- •Summary: Implant Retained Orbital Prosthesis
- •36.10 Implant Retained Orbital Prosthesis
- •36.11 Multisite Implant Retained Craniofacial Prosthesis
- •Summary: Conclusion
- •36.12 Conclusion
- •References
- •Summary: Adjuvant Treatment with Imiquimod
- •37.1 Adjuvant Treatment with Imiquimod
- •Summary: Adjuvant Treatment with Radiation
- •37.2 Adjuvant Treatment with Radiation
- •37.3 Nonsurgical Treatment of Aggressive Basal Cell Carcinoma
- •Summary: Photodynamic Therapy
- •37.5 Photodynamic Therapy
- •Summary: Off-Label Intraoperative PDT with Topical and Intralesional Aminolevulinic Acid on SCC of the Penis
- •Summary: Conclusion
- •37.7 Conclusion
- •References
- •References
- •39: Establishing a Mohs Practice
- •Summary: General Considerations
- •39.1 General Considerations
- •Summary: The Electronic Medical Record
- •39.2 The Electronic Medical Record
- •39.3 Credentials, Licensure, and Malpractice Insurance
- •Summary: Quality Assurance
- •39.4 Quality Assurance
- •Summary: Cameras
- •39.5 Cameras
- •Summary: Care of Instruments
- •39.6 Care of Instruments
- •Summary: Work Rooms
- •39.7 Work Rooms
- •Summary: Microscopes
- •39.8 Microscopes
- •Summary: Instrumentation
- •39.9 Instrumentation
- •Summary: Regulations
- •39.10 Regulations
- •Summary: Reception Area
- •39.11 Reception Area
- •Summary: Waiting Area
- •39.12 Waiting Area
- •Summary: Exam/Surgery Rooms
- •39.13 Exam/Surgery Rooms
- •Summary: Nurses Work Station
- •39.15 Nurses Work Station
- •Summary: Personnel
- •39.16 Personnel
- •Summary: The Laboratory
- •39.17 The Laboratory
- •Summary: Space
- •39.18 Space
- •Summary: Personal Protective Equipment
- •39.19 Personal Protective Equipment
- •Summary: Mapping and Grossing the Tissue
- •39.20 Mapping and Grossing the Tissue
- •Summary: Devices to Aid Embedding
- •39.22 Devices to Aid Embedding
- •Summary: Cryosectioning Tissue
- •39.23 Cryosectioning Tissue
- •Summary: Staining
- •39.24 Staining
- •Summary: Coverslipping
- •39.25 Coverslipping
- •Summary: At the End of the Day
- •Summary: Permanent Sections and Immunostains
- •39.27 Permanent Sections and Immunostains
- •39.27.1 Immunostains
- •Summary: Training of Laboratory Technicians
- •39.28 Training of Laboratory Technicians
- •Summary: Inspections and Regulations
- •39.29 Inspections and Regulations
- •Summary: Marketing
- •39.30 Marketing
- •Summary: Preoperative Consultation
- •39.31 Preoperative Consultation
- •Summary: Brochures and Handouts
- •39.32 Brochures and Handouts
- •Summary: Operative Consents
- •39.33 Operative Consents
- •Summary: Conclusion
- •39.34 Conclusion
- •Reference
- •Summary: The Brazilian Perspective
- •40.1 The Brazilian Perspective
- •Summary: The Argentinean Perspective
- •40.2 The Argentinean Perspective
- •Summary: Conclusion
- •40.3 Conclusion
- •References
- •References
- •42.1 Characteristics of Skin Cancers in East Asia
- •Summary: Treatment of Skin Cancers in East Asia
- •42.2 Treatment of Skin Cancers in East Asia
- •42.2.1 Standard Treatment of Skin Cancers
- •42.2.2 Present State of MMS in East Asia
- •Summary: Conclusion
- •42.3 Conclusion
- •References
- •43.1 Introduction and Brief History of Mohs Micrographic Surgery in Australia and New Zealand
- •43.2 Work Practices of Australian Mohs Surgeons
- •43.2.1 Background
- •43.2.2 Mohs Caseload
- •43.2.3 Conclusion
- •Summary: The Australian Mohs Database
- •43.3 The Australian Mohs Database
- •43.3.1 Introduction
- •43.3.3 Squamous Cell Carcinoma Treated with Mohs Micrographic Surgery in Australia
- •43.3.4 Conclusion
- •43.4.1 Mohs for Invasive SCC and SCC In Situ of the Nail Apparatus
- •43.4.2 Extensive Use of Secondary Wound Healing in a Knowledgeable Patient
- •Summary: Mohs Surgery in New Zealand
- •43.5 Mohs Surgery in New Zealand
- •Summary: Conclusions
- •43.6 Conclusions
- •References
- •Summary: Introduction
- •44.1 Introduction
- •Summary: Patient Safety Considerations
- •44.2 Patient Safety Considerations
- •44.2.1 The Preoperative Visit
- •44.2.2 Past Medical History and Physical Exam
- •Summary: Information for Patients
- •44.3 Information for Patients
- •44.3.1 Cardiovascular Complications
- •44.3.2 Antibiotic Prophylaxis
- •44.3.3 Anticoagulation
- •44.3.4 Anesthesia
- •44.3.5 Allergies
- •Summary: Planning for the Surgical Day
- •44.4 Planning for the Surgical Day
- •44.5.1 Patient Emergencies
- •44.5.2 Staff Safety
- •44.5.3 Mohs Lab Safety
- •Summary: Conclusion
- •44.6 Conclusion
- •References
- •Summary: Introduction
- •45.1 Introduction
- •Summary: The Four Elements
- •45.2 The Four Elements
- •Summary: Standard of Care
- •45.3 Standard of Care
- •Summary: Clinical Guidelines
- •45.4 Clinical Guidelines
- •Summary: Legal Relevance
- •45.5 Legal Relevance
- •Summary: Case Example 1
- •45.6 Case Example 1
- •Summary: Case Example 2
- •45.7 Case Example 2
- •Summary: Ethical Relevance
- •45.8 Ethical Relevance
- •45.8.1 Actinic Keratoses
- •45.8.1.1 Invasive Techniques
- •Cryosurgery
- •Curettage and Electrodessication
- •Dermabrasion and Chemical Peels
- •Carbon Dioxide or Erbium:YAG Laser Ablation
- •45.8.1.2 Non-invasive Techniques
- •Topical Chemotherapy
- •Photodynamic Therapy (PDT)
- •References
- •Summary: Introduction
- •46.1 Introduction
- •Summary: Medical Malpractice
- •46.2 Medical Malpractice
- •46.2.1 Duty
- •46.2.2 Breach of Duty
- •46.2.3 Causation
- •46.2.4 Damages
- •Summary: Consent/Refusal for Treatment
- •46.3 Consent/Refusal for Treatment
- •46.3.1 Implied Consent
- •46.3.2 Express Consent
- •46.3.3 Informed Consent
- •46.3.3.2 Reasonable Patient Standard/Legal Standard
- •Summary: Medical Records
- •46.4 Medical Records
- •46.5 Complications in Skin Cancer Treatment
- •Summary: Rectifying Adverse Events: Key Steps
- •46.6 Rectifying Adverse Events: Key Steps
- •46.6.1 Build Trust
- •46.6.2 Take an Active Role
- •46.6.3 Help the Patient
- •46.6.4 Enlist Help from Others
- •46.6.5 Be Available
- •46.6.6 Contact the Malpractice Carrier
- •46.6.7 Preserve Evidence
- •46.6.8 Document the Facts of the Event
- •Summary: Conclusion
- •46.7 Conclusion
- •References
- •Summary: Introduction
- •47.1 Introduction
- •47.3 The Potential Detrimental Impact of Mohs Surgery
- •47.3.4 Negative Self-Image
- •47.4.1 Social Phobia
- •47.4.2 Generalized Anxiety Disorder
- •47.4.3 Depression
- •Summary: Conclusion
- •47.5 Conclusion
- •References
- •Index
28 Mohs Surgery for Periungual and Subungual Skin Cancer |
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functional and cosmetic results. Rarely, if the whole matrix has been excised, a split-thickness skin graft may be considered.
After completion of the Mohs surgery without a repair, a pressure dressing is applied. The pressure dressing is used to facilitate hemostasis by applying constant pressure along the surgical site. Vaseline or an antibiotic ointment is initially applied to the surgical site to promote wound healing. A non-stick dressing is placed over the site, and then gauze is cut and then applied. Paper tape may be used to secure the bandage. For exudative wounds, Kerlix may be applied to wrap the entire digit. This dressing is removed by the patient after 24 hours. Oral antibiotics and painalleviating medications may also be given depending on the situation. Prescribing a sling for the patient to elevate the arm helps reduce postoperative edema and pain. For work on a patient’s toes, sandals, or a special boot that exposes the toes and laces along the dorsum of the foot, are useful.
Summary: Complications
•Extensor tendon rupture can occur when excising tissue proximal to the nail matrix.
Summary: Conclusions
•Mohs surgery is particularly useful in removing tumors of the nail unit because this technique preserves as much normal tissue as possible, especially nail matrix.
28.6Conclusions
While tumors of the nail unit are relatively rare, traditional surgical techniques of wide local excision or amputation can be debilitating for the patient. Mohs surgery offers many advantages compared to traditional surgical methods. Because Mohs surgery requires the mapping of the tumor, complete clearance of the disease may be obtained. As unaffected tissue (especially the matrix, either in part or totally) is spared, Mohs surgery assures maximal preservation of the surrounding noncancerous tissue. The ultimate benefit to the patient is that Mohs surgery provides an alternative surgical method that leads to a more cosmetically and functionally acceptable result for the patient.
References
28.5Complications
Primary complications with nail unit surgery include pain, infection, and swelling of the digit. Painalleviating medications such as hydrocodone and acetaminophen (VicodinRx) or codeine and acetaminophen (Tylenol #3Rx) are useful for alleviating patient discomfort. Oral antibiotics effective against Staphylococcus aureus and/or methicillin-resistant Staphylococcus aureus should be considered. Edema of the digit and hand is a complication that may cause temporary tenderness and stiffness along the digit. This problem will resolve gradually with time, and elevation of the extremity will expedite the recovery process.
Transection of the extensor tendon has occurred in one of our cases. If not repaired immediately, the patient will not be able to dorsiflex the finger.
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