procedures such as dermabrasion, medium or deep chemical peels, and ablative or non-ablative laser resurfacing cause such extensive epidermal injury that a history of cold sores is not a reliable indicator of reactivation risk, and all patients undergoing these procedures should receive antiviral prophylaxis regardless of history. For resurfacing procedures, this prophylaxis should continue until reepithelialization is complete, usually within 7–10 days.

Summary: Discussion of Postoperative Care

•The preoperative evaluation can be used to initiate the discussion of postoperative care and help frame patient expectations for the postoperative course.

postoperative visits will help maximize compliance and ensure optimal surgical outcomes.

Summary: Conclusion

•Medical care of the dermatologic surgery patient begins with a simple yet complete preoperative evaluation.

•After documentation of informed consent, confirmation of the presenting lesion and diagnosis, review of the patient’s past medical history and medications (with particular emphasis on anticoagulant medications), and assessment of the need for infection prophylaxis, a therapeutic plan can be tailored to the individual patient for optimal medical and surgical care.

A final point to be addressed in the preoperative consultation is initiating the discussion of postoperative healing and wound care. Patients should be informed of the expected wound healing process, including expected bruising and swelling, particularly on periorbital and perioral sites. Explanation of the expected time frame for discomfort, erythema, edema, ecchymosis, and bandage use at the initial consultation will prevent unwanted surprises postoperatively. Similarly, reminding patients that epidermal sutures, if placed, will require removal can help prepare for a second office visit. If it appears that a patient will have difficulty with dressing changes and wound care due to either physical disability or a difficult-to-reach operative site, the preoperative consultation is the time to begin arrangements for assistance, either from family members or a visiting nurse service. Finally, an important aspect of the treatment for skin cancer is ensuring adequate follow up screening for second malignancy, which occurs at high frequency in these patients. While the dermatologic surgeon may not be the physician performing this screening, it is important to remind patients of the need for follow up exams even before surgery has been performed. Because it is likely that patients will retain and absorb only a fraction of the counseling advice dispensed by physicians, repetition of these points at the preoperative, operative, and

When performed properly, the preoperative evaluation is a straightforward exercise that minimizes operative and postoperative complications. With adequate verification of the presenting location and diagnosis, and examination for signs of aggressive tumor behavior, an appropriate therapeutic plan can be developed with the informed consent of the patient. Modifications can then be made based on the patient’s medical history and medication use. These may include electing not to use electrodessication or electrocoagulation in patients with implantable cardiac defibrillators, choosing a less invasive reconstruction method for patients with impaired wound healing and poor functional status, or advising patients to avoid over-the-counter pain relievers and herbal supplements that impair hemostasis. Awareness of the risks of interrupting therapeutic anticoagulation, coupled with continuation of these anticoagulants preoperatively, may also decrease the incidence of serious thrombotic complications in the perioperative period. Similarly, appropriate use of antibiotic prophylaxis according to recently published guidelines can minimize infectious complications of dermatologic surgery while reducing the number of patients exposed to unnecessary antibiotic therapy. Medical care of the dermatologic surgery patient begins well before the surgical procedure, and optimal delivery of this care requires a directed and precise preoperative evaluation.

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T.L. Ebede (*)

Dermatology Service, Memorial Sloan Kettering Cancer Center,

New York, NY, USA e-mail: tebede@hotmail.com

I. Singh • K.S. Nehal

Dermatology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA

Summary: Introduction

•Office-based surgery is the standard for Mohs micrographic surgery. The minimum space requirements include: a comfortable waiting room, well-equipped operative rooms, a laboratory for frozen tissue processing/histopathology slide reading, and space for cleaning and sterilizing equipment. A contractor, architect, interior designer, and occupational health specialist, knowledgeable about surgical facilities, are critical members of the development team.