Americans has been reported to be from 5 to 15 times higher than that of the white population [6]. In Hawaii, keloids are found three times more commonly in the Japanese population and five times more commonly in the Chinese population than in white populations [7]. Because of this increased risk, care must be taken to minimize tension with wound closures. Patients should be counseled on the potential for hypertrophic scar and keloid formation, both of which may be treated with standard therapies of intralesional kenalog injection and pressure. Postoperative erythematous hypertrophic scars in Caucasians and lightly complected patients of color (skin types I–IV) may be treated with the pulsed dye laser. This author uses 595-nm at 10 mm spot, 0.5- ms pulse duration, and fluences of 3–6 J with appreciable fading in 1–3 treatments. Depressed scars may be treated with nonablative or ablative fraxel Laser.

When treating precancerous lesions, this author avoids use of liquid nitrogen in skin of color in favor of imiquimod in an effort to avoid posttreatment loss of pigment. One may also use light electrodessication (0.9–1.2 W) and curettage but must warn the patient of potential postinflammatory hyperpigmentation.

Summary: Conclusion

•Given increased aggressiveness of certain tumors (SCC, MM) in skin of color and disparities in survival when compared to Caucasian counterparts, increased physician efforts in screening and counseling patients of color with regard to their risks of skin cancer and sun protective behavior is crucial.

10.7 Conclusion

Although less common than in Caucasians, skin cancer does occur in ethnic skin, and these patients are more likely to die from their disease. This disparate morbidity and mortality is due to both delayed diagnosis and more aggressive biologic nature of these tumors in ethnic skin. While pigmented BCC is found more commonly in skin of color than in Caucasians, SCC is the most prevalent form of NMSC in skin of color. Although malignant melanoma occurs less frequently in skin of color, the aggressive acrolentiginous form

accounts for poor prognosis in these patients. While sun exposure appears to play a role in the development of BCC in ethnic skin, there is less of a correlation with SCC and MM due to the propensity of these skin cancers to occur in non-sun-exposed locations.

Little is known about the skin cancer awareness of patients with ethnic skin. Current skin cancer campaigns have focused on Caucasians in high-risk groups. Patients with ethnic skin who do not perceive themselves as being high risk are likely to ignore early warning signs of skin cancer, and physicians who do not associate skin cancer with ethnic skin may be less likely to consider it in a differential diagnosis or to counsel patients appropriately on risk prevention, surveillance, and follow-up. Better effort for public awareness must be instituted in ethnic communities. The combined efforts of physicians and improved public education will result in earlier diagnosis and better prognosis for patients with skin of color.

References

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2.Gloster Jr HM, Brodland DG. The epidemiology of skin cancer. Dermatol Surg. 1996;22:217–26.

3. Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006. CA Cancer J Clin. 2006;56:106–30.

4. US Census Bureau Population Division. Projections of the resident population by race, Hispanic origin, and dativity: middle series, 1999–2100. Washington: US Census Bureau; 2000.

5. Broadland D, Amonette R, Hanke W, et al. The history and evolution of Mohs micrographic surgery. Dermatol Surg. 2000;26:303–7.

6.LeFlore IC. Misconceptions regarding elective plastic surgery in the black patient. J Natl Med Assoc. 1980; 72:947–8.

7. Arnold HL, Franer FH. Keloids: etiology and management by excision and intensive prophylactic radiation. Arch Dermatol. 1959;80:772.

8. Montagna W. The architecture of black and white skin. J Am Acad Dermatol. 1991;24:29–37.

9. Halder RM, Bridgeman-Shah S. Skin cancer in African Americans. Cancer. 1995;75:667–73.

10. Halder RM, Ara CJ. Skin cancer and photoaging in ethnic skin. Dermatol Clin. 2003;21:725–32.

11.American Cancer Society: Non melanoma skin cancer detailed guide. http://documents.cancer.org/118.00.

12. Matsuoka LY, Schauer PK, Sordillo PP. Basal cell carcinoma in black patients. J Am Acad Dermatol. 1981;4(6):670–2.

13.Briley JJ, Chaveda K, Lynfield YL. Sunscreen use and usefulness in African Americans. J Drugs Dermatol. 2007;6(1): 19–22.

14.Ferdinand KC, Armani AM. The management of hypertension in African Americans. Crit Pathw Cardiol. 2007; 6(2):67–71.

15.Nadiminti U, Rakkhit T, Washington C. Morpheaform basal cell carcinoma in African Americans. Dermatol Surg. 2004;30:1550–2.

16. Chorun L, Norris JE, Gupta M. Basal cell carcinoma in Blacks: a report of 15 cases. Ann Plast Surg. 1994;33:90–5.

17. Mora RG, Perniciaro C. Cancer of the skin in blacks: a review of 163 black patients with cutaneous squamous cell carcinoma. J Am Acad Dermatol. 1981;5:535–43.

18. Koh D, Wang H, et al. Basal cell carcinoma, squamous cell carcinoma and melanoma of the skin: analysis of the Singapore cancer registry data 1968–1997. Br J Dermatol. 2003;148:1161–6.

19. Suzuki T, Ueda M, Naruse K, et al. Incidence of actinic keratosis of Japanese in Kasai City, Hyogo. J Dermatol Sci. 1997;16:74–8.

20. Hale EK, Jorizzo J, Nehal KS, et al. Current concepts in the management of actinic keratosis. J Drugs Dermatol. 2004; 3(2 suppl):S3–16.

21. Mora RG, Perniciaro C, Lee B. Cancer of the skin in blacks III: a review of nineteen black patients with Bowen’s disease. J Am Acad Dermatol. 1984;11:557–62.

22. Sing B, Bhaya M, Shaha A, Har-El G, Lucente FE. Presentation, course and outcome of head and neck cancer

in African Americans: a case controlled study. Laryngoscope. 1998;108:1159–63.

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24. Mora RG. Surgical and aesthetic considerations of cancer of the skin in the black American. J Dermatol Surg Oncol. 1986;12:24–31.

25. Jackson BA. Skin cancer in skin of color. In: MacFarlane DF, editor. Skin cancer management: a practical approach. New York: Springer; 2010. p. 217–24.

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M. Zabielinski

Department of Dermatology and Cutaneous Surgery,

University of Miami Leonard M. Miller School of Medicine,

Miami, FL, USA

M.P. McLeod ¥ S. Choudhary

Department of Dermatology and Cutaneous Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA

Summary: The General Office Setup

¥A well-prepared and smoothly running ofÞce and lab are very important in performing successful Mohs micrographic surgery.

¥Investing in equipment and organization allows for an organized, efÞcient, and safe practice.

K. Nouri (*)

Department of Dermatology and Cutaneous Surgery,

University of Miami Leonard M. Miller School of Medicine,

Miami, FL, USA

Sylvester Comprehensive Cancer Center,

University of Miami Hospital and Clinics, Miami, FL, USA e-mail: knouri@med.miami.edu

11.1The General Office Setup

A well-prepared and smoothly running ofÞce and lab are very important in performing successful Mohs surgery. Throughout the day, patients move from the operating room to the surgical reception area. While this is occurring, tissue specimens are being transported

between the operating room, histopathology laboratory, and the microscope. Therefore, investing in quality equipment and organization allows for an organized, efÞcient, and safe practice.

In order to attain such a practice, it is necessary to have a properly equipped operating room, a laboratory to process the tissue specimens, an area for histopathology slide reading, and a space to clean and sterilize instruments. As each of these areas of the ofÞce is discussed, pertinent equipment and supplies will be addressed.

The general setup of the ofÞce is as important as the administration and patient scheduling in order to have an efÞcient practice. It is important to have an experienced and responsible ofÞce manager who can attend to the details of payment, paperwork, staff, and patient scheduling. In addition, it is also useful to have one or two medical assistants and one or two experienced nurses or physician assistants to assist with procedures.

Summary: The Operating Room (OR)

¥The operating room should be well lit, ventilated, spacious, and organized.

¥Medicare certiÞcation, as well as local and state regulations, may mandate certain operating room conÞgurations, and it is important to abide by these regulations.

¥Essential monitoring and emergency equipment should be readily available.

¥The entire ofÞce staff should be CPR trained and certiÞed.

¥At least two digital cameras are necessary for documentation.

¥Proper waste containers include one for noncontaminated, non-sharps waste, one for sharps, and one for contaminated waste.

11.2The Operating Room (OR)

The operating room should be appropriately lit, ventilated, spacious, and organized. There needs to be adequate space for the operating table, patient monitoring equipment, multiple large Mayo stands, cabinets and

storage for instruments, a sink, and electrosurgical equipment. The surgeon should be able to move 360¡ around the patient table and have enough space to comfortably operate standing or sitting. Medicare certiÞcation, as well as local and state regulations, may mandate certain operating room conÞgurations, and it is important to abide by these regulations [1]. The American Academy of Dermatology has also written guidelines for ofÞce surgical facilities in the Journal of the American Academy of Dermatology.

The patient room should be clean and aesthetically appealing. An additional sitting chair should be available for holding the patientÕs belongings or can be used for seating the family member or friend. Excellent general room lighting should be supplemented with large, cool, and focusable overhead OR lights. Locking cabinets allow for storage of sutures and instruments in an organized and highly accessible fashion [1].

The surgical table should be foot operable to position and should be well padded and comfortable for the patient. For Mohs surgeons who prefer to sit while operating, a comfortable, sturdy, foot adjustable rolling surgical chair may be located on each side of the surgical table. The Mohs surgeon frequently moves from one side of the table to the other, and therefore, time will not be lost when switching sides [1].

Soothing music can be played in the operating room at an appropriate volume. It can be provided with an iPhone or iPod (or any other MP3) connected to speakers, or with a small compact disc player, although a compact disc player does not allow for selection and storage of a large variety and quantity of music. If the surgeon or the patient has a speciÞc preference, then an iPhone or iPod can allow access to many genres of music. Meditation and classical music can also be relaxing for both the patient and the Mohs surgeon, although any soft music that is not distracting will sufÞce.

Although expensive, providing a high-deÞnition screen television is a method to distract and entertain patients while they are waiting between layers (and for general dermatology patients that are waiting too). The television can be programmed to be educational or can be used to advertise other ofÞce procedures available. Another option is to have an appropriate movie playing at a low volume.

If possible, the OR temperature control should be accessible directly inside the room to allow for

adjustment as needed. The Mohs surgeon may require a cooler temperature than the rest of the ofÞce that may be uncomfortable for the staff and other patients. If the Mohs surgeon usually prefers a cooler temperature, instruct patients to bring a blanket to the ofÞce for use while in the OR or have them available [1].

Essential monitoring and emergency equipment includes oxygen with a delivery system, blood pressure and pulse monitors, a manual suctioning device, Þre extinguishers, an emergency eyewash station, and hands-off phone intercom capability. A convenient way to monitor all vital signs in one location is with a vital signs diagnostic station with a rolling ßoor stand. Additional equipment includes the following: blood pressure, pulse, and time data printer; pulse oximeter with plethsymograph display, cardiac monitorÐdeÞbrillator; battery-operated backup lighting; and full advanced cardiac life support capability. The cardiac monitor deÞbrillator should be light, compact, portable, and easy to use [1].

Moreover, the entire ofÞce staff should be CPR certiÞed; this is best accomplished by having a CPR training group providing annual classes in the ofÞce. The Mohs surgeon and OR assistants should have ACLS certiÞcation in case of an emergency [1].

A device that should be available in the operating room is a high-grade manual suction device which is fast and easy to use in case the patient is at risk for aspirating vomitus or other substances and liquids. In general, electric suction devices are useful because they remove blood from the operative Þeld during surgery. In Mohs surgery, these devices are seldom required; however, they are essential in certain situations. For example, blood can pool and accumulate in certain areas, such as the medial canthus or the ear canal, completely obscuring the surgical Þeld. These devices are relatively inexpensive and have disposable tubing [1].

At least two digital cameras need to be available for use. There should be a designated area where they are placed in between uses. The physician assistants and medical assistants should be taught how and when to use them. The cameras are useful for several reasons. First, it is important to document all lesions, biopsies, and repairs. A suspicious lesion should be circled with a marking pen before it is biopsied so that it can be easily noted on pictures. Before a biopsy, one or two very close-up, focused pictures should be taken of the lesion and one or two should be taken farther away to orient

the doctor to the anatomic location. This technique will allow the physician to better locate the biopsy site when patient returns to have the surgery performed. Pictures are also used to document intraoperative mapping and to record progress of the surgery after each Mohs stage if the repair will be performed by a reconstructive surgeon other than the Mohs surgeon. Each room should have a hand-held mirror, which is used to show patients their repair or bandages; or more importantly, it is also used to conÞrm tumor location before Mohs surgery if the biopsy site persists to be in question.

The operating room should contain multiple large Mayo stands to hold separate sterile surgical trays for each Mohs patient. These stands are easily height adjustable and have a ßat sturdy base [1]. Each tray should be labeled with the patientÕs name, preventing its use for the wrong patient.

Large numbers of surgical gloves are used during Mohs surgery. Every surgeon will develop their preference for gloves, including size, brand, packaging, and whether or not they are powdered. The surgeon and physician assistant should have a large number of sterile gloves available in storage at all times.

An electrosurgical device for hemostasis is essential for Mohs surgery and other dermatological procedures. A sterile-dedicated electrode should be used for each patient; these are re-sterilizable and can be left in a sterilization envelope labeled with the patientÕs name between uses. The tip of the electrode stays sterile during use, but the shank does not. Use electrosurgery with caution if the patient has a pacemaker. In addition, the electrosurgical unitÕs ÒgroundÓ may interfere with EKG monitoring and recording [1].

It is important that electrocoagulation is limited to what is necessary in order to prevent electrosurgical artifacts on successive stages, which may mimic carcinoma. The use of pressure dressings between stages minimizes the need for extensive electrocoagulation that may contribute to these artifacts. Using a jewelerÕs or splinter forcep for pinpoint hemostasis is another way to minimize artifact. Additionally, excessive electrocoagulation can result in a poor cosmetic outcome because it increases thermal tissue damage beyond the immediate wound. White and brown ½″, 1″, and 2″ micropore paper tapes are used to apply the pressure dressing. White Micropore paper tape, which is less expensive than brown, is used to secure the dressings between stages of Mohs surgery. Brown tape is more aesthetically pleasing as it