Preoperative Evaluation

Summary: Introduction

•The preoperative evaluation is a critical aspect of dermatologic surgery that helps establish rapport,maximizeefficiency,minimizecomplications, and facilitate optimal surgical outcomes.

3.1Introduction

The preoperative evaluation is a critical but potentially overlooked aspect of dermatologic surgery. Because of the lack of general anesthesia and minimal morbidity associated with most dermatologic procedures, some practitioners may regard a systematic preoperative evaluation as superfluous or unnecessary. The skilled surgeon, however, will recognize that an appropriate preoperative evaluation lays the foundation for procedures that have safe and high quality outcomes. It helps establish rapport, creates realistic patient expectations, and allows for more efficient workflow at the time of surgery. In addition, it allows the dermatologic surgeon to anticipate and prevent intraoperative and postoperative complications, and optimize postoperative care with patient education.

Summary: Initial Consultation and Informed

Consent

•The initial consultation forms the basis for all subsequent interactions between the surgeon and the patient.

•Establishing rapport, setting appropriate expectations, determining the complexity and urgency of the surgical case, and discussing the indications for and alternatives to surgery are essential aspects of the initial evaluation.

•Discussion of the risks and benefits of any procedure and documentation of patient informed consent are mandatory prerequisites to dermatologic surgery.

a separate visit. First, it allows for a discussion between the patient and physician regarding the diagnosis, prognosis, and indications for surgery before a commitment has been made to proceed with a given surgical treatment. Specifically, for Mohs micrographic surgery, the consult visit provides the opportunity to explain in detail the Mohs technique as well as other surgical or nonsurgical options for treatment. In addition to answering the patient’s questions and preparing him or her for the logistical details of the procedure, this brief discussion builds confidence in the physician and establishes rapport. As such, it may be useful to have a family member or caregiver present at the time of initial consultation. In some circumstances, it may be a spouse or adult son or daughter who has more anxiety regarding surgery than the patient himself or herself.

Scheduling the consultative visit prior to the day of surgery also allows for a more efficient workflow on the day of the procedure. The experienced surgeon can assess the complexity of the case in consultation, including the probability of multiple stages and complicated surgical repairs. This allows for more appropriate scheduling of cases, with a more even distribution of complex and straightforward cases on any given day. In addition, scheduling the surgical procedure according to the medical urgency of the case (e.g., rapidly growing squamous cell carcinoma versus superficial basal cell carcinoma) is accomplished more effectively after an initial consultation. The need for antibiotic prophylaxis can also be assessed at the preoperative consultation, allowing appropriate treatment prior to surgery (discussed below, Sect. 3.6). Finally, holding the initial consultation in the surgical suite where the surgery will be performed allows patients to become familiar with transportation to the office and navigation within the building. It may also help to alleviate anxiety on the day of surgery if the patient is arriving at a familiar location.

Another critical aspect of the initial consultation is setting appropriate patient expectations. Although “scarless” surgery may be an ideal to strive for, any surgical intervention on visible skin will have aesthetic and possibly functional consequences. Discussion of this fact with the patient prior to surgery will improve patient satisfaction and may decrease the incidence

Consent

While it is possible to have the preoperative evaluation on the same day as the surgical procedure, there are several advantages to scheduling the initial consultation as

complaints. Similarly, patients may focus newfound attention on their facial features after surgery and may incidentally identify preexisting congenital or acquired asymmetry or anatomic variation postoperatively that is completely unrelated to the surgery. These subtle

findings should be identified by the surgeon and pointed out to the patient at the preoperative evaluation. Finally, asking the patient about prior surgical procedures or trauma and examining the resulting scars can be informative in anticipating poor wound healing, spread scars, or tendency for keloid formation. This not only provides an opportunity to gain insight into the patient’s understanding of wound healing but also an occasion to properly educate the patient on this process.

Informed consent is a prerequisite to any medical procedure, and Mohs micrographic surgery is no exception. As noted above, the indications and alternatives to Mohs, including standard surgical excision or no treatment, must be adequately explained to the patient so that he or she may make an informed decision to proceed. The potential risks of surgery must also be clearly explained in language that is understood by the layperson. This includes the standard procedural risks such as pain, bleeding, infection, scarring and cosmetic distortion, as well as Mohs-specific risks such as recurrence of the primary tumor and anatomically specific functional consequences such as facial nerve palsy or ectropion. Proper informed consent also includes offering a clear opportunity for the patient to ask any questions about the procedure. Ideally, the surgeon performing the procedure will be the one obtaining informed consent. A standard consent form can be a useful adjunct to this discussion and provides a clear documentation of patient consent (via signature) in the medical record. Because every surgical case has unique features, however, the preprinted consent form is no substitute for a thorough discussion between patient and physician.

Summary: History of Present Illness

and Physical Examination

•Historical information can be useful to anticipate the complexity of a surgical case, and verification of the pathologic diagnosis is essential to direct appropriate therapy.

•The location of the lesion should be documented prior to surgery and confirmed with photographic records if available.

•The physical exam is focused on signs suggestive of aggressive tumor behavior and underlying medical conditions that may complicate dermatologic surgery.

3.3History of Present Illness and Physical Examination

As with any medical evaluation, the history of the patient’s chief complaint is of paramount importance. The most basic piece of historical information for the dermatologic surgeon is the duration of the lesion in question. Because most cutaneous malignancies tend to have a steady growth rate (the doubling time for basal cell carcinoma has been estimated at 6–12 months) [1], the duration of the lesion provides an estimate of the expected size and depth. Conversely, if a patient reports that a large lesion with extensive tissue destruction has been present for only a few weeks, this may imply aggressive biologic behavior or may indicate an element of neglect or psychiatric disease in the patient.

A critical historical point is whether the lesion has been treated in the past. Is the lesion a recurrence of a previously excised tumor? Was the lesion treated ineffectively with electrodessication and curettage? Was the lesion initially assumed to be benign and treated with cryotherapy or laser destruction? All these scenarios will change the interaction of the tumor with the surrounding tissue. It has been shown that recurrent basal cell carcinomas are more likely to have positive margins on the initial stage than equivalent primary lesions [2]. In addition, the presence of reactive fibrosis in the dermis may alter the microscopic appearance of the tumor, or even create “skip areas” where the tumor is not entirely contiguous, but has separate foci of invasion. Awareness of these factors will help the surgeon more effectively plan for the procedure, and potentially decrease the possibility of post-Mohs recurrence.

The remainder of the history of present illness is focused on the assessment of symptoms that are suggestive of aggressive tumor behavior. While a small amount of discomfort may be associated with reactive inflammation around a lesion, the presence of significant pain or paresthesia should alert the physician to the possibility of perineural invasion [3]. Similarly, complaints of eyebrow ptosis, slurred speech, or drooling from the angle of the mouth are signs of motor neuropathy, and suggest a poor prognosis (Fig. 3.1). Other symptoms commonly reported for skin tumors include pruritus or bleeding, although these do not necessarily provide any prognostic information.

The surgeon must also review the pathology report. It is important to note whether aggressive histologic features, such as infiltrative, acantholytic, or poorly differentiated subtypes, or evidence of vascular or

Fig. 3.1 Temporal nerve palsy caused by advanced basal cell carcinoma of the ear and pre-auricular cheek. The patient is unable to open the left eye and there is marked ptosis of the left forehead and brow. The tumor was found to invade the zygomatic and temporal bones on computed tomography

perineural invasion are documented on the pathology report. These features, in conjunction with the primary diagnosis, can be used to appropriately triage the scheduling of the case as well as prepare the surgeon for potentially larger defects and more complicated repairs. In cases of atypical variants (e.g., basosquamous carcinoma) or unusual skin tumors, it is often useful for the Mohs surgeon to request the pathologic slides for personal review, as this will provide the surgeon with the most accurate information about the specific tumor.

The preoperative evaluation should also include a brief but detailed physical examination. An obvious prerequisite to surgery is the ability to identify the lesion to be treated, but this is not always easily accomplished. Particularly in patients with extensive actinic damage, dermatitis, or multiple prior procedures, it may be difficult to define a particular healed biopsy site within a background of multiple scars and keratoses. The most reliable way to ensure that the correct site is chosen for surgery is to incorporate information from multiple sources. The consultation request and the pathology report from the initial biopsy will identify a general anatomic area but will often not be specific. The patient is a valuable source of information as well; in our practice, the patient is asked to clearly identify the site with a mirror and marking pen prior to any surgery. This practice also helps to create a shared responsibility for the treatment between patient and physician. Even so, a recent study found that patients and physicians in a

Fig. 3.2 (a-b) Preoperative biopsy site verification with photography. The dotted lesion on the scalp in panel A and the circled lesion on the lower leg in panel B were both invasive squamous cell carcinoma on biopsy. On a background of extensive actinic damage, dermatitis, dyspigmentation, and scars from previous procedures, these biopsy sites would be difficult to identify without preoperative photography

Mohs surgery practice incorrectly identified surgical sites 4.4% of the time when preoperative biopsy-site photography was used to verify the correct site [4]. Quality photographs from the time of biopsy, therefore, should be used whenever possible to ensure that surgery is performed on the intended lesion (Fig. 3.2). Finally, when doubt persists about the exact location of a biopsied lesion, the referring physician should be consulted for further documentation and clarification.

In addition to verification of the site of the lesion, several additional features of the physical exam are