relevant to the preoperative evaluation. The patient’s temperature, pulse, blood pressure, and respiration rate should be noted and recorded in the medical chart before any procedure is initiated. Any evidence of fever or markedly elevated pulse (greater than 120) or blood pressure (greater than 200/110) should prompt the consideration of postponing surgery. Although anxiety regarding surgery may cause mild elevations in pulse or blood pressure, uncontrolled tachycardia or hypertension are relative contraindications to cutaneous surgery. Particularly for lesions on the face or dorsal forearms, the background of actinic damage should be noted, as this can confound the assessment of keratinocyte atypia on histopathologic examination. The size of the lesion should be assessed both by visual inspection and palpation with careful assessment for fixation to or distortion of underlying muscle or bone. Similarly, facial asymmetry or ptosis can be a sign of deeper invasion causing motor neuropathy, as noted above. For all cutaneous malignancies, a brief manual examination of the draining lymph node basin must be performed at the preoperative evaluation. If there is concern for extensive involvement of deep structures or metastatic disease, it may be necessary to defer surgery until diagnostic imaging and further staging has been performed. Taking into account the gross appearance of the lesion, the presence or absence of these signs of deeper invasion, and the laxity and rhytides of the surrounding skin, the surgeon can often formulate a plan for possible reconstructive options even before the patient is scheduled for surgery.

Summary: Past Medical History

•A standard medical history form can facilitate the preoperative evaluation, although each patient’s unique history should be discussed in detail.

•Dermatologic surgery can be performed in patients with cardiac conditions and implanted cardiac defibrillators with the use of proper precautions.

•Other medical conditions which may affect dermatologic surgery include diabetes, hepatic or renal disease, pregnancy, and immunosuppression.

•Overall functional status may be more important than chronologic age or specific medical conditions in predicting the response to surgery.

3.4Past Medical History

Review of the patient’s past medical history is an essential component of the preoperative evaluation. This process is made more efficient with the use of a standardized medical history form that can be completed by the patient prior to their visit or in the waiting area (Fig. 3.3). This allows the surgeon to rapidly identify the diagnoses and conditions most pertinent to the procedure at hand from a potentially complicated medical history. Any relevant details of the medical history, as well as how these will affect the planned surgical procedure, must then be discussed directly with the patient or their caregiver.

A fundamental question to be answered is whether the patient is a candidate for Mohs surgery. In general, there are no absolute contraindications to dermatologic surgery, and low risk procedures such as Mohs surgery can be safely performed in elderly patients and in those with stable comorbid conditions [5]. The individual risk-to-benefit ratio must be determined for each patient, taking into account their medical history and global functional status. An informed decision can then be made with the patient regarding the utility of the procedure and the optimal operative plan. Several factors to consider in this decision are discussed below.

For the patient with cardiac disease, it is important to determine whether the planned surgical procedure represents a significant risk for cardiac complications. Updated guidelines for preoperative cardiovascular evaluation in noncardiac surgery were published by the American College of Cardiology and American Heart Association in 2007 [6]. Dermatologic surgery is classified as a low cardiac risk procedure. As such, in cardiac patients without active cardiac conditions, the recommendation is to proceed with dermatologic surgery without further diagnostic workup. Active cardiac conditions to be excluded are unstable angina, myocardial infarction within 30 days, decompensated heart failure, symptomatic arrhythmia, and symptomatic aortic or mitral stenosis. A related historical issue is the concern for exacerbating hypertension with the administration of subcutaneous epinephrine in local anesthetics. In practice, this concern is unwarranted, as there is no significant increase in blood pressure after local epinephrine administration in dermatologic surgery, even in patients with preoperative hypertension [7]. Thus, once it has been established that a patient has stable cardiac disease and is asymptomatic, consultation with a

cardiologist is generally not required. It should be noted, however, that hypertension does increase the risk of local complications, including hematoma formation [7]. The surgeon may therefore wish to postpone surgery in cases of significant hypertension until after the blood pressure has been addressed by an internist.

The presence of a cardiac pacemaker or implantable cardioverter-defibrillator (ICD) represents another potential concern for the dermatologic surgeon, particularly in regard to the use of electrosurgery. There are several reported cases of electrical interference causing pacemaker or ICD malfunction in both the dermatologic and nondermatologic literature. Although modern ICDs are equipped with better shielding and advanced software to filter out exogenous electrical interference, they are also designed for more sensitive monitoring of endogenous cardiac rhythm, respirations, and physical activity. As such, there remains a significant risk of electrical interference compromising pacemaker or ICD function when using certain electrosurgical techniques [8]. While this risk is essentially absent when using electrocautery (i.e., heat cautery) since there is no transfer of electrical current to the patient, it is greatest with electrosection and electrocoagulation, in which high amperage current passes though the patient to the grounding plate. Bipolar electrosurgery, or electrocoagulation with biterminal forceps, minimizes risk to the patient by limiting current flow to a focal area between the two prongs of the treatment forceps.

After a case presentation and review of the mechanisms of electromagnetic interference, LeVasseur et al. published guidelines for the safe use of electrosurgery in patients with cardiac devices [9]. The first of these is the recommendation to use electrocautery alone. A second option is the use of biterminal forceps for electrocoagulation. Since neither of these techniques disperses electrical current away from the operative site, the remainder of the guidelines is of secondary importance if these techniques are used. If other forms of electrosurgery must be used, it is recommended that the indifferent electrode (grounding plate) is placed to minimize current transfer near the region of the heart, that a cardiologist is consulted to determine the patient’s dependence on the device, that pacemakers are placed in fixed rather than demand mode prior to surgery, that ICDs are deactivated prior to surgery if possible, that the patient is monitored preoperatively and intraoperatively with a 12-lead ECG, that electrosurgery is limited to short bursts of less than 5 s at a time, that the

electrical current is minimized, and that a contingency plan is specified in the event of life-threatening arrhythmia. A survey of dermatologic surgeons in 2000 found that these guidelines are not universally followed, however [10]. While the majority of surgeons reported using short bursts of current (71%) and minimizing electrical power when possible (61%), only about half used electrocautery or biterminal forceps (34% and 19%, respectively) and a small minority pursued ICD deactivation and cardiology consultation (15% and 11%, respectively). Despite the lack of universal adherence to these measures, there were only 31 reported cases of interference in a total of 1,959 years of surgical experience, representing an incidence of 1.6 cases of electrical interference per 100 years of surgical practice. The cardiac complications due to this interference ranged from skipped beats to inappropriate ICD firing and tachyarrhythmia; there was one patient with reported hemodynamic instability, but there were no cases of cardiac resuscitation or hospital admission, and there were no deaths reported in the survey. Importantly, there were no reported cases of interference with biterminal forceps, and only one case of suspected interference with electrocautery (because of the nature of the survey, it is unclear whether this represented true interference). Overall, therefore, it appears that the risk of cardiac complications from electrosurgery in patients with pacemakers or ICDs is low in the setting of dermatologic surgery, and that this risk can be essentially eliminated with the use of electrocautery or biterminal forceps.

Several other medical conditions are relevant to the preoperative evaluation and should be explicitly discussed with the patient. Patients with diabetes have impaired wound healing and a potentially increased risk of postoperative infection, owing to inhibition of chemotaxis and phagocytosis by hyperglycemia. The slower rate of wound healing in these patients is particularly pronounced on the distal lower extremities, where coincident vascular disease impairs wound perfusion. Similarly, patients with poor nutritional status, either from dietary insufficiency, gastrointestinal malabsorption, or cachexia from systemic malignancy will have impaired healing of surgical wounds. These factors should be considered when planning the closure of large surgical defects, as complicated repairs are less likely to succeed in patients with compromised healing ability. The presence of chronic renal or hepatic disease may also inhibit wound repair and can alter the

clearance of local anesthetics. Amide anesthetics such as lidocaine are metabolized by the liver then excreted by the kidneys. Patients with severe liver disease may be at particularly increased risk of lidocaine toxicity when used at doses approaching 4.5 mg/kg (the recommended maximum dose for plain lidocaine).

The presence of a bleeding diathesis, either inherited or acquired, should also be determined prior to surgery. An otherwise occult bleeding tendency may be elicited by inquiring about easy bruising, bleeding gums, or problems with prior surgical procedures. Suspicion for a hematologic disorder can be followed up with laboratory testing, including complete blood count, prothrombin time, and partial thromboplastin time. Patients with advanced liver or kidney disease are also at increased risk of postoperative bleeding, due to decreased platelet number and function. The surgeon should exercise extra precautions to ensure both intraoperative and postoperative hemostasis in these patients.

The pregnant patient presents a unique challenge to the dermatologic surgeon. While pregnancy is not a contraindication to surgery, several of the common medications used in dermatologic procedures can have adverse effects on the developing fetus. The United States Food and Drug Administration has published a rating system to define the safety of medications in pregnant patients (Table 3.1). Lidocaine is a category B medication and is thus the local anesthetic of choice in pregnant patients. Even so, lidocaine has been documented to cross the placenta, and it should be used with caution in the first trimester when fetal organogenesis occurs. The longer-acting bupivacaine, which is often mixed with lidocaine in Mohs surgery practices, is rated as category C and is not recommended due to animal studies showing increased risk of fetal deathandskeletalabnormalities.Theuseofsubcutaneous

epinephrine in pregnancy remains controversial, and it is classified as pregnancy category C. Although there is a theoretical risk of uterine artery contraction with high doses of epinephrine, no clear teratogenic effects have been documented in humans despite a long history of use [11]. Adjunctive sedative or analgesic medications should generally be avoided in pregnancy. Benzodiazepine anxiolytics such as diazepam are rated as class D due to increased risk of birth defects, and narcotic analgesics such as morphine and hydrocodone are class C. Acetaminophen, however, is class B and is generally regarded as safe for postoperative analgesia. In addition to selecting appropriate anesthesia for surgery, the surgeon must also be aware of the physiologic changes of pregnancy that may impact the procedure. Perhaps the most important of these is the tendency for the gravid uterus to compress the vena cava in the second and third trimester causing hypotension, tachycardia, and dyspnea in the supine patient. This can be prevented by positioning the patient in the left lateral tilt position [11].

In addition to the general medical conditions discussed above, there are several specific conditions that have a direct impact on the treatment of cutaneous malignancy. The increased incidence and metastatic potential of squamous cell carcinoma in transplant patients on chronic immunosuppression have been well documented. In kidney or heart transplant patients, there is a 65-fold increased risk of cutaneous squamous cell carcinoma, and up to 45% of transplant patients will develop skin cancer within 10 years of their transplant, depending on climate and UV exposure [12]. In addition, the behavior of these neoplasms is more aggressive in transplant patients. The early progression and metastasis of these tumors are evidenced by the fact that in some reports cutaneous malignancy accounts for

up to 27% of all deaths in transplant patients after the first 4 years [12]. The surgeon must be aware of this increased risk of progression, local recurrence, and subsequent second malignancy. In addition to expediting early surgery and adjusting the operative plan for invasive and aggressive tumors, it is also critical to ensure appropriate follow up and screening skin exams for these patients. In some practices, the dermatologic surgeon assumes primary dermatologic care for transplant patients at high risk for multiple cutaneous carcinomas. With regard to prophylactic antibiotics for prevention of surgical site infection in immunosuppressed patients, there is not sufficient clinical data to recommend this practice, and each case must be considered on an individual basis, incorporating other risk factors and the location of the surgical site (see Sect. 3.6 below).

In addition to iatrogenic immunosuppression for organ transplant, other forms of immunocompromise must be addressed prior to surgery. In particular, chronic lymphocytic leukemia (CLL) is usually an indolent hematologic malignancy associated with modest immunosuppression, but it appears to have a disproportionate effect on the behavior of cutaneous malignancy. Like patients with solid organ transplants, patients with CLL exhibit an increased incidence of BCC and SCC as well as more rapid progression and metastasis of these tumors. A retrospective study of head and neck basal cell carcinoma in patients with CLL found that these patients also had a 14-fold increased risk of BCC recurrence. Despite the use of Mohs surgery on banalappearing tumors with typical histologic features, the recurrence of BCC at 3 and 5 years was 12% and 22%, respectively, compared to 0% and 2% in controls [13]. The use of micrographic margin control is particularly problematic in patients with CLL due to the presence of obscuring leukemic infiltrates in many patients [14]. The surgeon must be meticulous in examining histologic margins in these patients and may wish to consider taking more generous margins in certain cases. Similar to patients with immunocompromise, certain patients with inherited or acquired neoplasia syndromes appear to be at higher risk of recurrence and subsequent cutaneous malignancies. This includes genetic syndromes such as the basal cell nevus syndrome (Gorlin syndrome) and acquired conditions such as extensive actinic damage in what has been termed the actinic neoplasia syndrome [15]. Because these patients may also require a more involved surgical approach and closer postoperative monitoring, the surgeon should determine

the number, type, and location of prior skin cancers in all patients during the preoperative evaluation.

Finally, psychiatric disease and social habits can also affect surgical outcomes. Patients with depression, dementia, or other psychiatric disorders are often less able to perform appropriate postoperative care and may be at higher risk for wound infection, scarring, or other complications. A caregiver or home nursing visits may be useful in these cases to ensure proper dressing care. If a patient exhibits excessive anxiety about the planned procedure during the preoperative evaluation, it may be beneficial to prescribe an anxiolytic such as diazepam. We have found that 2–5 mg of diazepam taken orally 1 h prior to surgery can be an effective adjunct in patients with moderate anxiety. As discussed above, the preoperative evaluation itself can also minimize patient anxiety by establishing an effective relationship with the patient. More intensive sedation, if required, should be performed in consultation with an anesthesiologist. The use of ethanol and tobacco can also adversely impact surgical outcomes, and patients must be questioned about these habits prior to surgery. Ethanol functions as a mild anticoagulant, and patients should be counseled to avoid alcohol consumption for 24–48 h after surgery. Nicotine, in contrast, has a vasoconstrictive and prothrombotic effect and may be more problematic for surgical patients. This is particularly true when repairs are performed with flaps or full-thickness skin grafts that require optimal vascular function to survive. A retrospective study in the plastic surgery literature found that tobacco use was strongly correlated with skin flap necrosis after face lift surgery, with an odds ratio of 12.46 [16]. Patients should be counseled to abstain from smoking for 1 week before and after surgery. Involvement of the patient’s primary care physician in this process can help with compliance and may facilitate permanent abstention from tobacco use and significant overall health benefits.

Due to the disproportionate incidence of skin cancer in elderly patients, dermatologic surgeons are increasingly required to perform surgery on geriatric patients with multiple comorbid conditions as described above. In addition to the contribution of each individual condition, however, the patient’s overall functional status appears to be a more important predictor of outcome after invasive procedures. One recent study found that after major surgery in patients over 65 years of age, the most important predictor of survival to 6 months was the preoperative functional