Faculty Bibliography

There is controversy regarding the optimal surgical modality and ideal recommended margins for treating melanoma in situ (MIS) and invasive melanoma (IM). Although wide local excision is recommended, staged excision offers excellent margin control and low recurrence rates. In this manuscript, we reviewed a 10-year experience of staged excisions for the treatment of MIS and IM. A retrospective review was performed of 130 MIS and 32 IM cases treated with staged excision from April 2012 to April 2022. Staged excision was performed on the head and neck in 102 (79%) MIS and 23 (72%) IM cases. Approximately 10% of cases required surgical margins above the current recommendations (11 (9%) MIS and 6 (19%) IM). Twenty-three (19%) MIS and 7 (22%) IM cases required more than one excision to obtain clearance. Recurrence rates among MIS and IM were 0.0% and 0.6%, respectively. Upstaging occurred in 5 (4%) MIS and 7 (22%) IM cases. Complex repairs were performed on 82 (63%) MIS and 17 (53%) IM cases. Our findings revealed that staged excision provides effective margin control and low recurrence rates. Approximately 10% of patients required margins greater than the current recommendations, leading to larger defects and more complex repairs.

INTRODUCTION/BACKGROUND:Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty restoring nasal contour. METHODS:We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3.0 centimeters (cm) in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months post-operatively. RESULTS:In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. CONCLUSION/CONCLUSIONS:We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in sub selected patients.

IMPORTANCE/UNASSIGNED:Primary cutaneous squamous cell carcinoma is usually curable; however, a subset of patients develops poor outcomes, including local recurrence, nodal metastasis, distant metastasis, and disease-specific death. OBJECTIVES/UNASSIGNED:To evaluate all evidence-based reports of patient risk factors and tumor characteristics associated with poor outcomes in primary cutaneous squamous cell carcinoma and to identify treatment modalities that minimize poor outcomes. DATA SOURCES/UNASSIGNED:PubMed, Embase, and SCOPUS databases were searched for studies of the topic in humans, published in the English language, from database inception through February 8, 2022. STUDY SELECTION/UNASSIGNED:Two authors independently screened the identified articles and included those that were original research with a sample size of 10 patients or more and that assessed risk factors and/or treatment modalities associated with poor outcomes among patients with primary cutaneous squamous cell carcinoma. DATA EXTRACTION AND SYNTHESIS/UNASSIGNED:Data extraction was performed by a single author, per international guidelines. The search terms, study objectives, and protocol methods were defined before study initiation. A total of 310 studies were included for full-text assessment. Owing to heterogeneity of the included studies, a random-effects model was used. Data analyses were performed from May 25 to September 15, 2022. MAIN OUTCOMES AND MEASURES/UNASSIGNED:For studies of risk factors, risk ratios and incidence proportions; and for treatment studies, incidence proportions. RESULTS/UNASSIGNED:In all, 129 studies and a total of 137 449 patients with primary cutaneous squamous cell carcinoma and 126 553 tumors were included in the meta-analysis. Several patient risk factors and tumor characteristics were associated with local recurrence, nodal metastasis, distant metastasis, disease-specific death, and all-cause death were identified. Among all factors reported by more than 1 study, the highest risks for local recurrence and disease-specific death were associated with tumor invasion beyond subcutaneous fat (risk ratio, 9.1 [95% CI, 2.8-29.2] and 10.4 [95% CI, 3.0- 36.3], respectively), and the highest risk of any metastasis was associated with perineural invasion (risk ratio, 5.0; 95% CI, 2.3-11.1). Patients who received Mohs micrographic surgery had the lowest incidence of nearly all poor outcomes; however, in some results, the 95% CIs overlapped with those of other treatment modalities. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This meta-analysis identified the prognostic value of several risk factors and the effectiveness of the available treatment modalities. These findings carry important implications for the prognostication, workup, treatment, and follow-up of patients with primary cutaneous squamous cell carcinoma. TRIAL REGISTRATION/UNASSIGNED:PROSPERO Identifier: CRD42022311250.

Deliberate practice-based medical education has demonstrated superiority in trainee acquisition and maintenance of skills in several surgical subspecialties. In an effort to highlight the impact of a deliberate practice-based surgical curriculum on the technical proficiency of dermatology residents, a prospective cohort study including first- and second-year dermatology residents was performed. A total of 87.5% (7 of 8) first-year dermatology residents completed three hands-on simulations at 6-week intervals. Additionally, six of eight (75.0%) second-year dermatology residents at the same institution were evaluated at a single point-in-time session without accessing the surgical curriculum prior. A 5-point global rating scale (GRS) was used to assess resident performance on six core surgical techniques. Nonparametric ANOVA statistical methods using the Kruskal-Wallis test was performed. The residents' overall GRS increased from a median of 1-2.75 after completion of the curriculum (p < 0.01). There was a significant improvement in the median scores of each tested surgical technique. The first-year residents had a greater overall GRS after completion of the curriculum compared to the second-year residents (median of 2.13 versus 1.88, p < 0.001). Limitations include the small sample size and lack of a synchronized control group. Our study highlights the use of deliberate practice-based strategies as an effective modality in teaching surgical skills to dermatology residents.

B-cell chronic lymphocytic leukemia (CLL) is the most prevalent leukemia in the United States, and its diagnosis can have many dermatologic implications. For one, the cutaneous manifestations of CLL include several entities, most notably leukemia cutis, eosinophilic dermatosis of hematologic malignancy, and a heightened risk of skin infections. Additionally, CLL patients are at an increased risk of secondary malignancies, most commonly of the skin. Furthermore, a number of commonly utilized treatments for CLL have cutaneous implications which should be considered in the interdisciplinary management of CLL patients. In this review, we will provide an update on the diverse cutaneous manifestations of CLL and CLL-directed therapies in order to help guide dermatologic management of this increasingly prevalent patient population.

BACKGROUND:People of African, Asian, Hispanic or Latino, Pacific Islander, and Native Indian descent are considered people of color by the Skin of Color Society (SOCS). OBJECTIVES/OBJECTIVE:In this study, we assess incidence, risk factors, clinical characteristics, histopathology, treatment, and survival for skin malignancies in people of color as defined by the SOCS, by systematically reviewing the literature. METHODS:An electronic literature search of the PubMed, EMBASE, and MEDLINE databases was performed. Articles published from 1 January 1990 through 12 December 2020 were included in the search. RESULTS:We identified 2666 publications potentially meeting the study criteria. Titles and abstracts of these studies were reviewed and 2353 were excluded. The full text of 313 articles were evaluated and 251 were included in this review. CONCLUSION/CONCLUSIONS:Differences in incidence, patterns, treatment, and survival exist among people of color for cutaneous malignancies. Further research and initiatives are needed to account for and mitigate these differences.