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Smoking linked to increased complication risk after Mohs surgery

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Sun, 06/30/2019 - 07:56

Current and former smokers are at significantly increased risk for acute complications after Mohs surgery, based on data from a retrospective case-control study of 1,008 adult patients.

Terroa/iStock/Getty Images

The increased risk of complications for smokers following many types of surgery is well documented; however, “the effect of smoking in the specific setting of cutaneous tissue transfer is not well characterized in the literature describing outcomes after Mohs reconstruction,” wrote Chang Ye Wang, MD, of St. Louis University, Missouri, and colleagues.

To determine the impact of smoking on acute and long-term complications, the researchers reviewed data from 1,008 adults (396 women and 612 men) who underwent Mohs surgery between July 1, 2012, and June 30, 2016, at a single center. The study population included 128 current smokers, 385 former smokers, and 495 never smokers. The age of the patients ranged from 21 years to 90 years, with a median of 70 years. The results were published in JAMA Facial Plastic Surgery.

The overall rate of acute complications was 4.1%, and the most common complication was infection, in 19 cases; others were 10 cases of flap or graft necrosis, 10 cases of wound dehiscence, and 6 of cases of hematoma or uncontrolled bleeding; some patients experienced more than one of these complications. The risk of acute complications increased for current smokers (odds ratio 9.58) and former smokers (OR, 3.64) in a multivariate analysis. Increased risk of acute complications also was associated with a larger defect (OR, 2.25) and use of free cartilage graft (OR, 8.19).

The researchers defined acute complications as “any postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention,” and long-term complications as “any postsurgical functional defect or unsatisfactory cosmesis that prompted the patient to request an additional procedural intervention or the surgeon to offer it.”

The overall rate of long-term complications was 7.4%. A procedure in the center of the face was associated with a 25% increased risk of long-term complications (OR, 25.4). Other factors associated with an increased risk of long-term complications were the use of interpolation flap or flap-graft combination (OR, 3.49), larger flaps (OR, 1.42), and presence of basal cell carcinomas or other basaloid tumors (OR, 3.43). Smoking was not associated with an increased risk of long-term complications, and an older age was associated with a decreased risk of long-term complications (OR, 0.66).

The findings were limited by the retrospective study design and unblinded data collection, as well as a lack of photographs of all patients at matching time points, the researchers said. However, the results are consistent with previous studies and “may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling,” they added.

The researchers had no financial conflicts to disclose.

SOURCE: Wang CY et al. JAMA Facial Plast. Surg. 2019 June 13. doi: 10.1001/jamafacial.2019.0243.

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Current and former smokers are at significantly increased risk for acute complications after Mohs surgery, based on data from a retrospective case-control study of 1,008 adult patients.

Terroa/iStock/Getty Images

The increased risk of complications for smokers following many types of surgery is well documented; however, “the effect of smoking in the specific setting of cutaneous tissue transfer is not well characterized in the literature describing outcomes after Mohs reconstruction,” wrote Chang Ye Wang, MD, of St. Louis University, Missouri, and colleagues.

To determine the impact of smoking on acute and long-term complications, the researchers reviewed data from 1,008 adults (396 women and 612 men) who underwent Mohs surgery between July 1, 2012, and June 30, 2016, at a single center. The study population included 128 current smokers, 385 former smokers, and 495 never smokers. The age of the patients ranged from 21 years to 90 years, with a median of 70 years. The results were published in JAMA Facial Plastic Surgery.

The overall rate of acute complications was 4.1%, and the most common complication was infection, in 19 cases; others were 10 cases of flap or graft necrosis, 10 cases of wound dehiscence, and 6 of cases of hematoma or uncontrolled bleeding; some patients experienced more than one of these complications. The risk of acute complications increased for current smokers (odds ratio 9.58) and former smokers (OR, 3.64) in a multivariate analysis. Increased risk of acute complications also was associated with a larger defect (OR, 2.25) and use of free cartilage graft (OR, 8.19).

The researchers defined acute complications as “any postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention,” and long-term complications as “any postsurgical functional defect or unsatisfactory cosmesis that prompted the patient to request an additional procedural intervention or the surgeon to offer it.”

The overall rate of long-term complications was 7.4%. A procedure in the center of the face was associated with a 25% increased risk of long-term complications (OR, 25.4). Other factors associated with an increased risk of long-term complications were the use of interpolation flap or flap-graft combination (OR, 3.49), larger flaps (OR, 1.42), and presence of basal cell carcinomas or other basaloid tumors (OR, 3.43). Smoking was not associated with an increased risk of long-term complications, and an older age was associated with a decreased risk of long-term complications (OR, 0.66).

The findings were limited by the retrospective study design and unblinded data collection, as well as a lack of photographs of all patients at matching time points, the researchers said. However, the results are consistent with previous studies and “may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling,” they added.

The researchers had no financial conflicts to disclose.

SOURCE: Wang CY et al. JAMA Facial Plast. Surg. 2019 June 13. doi: 10.1001/jamafacial.2019.0243.

Current and former smokers are at significantly increased risk for acute complications after Mohs surgery, based on data from a retrospective case-control study of 1,008 adult patients.

Terroa/iStock/Getty Images

The increased risk of complications for smokers following many types of surgery is well documented; however, “the effect of smoking in the specific setting of cutaneous tissue transfer is not well characterized in the literature describing outcomes after Mohs reconstruction,” wrote Chang Ye Wang, MD, of St. Louis University, Missouri, and colleagues.

To determine the impact of smoking on acute and long-term complications, the researchers reviewed data from 1,008 adults (396 women and 612 men) who underwent Mohs surgery between July 1, 2012, and June 30, 2016, at a single center. The study population included 128 current smokers, 385 former smokers, and 495 never smokers. The age of the patients ranged from 21 years to 90 years, with a median of 70 years. The results were published in JAMA Facial Plastic Surgery.

The overall rate of acute complications was 4.1%, and the most common complication was infection, in 19 cases; others were 10 cases of flap or graft necrosis, 10 cases of wound dehiscence, and 6 of cases of hematoma or uncontrolled bleeding; some patients experienced more than one of these complications. The risk of acute complications increased for current smokers (odds ratio 9.58) and former smokers (OR, 3.64) in a multivariate analysis. Increased risk of acute complications also was associated with a larger defect (OR, 2.25) and use of free cartilage graft (OR, 8.19).

The researchers defined acute complications as “any postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention,” and long-term complications as “any postsurgical functional defect or unsatisfactory cosmesis that prompted the patient to request an additional procedural intervention or the surgeon to offer it.”

The overall rate of long-term complications was 7.4%. A procedure in the center of the face was associated with a 25% increased risk of long-term complications (OR, 25.4). Other factors associated with an increased risk of long-term complications were the use of interpolation flap or flap-graft combination (OR, 3.49), larger flaps (OR, 1.42), and presence of basal cell carcinomas or other basaloid tumors (OR, 3.43). Smoking was not associated with an increased risk of long-term complications, and an older age was associated with a decreased risk of long-term complications (OR, 0.66).

The findings were limited by the retrospective study design and unblinded data collection, as well as a lack of photographs of all patients at matching time points, the researchers said. However, the results are consistent with previous studies and “may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling,” they added.

The researchers had no financial conflicts to disclose.

SOURCE: Wang CY et al. JAMA Facial Plast. Surg. 2019 June 13. doi: 10.1001/jamafacial.2019.0243.

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Social media use linked to acceptance of cosmetic surgery

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Thu, 06/27/2019 - 11:30

Use of social media platforms such as Tinder, Snapchat, and Instagram, particularly in conjunction with photo-editing applications, may increase an individual’s acceptance of cosmetic surgery, a new study suggests.

In JAMA Facial Plastic Surgery, researchers report the outcomes of a web-based survey study involving 252 participants, 73.0% of whom were female. The survey asked participants about their use of social media, photo-editing tools such as Photoshop, VSCO, and Snapchat filters, and answered questionnaires to assess their self-esteem, self-worth, and attitudes toward cosmetic surgery.

All participants used at least one social media platform, with a mean of seven, and used a mean of two photo-editing applications; the analysis found that those who used more social media platforms were more likely to consider cosmetic surgery.

People who used Tinder and Snapchat ­– with or without photo filters – showed greater acceptance of cosmetic surgery, while those who used the photography mobile app VSCO and Instagram photo filters showed greater consideration but not acceptance of cosmetic surgery, compared with nonusers.

Participants whose self-worth was more closely tied to their appearance showed greater acceptance of cosmetic surgery. When it came to self-esteem, participants who used YouTube, WhatsApp, VSCO, and Photoshop had lower self-esteem scores, compared with nonusers.

Overall, nearly two-thirds of survey participants said they used photo-editing applications to change the lighting of images, but only 5.16% said they used these applications to make changes to face or body shape. This distinction was also seen in their acceptance of cosmetic surgery scores: Those who said they made changes to face and body shape showed higher acceptance scores than nonusers, but this was not seen in those who only used it for lighting adjustments.

“The rising trend of pursuing cosmetic surgery based on social media inspiration highlights the need to better understand patients’ motivations to seek cosmetic surgery,” wrote Jonlin Chen, a medical student at Johns Hopkins University, Baltimore, and coauthors.

Commenting on the association between YouTube use, lower self-esteem, and higher acceptance of cosmetic surgery, the authors suggested that the platform may generate appearance comparisons between users by allowing them to access beauty-related videos and connect with other users interested in cosmetics.

Michael J. Reilly, MD, department of otolaryngology–head and neck surgery and Keon M. Parsa, MD, from the department of psychiatry at MedStar Georgetown University Hospital in Washington, commented in an accompanying editorial that the findings of this study illustrate an increased trend seen by facial plastic surgeons (JAMA Facial Plast Surg. 2019 June 27. doi: 10.1001/jamafacial.2019.0419). The study “shows the importance of understanding the underlying motives and characteristics of individuals seeking cosmetic surgery.” They noted that facial plastic surgeons can play a role in helping patients to improve their self-esteem, but it is also important to be aware of the clinical signs of depression, anxiety, and social isolation and refer for appropriate nonsurgical support when there are mental health concerns that go beyond the knife and needle.

The authors of the study did note that their choice of a web-based survey meant the demographic was likely to be skewed toward a younger, more social media–savvy demographic, and may not necessarily represent the broader population of individuals seeking cosmetic surgery.

No funding or conflicts of interest were declared.

SOURCE: Chen J et al. JAMA Facial Plast Surg. 2019 Jun 27. doi: 10.1001/jamafacial.2019.0328.

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Use of social media platforms such as Tinder, Snapchat, and Instagram, particularly in conjunction with photo-editing applications, may increase an individual’s acceptance of cosmetic surgery, a new study suggests.

In JAMA Facial Plastic Surgery, researchers report the outcomes of a web-based survey study involving 252 participants, 73.0% of whom were female. The survey asked participants about their use of social media, photo-editing tools such as Photoshop, VSCO, and Snapchat filters, and answered questionnaires to assess their self-esteem, self-worth, and attitudes toward cosmetic surgery.

All participants used at least one social media platform, with a mean of seven, and used a mean of two photo-editing applications; the analysis found that those who used more social media platforms were more likely to consider cosmetic surgery.

People who used Tinder and Snapchat ­– with or without photo filters – showed greater acceptance of cosmetic surgery, while those who used the photography mobile app VSCO and Instagram photo filters showed greater consideration but not acceptance of cosmetic surgery, compared with nonusers.

Participants whose self-worth was more closely tied to their appearance showed greater acceptance of cosmetic surgery. When it came to self-esteem, participants who used YouTube, WhatsApp, VSCO, and Photoshop had lower self-esteem scores, compared with nonusers.

Overall, nearly two-thirds of survey participants said they used photo-editing applications to change the lighting of images, but only 5.16% said they used these applications to make changes to face or body shape. This distinction was also seen in their acceptance of cosmetic surgery scores: Those who said they made changes to face and body shape showed higher acceptance scores than nonusers, but this was not seen in those who only used it for lighting adjustments.

“The rising trend of pursuing cosmetic surgery based on social media inspiration highlights the need to better understand patients’ motivations to seek cosmetic surgery,” wrote Jonlin Chen, a medical student at Johns Hopkins University, Baltimore, and coauthors.

Commenting on the association between YouTube use, lower self-esteem, and higher acceptance of cosmetic surgery, the authors suggested that the platform may generate appearance comparisons between users by allowing them to access beauty-related videos and connect with other users interested in cosmetics.

Michael J. Reilly, MD, department of otolaryngology–head and neck surgery and Keon M. Parsa, MD, from the department of psychiatry at MedStar Georgetown University Hospital in Washington, commented in an accompanying editorial that the findings of this study illustrate an increased trend seen by facial plastic surgeons (JAMA Facial Plast Surg. 2019 June 27. doi: 10.1001/jamafacial.2019.0419). The study “shows the importance of understanding the underlying motives and characteristics of individuals seeking cosmetic surgery.” They noted that facial plastic surgeons can play a role in helping patients to improve their self-esteem, but it is also important to be aware of the clinical signs of depression, anxiety, and social isolation and refer for appropriate nonsurgical support when there are mental health concerns that go beyond the knife and needle.

The authors of the study did note that their choice of a web-based survey meant the demographic was likely to be skewed toward a younger, more social media–savvy demographic, and may not necessarily represent the broader population of individuals seeking cosmetic surgery.

No funding or conflicts of interest were declared.

SOURCE: Chen J et al. JAMA Facial Plast Surg. 2019 Jun 27. doi: 10.1001/jamafacial.2019.0328.

Use of social media platforms such as Tinder, Snapchat, and Instagram, particularly in conjunction with photo-editing applications, may increase an individual’s acceptance of cosmetic surgery, a new study suggests.

In JAMA Facial Plastic Surgery, researchers report the outcomes of a web-based survey study involving 252 participants, 73.0% of whom were female. The survey asked participants about their use of social media, photo-editing tools such as Photoshop, VSCO, and Snapchat filters, and answered questionnaires to assess their self-esteem, self-worth, and attitudes toward cosmetic surgery.

All participants used at least one social media platform, with a mean of seven, and used a mean of two photo-editing applications; the analysis found that those who used more social media platforms were more likely to consider cosmetic surgery.

People who used Tinder and Snapchat ­– with or without photo filters – showed greater acceptance of cosmetic surgery, while those who used the photography mobile app VSCO and Instagram photo filters showed greater consideration but not acceptance of cosmetic surgery, compared with nonusers.

Participants whose self-worth was more closely tied to their appearance showed greater acceptance of cosmetic surgery. When it came to self-esteem, participants who used YouTube, WhatsApp, VSCO, and Photoshop had lower self-esteem scores, compared with nonusers.

Overall, nearly two-thirds of survey participants said they used photo-editing applications to change the lighting of images, but only 5.16% said they used these applications to make changes to face or body shape. This distinction was also seen in their acceptance of cosmetic surgery scores: Those who said they made changes to face and body shape showed higher acceptance scores than nonusers, but this was not seen in those who only used it for lighting adjustments.

“The rising trend of pursuing cosmetic surgery based on social media inspiration highlights the need to better understand patients’ motivations to seek cosmetic surgery,” wrote Jonlin Chen, a medical student at Johns Hopkins University, Baltimore, and coauthors.

Commenting on the association between YouTube use, lower self-esteem, and higher acceptance of cosmetic surgery, the authors suggested that the platform may generate appearance comparisons between users by allowing them to access beauty-related videos and connect with other users interested in cosmetics.

Michael J. Reilly, MD, department of otolaryngology–head and neck surgery and Keon M. Parsa, MD, from the department of psychiatry at MedStar Georgetown University Hospital in Washington, commented in an accompanying editorial that the findings of this study illustrate an increased trend seen by facial plastic surgeons (JAMA Facial Plast Surg. 2019 June 27. doi: 10.1001/jamafacial.2019.0419). The study “shows the importance of understanding the underlying motives and characteristics of individuals seeking cosmetic surgery.” They noted that facial plastic surgeons can play a role in helping patients to improve their self-esteem, but it is also important to be aware of the clinical signs of depression, anxiety, and social isolation and refer for appropriate nonsurgical support when there are mental health concerns that go beyond the knife and needle.

The authors of the study did note that their choice of a web-based survey meant the demographic was likely to be skewed toward a younger, more social media–savvy demographic, and may not necessarily represent the broader population of individuals seeking cosmetic surgery.

No funding or conflicts of interest were declared.

SOURCE: Chen J et al. JAMA Facial Plast Surg. 2019 Jun 27. doi: 10.1001/jamafacial.2019.0328.

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Systematic review indicates cutaneous laser therapy may be safe during pregnancy

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Mon, 06/03/2019 - 15:07

 

Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.



The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO2.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO2 laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.

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Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.



The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO2.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO2 laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.

 

Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.



The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO2.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO2 laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.

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Five rules for evaluating melanonychia

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Mon, 06/03/2019 - 11:13

 

– Many dermatologists find melanonychia to be intimidating. The clinical features are ambiguous, and the prospect of doing a painful nail apparatus biopsy can be daunting for the inexperienced. As a result, the biopsy gets delayed and melanoma of the nail is often initially a missed diagnosis, not uncommonly for years, with devastating consequences.

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Dr. Nathaniel Jellinek

Here are five teaching points on melanonychia provided by nail disease expert and Mohs surgeon Nathaniel Jellinek, MD, at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rule #1: Always look beyond the nail

When a light-skinned person presents with more than one nail with pigmentation, the likelihood that one of them is melanoma is much less than if there is only one nail with melanonychia, according to Dr. Jellinek, a dermatologist in private practice in East Greenwich, R.I.

Also, be sure to look at the skin and mucosa. Consider the medications the patients may be taking: For example, cyclophosphamide (Cytoxan) is notorious for causing nail changes as a side effect. A past medical history of lichen planus, carpal tunnel syndrome, Addison disease, or other conditions may explain the melanonychia.

Nathaniel Jellinek, MD
Melanonychia in Laugier-Hunziker syndrome

Laugier-Hunziker syndrome is a condition worth getting to know. It’s an acquired disorder characterized longitudinal melanonychia and other pigmentary changes, which may include diffuse hyperpigmentation of the orolabial mucosa, ocular pigment, and/or pigmented palmoplantar lesions. It’s said to be rare, but Dr. Jellinek disagrees.

“Learn this one if you don’t know it. I see a case about every 2 weeks. It’s not heritable and not associated with any other medical condition,” he said.

Rule #2: Your dermatoscope is great for nails

What Dr. Jellinek considers to be among the all-time best papers on the value of dermoscopy for nail pigmentation was authored by French investigators. They analyzed 148 consecutive cases of longitudinal melanonychia and concluded that the dermoscopic combination of a brown background coupled with irregular longitudinal lines in terms of color, spacing, diameter, and/or lack of parallelism strongly suggests melanoma. A micro-Hutchinson’s sign, while a rare finding, occurred only in melanoma, where it represented periungual spread of a radial growth phase malignancy (Arch Dermatol. 2002 Oct;138[10]:1327-33).

“I think nail dermoscopy is most helpful for subungual hemorrhage. I average one referral per week for hemorrhage under the nail. On dermoscopy it’s as if someone took paint and threw it at the nail. Purple to brown blood spots, with no background color. This should be a doorway diagnosis of hemorrhage,” Dr. Jellinek said.

Rule #3: Know when you don’t know

“This is really the key for me,” the dermatologist commented. “There are automatic cases for biopsy, and more commonly routine cases for reassurance. But the gray zone, when you know you don’t know, is the key decision making moment.”

When something just doesn’t feel right, there’s absolutely nothing wrong with getting a second opinion, he stressed.

“It’s worthwhile getting to know people whose opinions you trust. There’s a saying I like to teach our fellows: ‘Never worry alone.’ So if you’re worried about someone, listen to that inner voice. There’s no shame in getting a second opinion. It’s great! Patients are never upset, either. They feel really well taken care of,” he said.

 

 

Rule #4: Don’t wimp out when a biopsy is warranted

Many dermatologists hem and haw about doing a biopsy for a concerning lesion on the nail, when they wouldn’t hesitate to biopsy a similarly suspicious lesion on the face.

But it’s essential to biopsy the right area, he added. For longitudinal melanonychia, that’s the matrix. The nail plate is the wrong place; a biopsy obtained there will result in an inappropriate benign diagnosis.

Nathaniel Jellinek, MD
Melanonychia from matrix lentigo

“The starter set is to do a punch biopsy. This is your gateway drug to the world of nail surgery. Lots of dermatologists are intimidated by nail surgery, but if you can do any minor surgery, you can do a punch of the matrix. All it takes is a little practice. And if all you can do is punch biopsies, you’re good for your career. If you can do that, you’re golden. There are people who’ve just done punch biopsies for their whole career and they don’t miss melanomas,” he said.

Step one is to undermine the proximal nail fold using a pediatric elevator, which costs only about $30. “If you’re going to do a lot of nail surgery, they’re really helpful,” he said.



There’s no need at all to evulse the nail. Just make oblique incisions in the proximal nail fold in order to reflect it and look at the matrix. A 3-mm punch is standard, directed right over the origin of the pigment. Resist the temptation to force or squeeze the specimen in order to extract it. Instead, use really fine-tipped scissors to nibble at the base of the specimen, then gently pull it out, making an effort to keep the nail plate attached to the digit and avoid getting it stuck up in the punch.

Rule #5: Have dermatopathologists extensively experienced with nail pathology on your Rolodex

The histopathologic findings present in early subungual melanoma in situ are often too subtle for general dermatopathologists to appreciate, in Dr. Jellinek’s experience. He cited other investigators’ study of 18 cases of subungual melanoma in situ, all marked by longitudinal melanonychia. Only half showed the classic giveaway on the original nail matrix biopsy, consisting of a significantly increased number of atypical melanocytes with marked nuclear atypia. Blatant pagetoid spread was infrequent. However, all 18 cases displayed a novel, more subtle, and previously undescribed finding: haphazard and uneven distribution of atypical solitary melanocytes with variably sized and shaped hyperchromatic nuclei (J Cutan Pathol. 2016 Jan;43[1]:41-52).

Dr. Jellinek reported having no financial conflicts regarding his presentation. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

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– Many dermatologists find melanonychia to be intimidating. The clinical features are ambiguous, and the prospect of doing a painful nail apparatus biopsy can be daunting for the inexperienced. As a result, the biopsy gets delayed and melanoma of the nail is often initially a missed diagnosis, not uncommonly for years, with devastating consequences.

Bruce Jancin/MDedge News
Dr. Nathaniel Jellinek

Here are five teaching points on melanonychia provided by nail disease expert and Mohs surgeon Nathaniel Jellinek, MD, at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rule #1: Always look beyond the nail

When a light-skinned person presents with more than one nail with pigmentation, the likelihood that one of them is melanoma is much less than if there is only one nail with melanonychia, according to Dr. Jellinek, a dermatologist in private practice in East Greenwich, R.I.

Also, be sure to look at the skin and mucosa. Consider the medications the patients may be taking: For example, cyclophosphamide (Cytoxan) is notorious for causing nail changes as a side effect. A past medical history of lichen planus, carpal tunnel syndrome, Addison disease, or other conditions may explain the melanonychia.

Nathaniel Jellinek, MD
Melanonychia in Laugier-Hunziker syndrome

Laugier-Hunziker syndrome is a condition worth getting to know. It’s an acquired disorder characterized longitudinal melanonychia and other pigmentary changes, which may include diffuse hyperpigmentation of the orolabial mucosa, ocular pigment, and/or pigmented palmoplantar lesions. It’s said to be rare, but Dr. Jellinek disagrees.

“Learn this one if you don’t know it. I see a case about every 2 weeks. It’s not heritable and not associated with any other medical condition,” he said.

Rule #2: Your dermatoscope is great for nails

What Dr. Jellinek considers to be among the all-time best papers on the value of dermoscopy for nail pigmentation was authored by French investigators. They analyzed 148 consecutive cases of longitudinal melanonychia and concluded that the dermoscopic combination of a brown background coupled with irregular longitudinal lines in terms of color, spacing, diameter, and/or lack of parallelism strongly suggests melanoma. A micro-Hutchinson’s sign, while a rare finding, occurred only in melanoma, where it represented periungual spread of a radial growth phase malignancy (Arch Dermatol. 2002 Oct;138[10]:1327-33).

“I think nail dermoscopy is most helpful for subungual hemorrhage. I average one referral per week for hemorrhage under the nail. On dermoscopy it’s as if someone took paint and threw it at the nail. Purple to brown blood spots, with no background color. This should be a doorway diagnosis of hemorrhage,” Dr. Jellinek said.

Rule #3: Know when you don’t know

“This is really the key for me,” the dermatologist commented. “There are automatic cases for biopsy, and more commonly routine cases for reassurance. But the gray zone, when you know you don’t know, is the key decision making moment.”

When something just doesn’t feel right, there’s absolutely nothing wrong with getting a second opinion, he stressed.

“It’s worthwhile getting to know people whose opinions you trust. There’s a saying I like to teach our fellows: ‘Never worry alone.’ So if you’re worried about someone, listen to that inner voice. There’s no shame in getting a second opinion. It’s great! Patients are never upset, either. They feel really well taken care of,” he said.

 

 

Rule #4: Don’t wimp out when a biopsy is warranted

Many dermatologists hem and haw about doing a biopsy for a concerning lesion on the nail, when they wouldn’t hesitate to biopsy a similarly suspicious lesion on the face.

But it’s essential to biopsy the right area, he added. For longitudinal melanonychia, that’s the matrix. The nail plate is the wrong place; a biopsy obtained there will result in an inappropriate benign diagnosis.

Nathaniel Jellinek, MD
Melanonychia from matrix lentigo

“The starter set is to do a punch biopsy. This is your gateway drug to the world of nail surgery. Lots of dermatologists are intimidated by nail surgery, but if you can do any minor surgery, you can do a punch of the matrix. All it takes is a little practice. And if all you can do is punch biopsies, you’re good for your career. If you can do that, you’re golden. There are people who’ve just done punch biopsies for their whole career and they don’t miss melanomas,” he said.

Step one is to undermine the proximal nail fold using a pediatric elevator, which costs only about $30. “If you’re going to do a lot of nail surgery, they’re really helpful,” he said.



There’s no need at all to evulse the nail. Just make oblique incisions in the proximal nail fold in order to reflect it and look at the matrix. A 3-mm punch is standard, directed right over the origin of the pigment. Resist the temptation to force or squeeze the specimen in order to extract it. Instead, use really fine-tipped scissors to nibble at the base of the specimen, then gently pull it out, making an effort to keep the nail plate attached to the digit and avoid getting it stuck up in the punch.

Rule #5: Have dermatopathologists extensively experienced with nail pathology on your Rolodex

The histopathologic findings present in early subungual melanoma in situ are often too subtle for general dermatopathologists to appreciate, in Dr. Jellinek’s experience. He cited other investigators’ study of 18 cases of subungual melanoma in situ, all marked by longitudinal melanonychia. Only half showed the classic giveaway on the original nail matrix biopsy, consisting of a significantly increased number of atypical melanocytes with marked nuclear atypia. Blatant pagetoid spread was infrequent. However, all 18 cases displayed a novel, more subtle, and previously undescribed finding: haphazard and uneven distribution of atypical solitary melanocytes with variably sized and shaped hyperchromatic nuclei (J Cutan Pathol. 2016 Jan;43[1]:41-52).

Dr. Jellinek reported having no financial conflicts regarding his presentation. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

 

– Many dermatologists find melanonychia to be intimidating. The clinical features are ambiguous, and the prospect of doing a painful nail apparatus biopsy can be daunting for the inexperienced. As a result, the biopsy gets delayed and melanoma of the nail is often initially a missed diagnosis, not uncommonly for years, with devastating consequences.

Bruce Jancin/MDedge News
Dr. Nathaniel Jellinek

Here are five teaching points on melanonychia provided by nail disease expert and Mohs surgeon Nathaniel Jellinek, MD, at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Rule #1: Always look beyond the nail

When a light-skinned person presents with more than one nail with pigmentation, the likelihood that one of them is melanoma is much less than if there is only one nail with melanonychia, according to Dr. Jellinek, a dermatologist in private practice in East Greenwich, R.I.

Also, be sure to look at the skin and mucosa. Consider the medications the patients may be taking: For example, cyclophosphamide (Cytoxan) is notorious for causing nail changes as a side effect. A past medical history of lichen planus, carpal tunnel syndrome, Addison disease, or other conditions may explain the melanonychia.

Nathaniel Jellinek, MD
Melanonychia in Laugier-Hunziker syndrome

Laugier-Hunziker syndrome is a condition worth getting to know. It’s an acquired disorder characterized longitudinal melanonychia and other pigmentary changes, which may include diffuse hyperpigmentation of the orolabial mucosa, ocular pigment, and/or pigmented palmoplantar lesions. It’s said to be rare, but Dr. Jellinek disagrees.

“Learn this one if you don’t know it. I see a case about every 2 weeks. It’s not heritable and not associated with any other medical condition,” he said.

Rule #2: Your dermatoscope is great for nails

What Dr. Jellinek considers to be among the all-time best papers on the value of dermoscopy for nail pigmentation was authored by French investigators. They analyzed 148 consecutive cases of longitudinal melanonychia and concluded that the dermoscopic combination of a brown background coupled with irregular longitudinal lines in terms of color, spacing, diameter, and/or lack of parallelism strongly suggests melanoma. A micro-Hutchinson’s sign, while a rare finding, occurred only in melanoma, where it represented periungual spread of a radial growth phase malignancy (Arch Dermatol. 2002 Oct;138[10]:1327-33).

“I think nail dermoscopy is most helpful for subungual hemorrhage. I average one referral per week for hemorrhage under the nail. On dermoscopy it’s as if someone took paint and threw it at the nail. Purple to brown blood spots, with no background color. This should be a doorway diagnosis of hemorrhage,” Dr. Jellinek said.

Rule #3: Know when you don’t know

“This is really the key for me,” the dermatologist commented. “There are automatic cases for biopsy, and more commonly routine cases for reassurance. But the gray zone, when you know you don’t know, is the key decision making moment.”

When something just doesn’t feel right, there’s absolutely nothing wrong with getting a second opinion, he stressed.

“It’s worthwhile getting to know people whose opinions you trust. There’s a saying I like to teach our fellows: ‘Never worry alone.’ So if you’re worried about someone, listen to that inner voice. There’s no shame in getting a second opinion. It’s great! Patients are never upset, either. They feel really well taken care of,” he said.

 

 

Rule #4: Don’t wimp out when a biopsy is warranted

Many dermatologists hem and haw about doing a biopsy for a concerning lesion on the nail, when they wouldn’t hesitate to biopsy a similarly suspicious lesion on the face.

But it’s essential to biopsy the right area, he added. For longitudinal melanonychia, that’s the matrix. The nail plate is the wrong place; a biopsy obtained there will result in an inappropriate benign diagnosis.

Nathaniel Jellinek, MD
Melanonychia from matrix lentigo

“The starter set is to do a punch biopsy. This is your gateway drug to the world of nail surgery. Lots of dermatologists are intimidated by nail surgery, but if you can do any minor surgery, you can do a punch of the matrix. All it takes is a little practice. And if all you can do is punch biopsies, you’re good for your career. If you can do that, you’re golden. There are people who’ve just done punch biopsies for their whole career and they don’t miss melanomas,” he said.

Step one is to undermine the proximal nail fold using a pediatric elevator, which costs only about $30. “If you’re going to do a lot of nail surgery, they’re really helpful,” he said.



There’s no need at all to evulse the nail. Just make oblique incisions in the proximal nail fold in order to reflect it and look at the matrix. A 3-mm punch is standard, directed right over the origin of the pigment. Resist the temptation to force or squeeze the specimen in order to extract it. Instead, use really fine-tipped scissors to nibble at the base of the specimen, then gently pull it out, making an effort to keep the nail plate attached to the digit and avoid getting it stuck up in the punch.

Rule #5: Have dermatopathologists extensively experienced with nail pathology on your Rolodex

The histopathologic findings present in early subungual melanoma in situ are often too subtle for general dermatopathologists to appreciate, in Dr. Jellinek’s experience. He cited other investigators’ study of 18 cases of subungual melanoma in situ, all marked by longitudinal melanonychia. Only half showed the classic giveaway on the original nail matrix biopsy, consisting of a significantly increased number of atypical melanocytes with marked nuclear atypia. Blatant pagetoid spread was infrequent. However, all 18 cases displayed a novel, more subtle, and previously undescribed finding: haphazard and uneven distribution of atypical solitary melanocytes with variably sized and shaped hyperchromatic nuclei (J Cutan Pathol. 2016 Jan;43[1]:41-52).

Dr. Jellinek reported having no financial conflicts regarding his presentation. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

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Ultrasound offers advantages for long-term lymph node surveillance in high-grade SCC patients

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Fri, 05/10/2019 - 08:55

– Ultrasound can be a very effective way to track early nodal metastasis in patients with high-stage cutaneous squamous cell carcinomas, and at a fraction of the cost of other imaging modalities.

Bogdanhoda/Thinkstock

The technique shows not only abnormal variations in the shape of nodes, but changes in the core and outer density, and vascular patterns, Emily Ruiz, MD, said at the annual meeting of the American College of Mohs Surgery. And over a 2-year surveillance period, this costs thousands less than radiation-based imaging.

Dr. Ruiz, director of the High-Risk Skin Cancer Clinic at Dana-Farber/Brigham and Women’s Cancer Center, Boston, said the standard imaging technique at that center used to be serial CT scans performed at diagnosis and every 6 months thereafter, for 2 years. But recently, the protocol changed: Ultrasound is now the preferred technique.

“The big problem with CT in this earlier disease, is that it can only identify the nodes that are enlarged, and doesn’t tell us anything about the etiology. Ultrasound, on the other hand, looks at a number of different features of the node.”

Tracking high-risk squamous cell carcinoma patients is a must, she said. “About 4% of people diagnosed with high-risk SCC will develop nodal metastases, and 1.5% of those will die from disease-specific death,” most often from locoregional disease. “So it’s critical to identify nodal diseases early as possible. Earlier identification leads to better outcomes.” Ultrasound simply provides more information about nodal metastasis, Dr. Ruiz added.

 

 

“The first thing we look at is the general architecture of the node. Resting and reactive nodes have a hypoechoic hilus and a hyperechoic cortex. As they become infiltrated with tumor, the hilus becomes more hyperechoic, and areas of metastasis stand out as much more hyperechoic than the surrounding node.”

Another tip-off is overall shape. If the ratio of the long axis to short axis diameter is less than 2, the lymph node is more likely to be malignant, she said.

“One more important factor that can’t be seen on CT is the node’s vascular pattern. Both resting and reactive nodes tend to have a centralized vascular pattern in the hilus. With tumor infiltration you start to see an asymmetrical vascularization as the nodes are replaced by tumor. The perfusion becomes much more peripheral.”

Michele G. Sullivan/MDedge News
Dr. Emily Ruiz

Cost is another consideration, Dr. Ruiz said. Five CT scans conducted over the recommended 2 years of follow-up will run about $5,000. Five scans with magnetic resonance imaging come in at about $6,500. PET CT is, of course, the most expensive, racking up a national average cost of $28,500 for five scans.

Ultrasound is amazingly inexpensive, Dr. Ruiz said. The national average cost of one scan is around $180, bringing the 2-year cost of five surveillance scans to $900.

Finally, clinicians and patients should consider the potential impact of repeated radiation exposure. “This can really add up over the follow-up period. Because there’s a 10-year latency period for these cancers, this might not be an issue for our older patients, but it really is something to consider in younger ones. “

However, she acknowledged that it’s not a completely rosy picture.

“Ultrasound is very user dependent, but we do think that by putting this in the hands of dermatologists with special training, we can solve this issue. In Europe, ultrasound’s very high sensitivity and specificity, combined with clinical exams, really improves disease detection.”

Unfortunately, at this point, anyone who wants to learn the technique has to go to Europe. “I trained in Germany, where I took a standard 3-day course, did 250 supervised scans, and completed an exam. I realize that’s unrealistic for most people,” she said. But a training protocol is being developed at Brigham and Women’s, under the auspices of the institution’s imaging experts, who felt that 3 days and 250 supervised scans was excessive. The Brigham and Women’s program comprises 8 hours of didactic training and at least 30 supervised scans with at least three abnormalities correctly identified, and will be put into place soon, Dr. Ruiz said.

The biggest obstacle to large-scale adoption of this protocol is data – there are not a lot, at least now.

“We are working on that, too. In conjunction with the Skin Cancer Foundation, we’re launching a prospective study. We want to recruit 80 patients with T2B/T3 cutaneous SCCs. They get both and ultrasound and a CT scan at diagnosis and every 6 months for 2 years,” she said.

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– Ultrasound can be a very effective way to track early nodal metastasis in patients with high-stage cutaneous squamous cell carcinomas, and at a fraction of the cost of other imaging modalities.

Bogdanhoda/Thinkstock

The technique shows not only abnormal variations in the shape of nodes, but changes in the core and outer density, and vascular patterns, Emily Ruiz, MD, said at the annual meeting of the American College of Mohs Surgery. And over a 2-year surveillance period, this costs thousands less than radiation-based imaging.

Dr. Ruiz, director of the High-Risk Skin Cancer Clinic at Dana-Farber/Brigham and Women’s Cancer Center, Boston, said the standard imaging technique at that center used to be serial CT scans performed at diagnosis and every 6 months thereafter, for 2 years. But recently, the protocol changed: Ultrasound is now the preferred technique.

“The big problem with CT in this earlier disease, is that it can only identify the nodes that are enlarged, and doesn’t tell us anything about the etiology. Ultrasound, on the other hand, looks at a number of different features of the node.”

Tracking high-risk squamous cell carcinoma patients is a must, she said. “About 4% of people diagnosed with high-risk SCC will develop nodal metastases, and 1.5% of those will die from disease-specific death,” most often from locoregional disease. “So it’s critical to identify nodal diseases early as possible. Earlier identification leads to better outcomes.” Ultrasound simply provides more information about nodal metastasis, Dr. Ruiz added.

 

 

“The first thing we look at is the general architecture of the node. Resting and reactive nodes have a hypoechoic hilus and a hyperechoic cortex. As they become infiltrated with tumor, the hilus becomes more hyperechoic, and areas of metastasis stand out as much more hyperechoic than the surrounding node.”

Another tip-off is overall shape. If the ratio of the long axis to short axis diameter is less than 2, the lymph node is more likely to be malignant, she said.

“One more important factor that can’t be seen on CT is the node’s vascular pattern. Both resting and reactive nodes tend to have a centralized vascular pattern in the hilus. With tumor infiltration you start to see an asymmetrical vascularization as the nodes are replaced by tumor. The perfusion becomes much more peripheral.”

Michele G. Sullivan/MDedge News
Dr. Emily Ruiz

Cost is another consideration, Dr. Ruiz said. Five CT scans conducted over the recommended 2 years of follow-up will run about $5,000. Five scans with magnetic resonance imaging come in at about $6,500. PET CT is, of course, the most expensive, racking up a national average cost of $28,500 for five scans.

Ultrasound is amazingly inexpensive, Dr. Ruiz said. The national average cost of one scan is around $180, bringing the 2-year cost of five surveillance scans to $900.

Finally, clinicians and patients should consider the potential impact of repeated radiation exposure. “This can really add up over the follow-up period. Because there’s a 10-year latency period for these cancers, this might not be an issue for our older patients, but it really is something to consider in younger ones. “

However, she acknowledged that it’s not a completely rosy picture.

“Ultrasound is very user dependent, but we do think that by putting this in the hands of dermatologists with special training, we can solve this issue. In Europe, ultrasound’s very high sensitivity and specificity, combined with clinical exams, really improves disease detection.”

Unfortunately, at this point, anyone who wants to learn the technique has to go to Europe. “I trained in Germany, where I took a standard 3-day course, did 250 supervised scans, and completed an exam. I realize that’s unrealistic for most people,” she said. But a training protocol is being developed at Brigham and Women’s, under the auspices of the institution’s imaging experts, who felt that 3 days and 250 supervised scans was excessive. The Brigham and Women’s program comprises 8 hours of didactic training and at least 30 supervised scans with at least three abnormalities correctly identified, and will be put into place soon, Dr. Ruiz said.

The biggest obstacle to large-scale adoption of this protocol is data – there are not a lot, at least now.

“We are working on that, too. In conjunction with the Skin Cancer Foundation, we’re launching a prospective study. We want to recruit 80 patients with T2B/T3 cutaneous SCCs. They get both and ultrasound and a CT scan at diagnosis and every 6 months for 2 years,” she said.

– Ultrasound can be a very effective way to track early nodal metastasis in patients with high-stage cutaneous squamous cell carcinomas, and at a fraction of the cost of other imaging modalities.

Bogdanhoda/Thinkstock

The technique shows not only abnormal variations in the shape of nodes, but changes in the core and outer density, and vascular patterns, Emily Ruiz, MD, said at the annual meeting of the American College of Mohs Surgery. And over a 2-year surveillance period, this costs thousands less than radiation-based imaging.

Dr. Ruiz, director of the High-Risk Skin Cancer Clinic at Dana-Farber/Brigham and Women’s Cancer Center, Boston, said the standard imaging technique at that center used to be serial CT scans performed at diagnosis and every 6 months thereafter, for 2 years. But recently, the protocol changed: Ultrasound is now the preferred technique.

“The big problem with CT in this earlier disease, is that it can only identify the nodes that are enlarged, and doesn’t tell us anything about the etiology. Ultrasound, on the other hand, looks at a number of different features of the node.”

Tracking high-risk squamous cell carcinoma patients is a must, she said. “About 4% of people diagnosed with high-risk SCC will develop nodal metastases, and 1.5% of those will die from disease-specific death,” most often from locoregional disease. “So it’s critical to identify nodal diseases early as possible. Earlier identification leads to better outcomes.” Ultrasound simply provides more information about nodal metastasis, Dr. Ruiz added.

 

 

“The first thing we look at is the general architecture of the node. Resting and reactive nodes have a hypoechoic hilus and a hyperechoic cortex. As they become infiltrated with tumor, the hilus becomes more hyperechoic, and areas of metastasis stand out as much more hyperechoic than the surrounding node.”

Another tip-off is overall shape. If the ratio of the long axis to short axis diameter is less than 2, the lymph node is more likely to be malignant, she said.

“One more important factor that can’t be seen on CT is the node’s vascular pattern. Both resting and reactive nodes tend to have a centralized vascular pattern in the hilus. With tumor infiltration you start to see an asymmetrical vascularization as the nodes are replaced by tumor. The perfusion becomes much more peripheral.”

Michele G. Sullivan/MDedge News
Dr. Emily Ruiz

Cost is another consideration, Dr. Ruiz said. Five CT scans conducted over the recommended 2 years of follow-up will run about $5,000. Five scans with magnetic resonance imaging come in at about $6,500. PET CT is, of course, the most expensive, racking up a national average cost of $28,500 for five scans.

Ultrasound is amazingly inexpensive, Dr. Ruiz said. The national average cost of one scan is around $180, bringing the 2-year cost of five surveillance scans to $900.

Finally, clinicians and patients should consider the potential impact of repeated radiation exposure. “This can really add up over the follow-up period. Because there’s a 10-year latency period for these cancers, this might not be an issue for our older patients, but it really is something to consider in younger ones. “

However, she acknowledged that it’s not a completely rosy picture.

“Ultrasound is very user dependent, but we do think that by putting this in the hands of dermatologists with special training, we can solve this issue. In Europe, ultrasound’s very high sensitivity and specificity, combined with clinical exams, really improves disease detection.”

Unfortunately, at this point, anyone who wants to learn the technique has to go to Europe. “I trained in Germany, where I took a standard 3-day course, did 250 supervised scans, and completed an exam. I realize that’s unrealistic for most people,” she said. But a training protocol is being developed at Brigham and Women’s, under the auspices of the institution’s imaging experts, who felt that 3 days and 250 supervised scans was excessive. The Brigham and Women’s program comprises 8 hours of didactic training and at least 30 supervised scans with at least three abnormalities correctly identified, and will be put into place soon, Dr. Ruiz said.

The biggest obstacle to large-scale adoption of this protocol is data – there are not a lot, at least now.

“We are working on that, too. In conjunction with the Skin Cancer Foundation, we’re launching a prospective study. We want to recruit 80 patients with T2B/T3 cutaneous SCCs. They get both and ultrasound and a CT scan at diagnosis and every 6 months for 2 years,” she said.

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Study finds increase in dermatologic prescriptions for postsurgical antibiotics

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Fri, 04/26/2019 - 09:47

The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

SOURCE: AAD 2019, Abstract 11356.

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The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

SOURCE: AAD 2019, Abstract 11356.

The prescription of oral antibiotics after benign excisions, malignant excisions, and Mohs surgery has increased over the past decade, according to an analysis presented at the annual meeting of the American Academy of Dermatology.

John Barbieri, MD, a dermatologist and postdoctoral research fellow at the University of Pennsylvania, Philadelphia, who presented the results, and colleagues examined data about antibiotic use in dermatology between 2008 and 2016. Overall, antibiotic use decreased during this period, primarily for chronic conditions such as acne and rosacea. On the other hand, antibiotic use associated with surgical visits increased by approximately 70%.

Using data from 2008 to 2016 in the Optum Clinformatics DataMart deidentified commercial claims database, the researchers performed a repeated cross-sectional analysis of oral antibiotic prescriptions associated with encounters for surgical procedures performed by dermatologists. They found that oral antibiotic prescriptions increased from 2.9% to 4.4% of visits for benign excisions, from 4.2% to 6.3% of visits for malignant excisions, and from 9.9% to 13.8% of visits for Mohs procedures during this time period. Oral antibiotic prescribing was more common for procedures that entailed a flap or graft and among patients with diabetes, female patients, and younger patients.


The investigators observed greater than twofold variation in antibiotic-prescribing rates across geographic census divisions. “If higher-prescribing divisions were to develop antibiotic prescribing rates similar to [those of] lower-prescribing divisions, antibiotic use could be decreased by over 50%,” Dr. Barbieri said. Before prescribing antibiotic prophylaxis, dermatologists should consider which patients benefit most from it, he added.

The investigators also examined the duration of antibiotic courses. The median course duration of postoperative antibiotics was 7 days. Randomized, controlled trials that collectively included more than 600 patients have failed to demonstrate a benefit of long postoperative courses of antibiotics, compared with perioperative antibiotics alone, said Dr. Barbieri. “While it may be hard to have true perioperative antibiotics available in a dermatology surgical clinic, there likely are opportunities to reduce these postoperative courses to a day or 3 days from this mean of 7 days that we observed in the study.” Reducing these courses would decrease the risk of antibiotic-associated complications such as nausea, diarrhea, and skin rashes, he added.

SOURCE: AAD 2019, Abstract 11356.

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International registry of laser surgery outcomes in the works

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– Researchers in the early stages of developing an international registry of outcomes in the field of laser surgery have found a lack of uniformity in outcome reporting from existing studies in the medical literature. They’ve also observed insufficient reporting of outcome definitions and under-representation of life impact domains.

“Today, laser therapy is not only an important treatment modality for cosmetic indications, but also for medical skin disorders and diseases,” lead study author Frederike Fransen said at the annual conference of the American Society for Laser Medicine and Surgery. “These disorders include inflammatory lesions, vascular and pigmented lesions, tumors, and scars. Although there are a lot of options for laser therapy, the evidence for most of these skin conditions is quite low, consisting mostly of case reports and case series. However, if we want more evidence-based practice, we need more practice-based evidence.”

A new effort to gain insight into safety and effectiveness of laser treatments known as the international Laser Treatment Dermatology Registry (LEAD) is a platform to address this challenge. “We envision a registry that connects expertise and experience of a large international team of laser specialists, clinicians, and researchers,” said Ms. Fransen, a PhD candidate in the department of dermatology at Amsterdam University Medical Center. “Our goal is to gain insight into safety and effectiveness of laser treatments.” The collaboration includes researchers from the Netherlands, Denmark, France, Germany, Italy, and Switzerland, and the team will be complemented by experts from the United States, Asia, and North Africa.


For the first phase of the endeavor, Ms. Fransen and Albert Wolkerstorfer, MD, PhD, of the University of Amsterdam worked with colleagues from the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN) to develop a consensus of outcomes to be included in the registry. This involved a literature review of 350 articles to explore the outcomes used in laser research. From these, the researchers identified 100 articles for outcome mapping: 25 randomized, controlled trials, 44 trials that were not randomized or controlled, and 31 case reports. Their review yielded 98 outcomes and 53 outcome instruments.

Ultimately, outcomes were assigned to eight domains, Ms. Fransen said: appearance, long-term effects, physician-reported physical signs, patient-reported physical signs, satisfaction, health-related quality of life, psychological functioning, and adverse events. Of these domains, the most commonly used in existing medical literature were appearance such as clinical improvement and clearance (81%), followed by adverse effects such as erythema and scarring (55%), physician-reported signs such as morphology (30%), and long-term effects such as recurrence (27%). Ms. Fransen and Dr. Wolkerstorfer observed under-representation of patient-centered outcomes, including satisfaction of appearance or treatment (29%), patient-reported physical signs such as overall state and severity of disease (12%), health-related quality of life (4%), and psychological functioning such as anxiety and depression (1%).

The analysis also revealed that different outcomes measures were used in the various studies, and inconstant definitions within scaling systems. For example, for clearance of lesions/no clearance of lesions, some studies defined excellent clearance as 75% or greater, and others defined marked clearance as 70% or greater. In addition, some studies that used percentage quintile grading as an outcome defined grade 5 as a greater than 95% improvement, while others defined grade 5 as “clear,” or a greater than 90% improvement.

The next step in developing the LEAD registry involves performing an international e-Delphi survey, a method to obtain agreement on outcomes for the registry among health care professionals and patients with different opinions and backgrounds. “The process ends when sufficient agreement is obtained,” Ms. Fransen said. “Looking at future steps, the development of this collaborative initiative with a minimum set of outcomes is essential. When establishing this registry we can achieve sufficient sample size and confirmatory cases toward stronger evidence of laser treatments for orphan diseases.”

The project was supported by the European Academy of Dermatology and Venereology and by an educational grant from ASLMS.

[email protected]

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– Researchers in the early stages of developing an international registry of outcomes in the field of laser surgery have found a lack of uniformity in outcome reporting from existing studies in the medical literature. They’ve also observed insufficient reporting of outcome definitions and under-representation of life impact domains.

“Today, laser therapy is not only an important treatment modality for cosmetic indications, but also for medical skin disorders and diseases,” lead study author Frederike Fransen said at the annual conference of the American Society for Laser Medicine and Surgery. “These disorders include inflammatory lesions, vascular and pigmented lesions, tumors, and scars. Although there are a lot of options for laser therapy, the evidence for most of these skin conditions is quite low, consisting mostly of case reports and case series. However, if we want more evidence-based practice, we need more practice-based evidence.”

A new effort to gain insight into safety and effectiveness of laser treatments known as the international Laser Treatment Dermatology Registry (LEAD) is a platform to address this challenge. “We envision a registry that connects expertise and experience of a large international team of laser specialists, clinicians, and researchers,” said Ms. Fransen, a PhD candidate in the department of dermatology at Amsterdam University Medical Center. “Our goal is to gain insight into safety and effectiveness of laser treatments.” The collaboration includes researchers from the Netherlands, Denmark, France, Germany, Italy, and Switzerland, and the team will be complemented by experts from the United States, Asia, and North Africa.


For the first phase of the endeavor, Ms. Fransen and Albert Wolkerstorfer, MD, PhD, of the University of Amsterdam worked with colleagues from the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN) to develop a consensus of outcomes to be included in the registry. This involved a literature review of 350 articles to explore the outcomes used in laser research. From these, the researchers identified 100 articles for outcome mapping: 25 randomized, controlled trials, 44 trials that were not randomized or controlled, and 31 case reports. Their review yielded 98 outcomes and 53 outcome instruments.

Ultimately, outcomes were assigned to eight domains, Ms. Fransen said: appearance, long-term effects, physician-reported physical signs, patient-reported physical signs, satisfaction, health-related quality of life, psychological functioning, and adverse events. Of these domains, the most commonly used in existing medical literature were appearance such as clinical improvement and clearance (81%), followed by adverse effects such as erythema and scarring (55%), physician-reported signs such as morphology (30%), and long-term effects such as recurrence (27%). Ms. Fransen and Dr. Wolkerstorfer observed under-representation of patient-centered outcomes, including satisfaction of appearance or treatment (29%), patient-reported physical signs such as overall state and severity of disease (12%), health-related quality of life (4%), and psychological functioning such as anxiety and depression (1%).

The analysis also revealed that different outcomes measures were used in the various studies, and inconstant definitions within scaling systems. For example, for clearance of lesions/no clearance of lesions, some studies defined excellent clearance as 75% or greater, and others defined marked clearance as 70% or greater. In addition, some studies that used percentage quintile grading as an outcome defined grade 5 as a greater than 95% improvement, while others defined grade 5 as “clear,” or a greater than 90% improvement.

The next step in developing the LEAD registry involves performing an international e-Delphi survey, a method to obtain agreement on outcomes for the registry among health care professionals and patients with different opinions and backgrounds. “The process ends when sufficient agreement is obtained,” Ms. Fransen said. “Looking at future steps, the development of this collaborative initiative with a minimum set of outcomes is essential. When establishing this registry we can achieve sufficient sample size and confirmatory cases toward stronger evidence of laser treatments for orphan diseases.”

The project was supported by the European Academy of Dermatology and Venereology and by an educational grant from ASLMS.

[email protected]

– Researchers in the early stages of developing an international registry of outcomes in the field of laser surgery have found a lack of uniformity in outcome reporting from existing studies in the medical literature. They’ve also observed insufficient reporting of outcome definitions and under-representation of life impact domains.

“Today, laser therapy is not only an important treatment modality for cosmetic indications, but also for medical skin disorders and diseases,” lead study author Frederike Fransen said at the annual conference of the American Society for Laser Medicine and Surgery. “These disorders include inflammatory lesions, vascular and pigmented lesions, tumors, and scars. Although there are a lot of options for laser therapy, the evidence for most of these skin conditions is quite low, consisting mostly of case reports and case series. However, if we want more evidence-based practice, we need more practice-based evidence.”

A new effort to gain insight into safety and effectiveness of laser treatments known as the international Laser Treatment Dermatology Registry (LEAD) is a platform to address this challenge. “We envision a registry that connects expertise and experience of a large international team of laser specialists, clinicians, and researchers,” said Ms. Fransen, a PhD candidate in the department of dermatology at Amsterdam University Medical Center. “Our goal is to gain insight into safety and effectiveness of laser treatments.” The collaboration includes researchers from the Netherlands, Denmark, France, Germany, Italy, and Switzerland, and the team will be complemented by experts from the United States, Asia, and North Africa.


For the first phase of the endeavor, Ms. Fransen and Albert Wolkerstorfer, MD, PhD, of the University of Amsterdam worked with colleagues from the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN) to develop a consensus of outcomes to be included in the registry. This involved a literature review of 350 articles to explore the outcomes used in laser research. From these, the researchers identified 100 articles for outcome mapping: 25 randomized, controlled trials, 44 trials that were not randomized or controlled, and 31 case reports. Their review yielded 98 outcomes and 53 outcome instruments.

Ultimately, outcomes were assigned to eight domains, Ms. Fransen said: appearance, long-term effects, physician-reported physical signs, patient-reported physical signs, satisfaction, health-related quality of life, psychological functioning, and adverse events. Of these domains, the most commonly used in existing medical literature were appearance such as clinical improvement and clearance (81%), followed by adverse effects such as erythema and scarring (55%), physician-reported signs such as morphology (30%), and long-term effects such as recurrence (27%). Ms. Fransen and Dr. Wolkerstorfer observed under-representation of patient-centered outcomes, including satisfaction of appearance or treatment (29%), patient-reported physical signs such as overall state and severity of disease (12%), health-related quality of life (4%), and psychological functioning such as anxiety and depression (1%).

The analysis also revealed that different outcomes measures were used in the various studies, and inconstant definitions within scaling systems. For example, for clearance of lesions/no clearance of lesions, some studies defined excellent clearance as 75% or greater, and others defined marked clearance as 70% or greater. In addition, some studies that used percentage quintile grading as an outcome defined grade 5 as a greater than 95% improvement, while others defined grade 5 as “clear,” or a greater than 90% improvement.

The next step in developing the LEAD registry involves performing an international e-Delphi survey, a method to obtain agreement on outcomes for the registry among health care professionals and patients with different opinions and backgrounds. “The process ends when sufficient agreement is obtained,” Ms. Fransen said. “Looking at future steps, the development of this collaborative initiative with a minimum set of outcomes is essential. When establishing this registry we can achieve sufficient sample size and confirmatory cases toward stronger evidence of laser treatments for orphan diseases.”

The project was supported by the European Academy of Dermatology and Venereology and by an educational grant from ASLMS.

[email protected]

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Consider 9-mm surgical margins for MIS

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– The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News
Dr. Christopher B. Zachary

“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).


Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).

In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).

Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).

Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.

“That had been my practice as well until quite recently,” he said.

Dr. Zachary reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

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– The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News
Dr. Christopher B. Zachary

“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).


Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).

In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).

Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).

Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.

“That had been my practice as well until quite recently,” he said.

Dr. Zachary reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

– The widely utilized 5-mm surgical margins for excision of melanoma in situ are inadequate in many cases, Christopher B. Zachary, MD, said at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

Bruce Jancin/MDedge News
Dr. Christopher B. Zachary

“You probably should be considering more like 9- or 10-mm margins for melanoma in situ,” advised Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

This has been a controversial matter. The recommendation for the long-standard 5-mm margins for excision of melanoma in situ (MIS) date back to a 1992 consensus opinion. Since then, however, persuasive data have emerged showing that 5-mm margins are often inadequate for clearance, and the latest American Academy of Dermatology guidelines for the management of primary cutaneous melanoma recommend margins of 5-10 mm (J Am Acad Dermatol. 2019 Jan;80[1]:208-50).


Dr. Zachary’s advice to go on the high side of that 5- to 10-mm zone is based in large part on studies led by John A Zitelli, MD, of the University of Pittsburgh. More than 20 years ago, Dr. Zitelli and his coinvestigators published a provocative prospective series of 535 patients whose melanomas – in situ or invasive – were excised via Mohs micrographic surgery with frozen section examination of the margins. A 9-mm margin successfully removed 95% of the melanomas, a 12-mm margin removed 97%, and a 6-mm margin successfully excised only 83% of the lesions (J Am Acad Dermatol. 1997 Sep;37(3 Pt 1):422-9).

In a follow-up study, Dr. Zitelli and his colleagues reported on a prospective series of 1,072 patients with 1,120 MIS, all excised by Mohs micrographic surgery with frozen sections (J Am Acad Dermatol. 2012 Mar;66[3]:438-44). They determined that 86% of the MIS were completely cleared using a 6-mm margin, compared with 98.9% excised with a 9 mm margin, a statistically significant difference (P less than .001).

Support for Dr. Zitelli’s stance that 5-mm margins for MIS are inadequate was provided by dermatologic surgeons at the Mayo Clinic in Scottsdale, Ariz. Of 46 patients who underwent Mohs micrographic surgery with immunostaining for excision of MIS, margins of 6 mm achieved clearance in only half of them. Surgical excision margins of 15 mm were required to successfully clear 96% of the MIS (Dermatol Surg. 2000 Aug;26[8]:771-84).

Quite a few hands shot up when Dr. Zachary asked how many members of his audience utilize 5-mm margins for surgical excision of MIS.

“That had been my practice as well until quite recently,” he said.

Dr. Zachary reported having no financial conflicts of interest regarding his presentation.

SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

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REPORTING FROM SDEF HAWAII DERMATOLOGY SEMINAR

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The 39th ASLMS meeting is now underway

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– At the annual meeting of the American Academy of Dermatology, the current and past presidents of the American Society for Laser Medicine and Surgery (ASLMS) sat down to discuss the Society’s annual meeting, taking place March 27-31, 2019, in Denver.

Vidyard Video

“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”

Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.

MDedge reporter Doug Brunk will be reporting from the meeting.

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– At the annual meeting of the American Academy of Dermatology, the current and past presidents of the American Society for Laser Medicine and Surgery (ASLMS) sat down to discuss the Society’s annual meeting, taking place March 27-31, 2019, in Denver.

Vidyard Video

“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”

Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.

MDedge reporter Doug Brunk will be reporting from the meeting.

 

– At the annual meeting of the American Academy of Dermatology, the current and past presidents of the American Society for Laser Medicine and Surgery (ASLMS) sat down to discuss the Society’s annual meeting, taking place March 27-31, 2019, in Denver.

Vidyard Video

“ASLMS is always an amazing meeting, and it’s a unique meeting,” said past president Mathew Avram, MD, director of the Dermatology Laser & Cosmetic Center at Massachusetts General Hospital, Boston. “At its core, it’s a scientific meeting ... you can take things back to your practice that change the practice of medicine.”

Current ASLMS president Eric Bernstein, MD, of Main Line Center for Laser Surgery, Ardmore, Pa., pointed out that, in addition to doctors and other health care practitioners, other available and accessible attendees include the engineers who build the lasers. And this year, injectables are being incorporated into the program.

MDedge reporter Doug Brunk will be reporting from the meeting.

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FDA panel calls for changes to breast implant rupture screening

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A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.

Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.



The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.

The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.

The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.

Mitchel L. Zoler/MDedge News
Dr. Frank R. Lewis Jr.

The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.

“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.

The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.

Mitchel L. Zoler/MDedge News
Dr. Karen E. Burke
The panel gave FDA staffers several suggestions on how to improve informed consent, as well as how to get word out to the general public that breast implants pose risks that merit serious consideration from prospective patients.

After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”

Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.



A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.

Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.

Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.

Dr. Binita Ashar

The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.

Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.

A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.

About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.

Mitchel L. Zoler/MDedge News
Dr. Pierre M. Chevray

Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.

“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.

 

 

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A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.

Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.



The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.

The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.

The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.

Mitchel L. Zoler/MDedge News
Dr. Frank R. Lewis Jr.

The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.

“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.

The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.

Mitchel L. Zoler/MDedge News
Dr. Karen E. Burke
The panel gave FDA staffers several suggestions on how to improve informed consent, as well as how to get word out to the general public that breast implants pose risks that merit serious consideration from prospective patients.

After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”

Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.



A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.

Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.

Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.

Dr. Binita Ashar

The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.

Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.

A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.

About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.

Mitchel L. Zoler/MDedge News
Dr. Pierre M. Chevray

Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.

“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.

 

 

A Food and Drug Administration advisory panel urged the agency to switch its recommended screening method for silent breast implant ruptures from MRI to ultrasound and to push the first screening examination back from the current 3 years post implant to 5 years.

Members of the FDA’s General and Plastic Surgery Advisory Panel also made suggestions to the FDA regarding how it might improve communication about the risks of breast implants to the public in general and to people considering implants in particular.



The panel also discussed the sort of safety and efficacy assessments the FDA should require for acellular dermal matrix (ADM), also known as mesh, to add the material’s label for use during breast reconstruction or implant augmentation. Surgeons have used mesh routinely as a surgical aid at other body sites, such as the abdomen. Although ADM is now also widely used during breast surgery, it has never undergone testing or labeling for use in that setting.

The FDA convened the advisory committee meeting largely to assess and discuss data and concerns about two recently appreciated complications of breast implant placement – breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) and a still poorly defined and described constellation of autoimmune and rheumatoid-like symptoms reported anecdotally by some breast implant recipients called Breast Implant Illness (BII). But agency officials asked the panel to also address these other issues related to the safety of breast implants and implant surgery.

The revised screening recommendations were primarily a response to a lack of compliance with current FDA recommendations to screen for breast implant rupture with MRI starting 3 years after placement and then every 2 years.

Mitchel L. Zoler/MDedge News
Dr. Frank R. Lewis Jr.

The problem is that a screening MRI costs about $1,500-$2,000 and is generally not covered by insurance when done for this purpose, although it is often covered when used to investigate a suspected rupture. The result is that less than 5% of implanted patients comply with the recommended screening schedule, noted committee chair Frank R. Lewis Jr., MD, executive director, emeritus, of the American Board of Surgery in Philadelphia.

“Effectively it’s a useless recommendation,” he said. “Ultrasound is far easier, quicker, and cheaper” and seems effective for screening.

The advisory panel recommended starting ultrasound screening 5 years after implantation, based on MRI screening data showing that virtually all ruptures don’t occur until after 5 years, and then following with ultrasound screening every 3 years after that. The panel recommended using MRI when the ultrasound result is equivocal or when the patient has symptoms suggesting rupture.

Mitchel L. Zoler/MDedge News
Dr. Karen E. Burke
The panel gave FDA staffers several suggestions on how to improve informed consent, as well as how to get word out to the general public that breast implants pose risks that merit serious consideration from prospective patients.

After hearing testimony during the sessions from several dozen women who told horror stories of the complications they experienced from breast implants, panel member Karen E. Burke, MD, PhD, spoke for many on the panel when she said “no doubt patients feel that the informed consent process failed them, that they were not aware of the risks.”

Dr. Burke suggested that patients must be informed so that they realize that breast implants are not static objects that will always sit unchanged in their body for the rest of their lives, that certain factors such as allergy or family history of tissue disease might predispose them to autoimmune-type reactions and that the diverse symptoms described for BII are possible sequelae.



A black box warning for the potential of developing anaplastic large-cell lymphoma should also go into the label, said Dr. Burke, a dermatologist who practices in New York City.

Dr. Lewis ridiculed the information booklets that implant manufacturers currently provide for patients as too long and dense. “They were not constructed to inform patients in the best way; they were constructed to provide legal protection.” He called for creating a two- or three-page list of potential adverse effects and points to consider.

Other panel members suggested public service advertisements similar to what is used to inform consumers about the risk from cigarettes. Dr. Burke recommended getting the word out about BII to other medical specialties that are more likely to see affected patients first, such as rheumatologists, immunologists, and dermatologists. She vowed to speak about these complications at an upcoming meeting of the American Academy of Dermatology. But other panel members noted that BII right now remains without any official medical definition nor clear causal link to breast implants.

Dr. Binita Ashar

The question of exactly what safety and efficacy data the FDA might require from manufacturers seeking a breast surgery indication for ADM was less clear.

Binita Ashar, MD, director of the FDA’s Division of Surgical Devices, highlighted the agency’s dilemma about considering data for a breast surgery indication. “The challenge for us is that we can’t expect a control arm because everyone today is using” mesh, she explained. “We’re looking for guidance on how to understand the risk-to-benefit profile” of ADM.

A plastic surgeon on the advisory panel, Pierre M. Chevray, MD, PhD, from Houston Methodist Hospital summarized the way ADM mesh reached its current niche in routine, U.S. breast surgery.

About 20 years ago, plastic surgeons began using mesh during implant surgery to improve eventual breast cosmesis. Surgeons began to wrap the implant in mesh and then attached the mesh to the pectoral muscle so that the implant could go on top of the muscle and not beneath it. It greatly diminished capsular contraction around the implant over time, reduced the risk for implant movement, and allowed for more natural positioning of the breast with the implant inside, he said.

Mitchel L. Zoler/MDedge News
Dr. Pierre M. Chevray

Another factor in the growing use of mesh was heavy promotion by manufacturers to a generation of plastic surgeons, Dr. Chevray said. But use of ADM may also lead to a slightly increased rate of seromas and infections.

“The benefit from mesh is hard to prove and is questionable” because it largely depends on a subjective assessment by a surgeon or patient, Dr. Chevray said. “The cost [of ADM] is substantial, but no data have shown that outcomes are better” with its use. Despite that, “nearly every surgeon uses mesh” these days, he noted.

 

 

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