Kai Munte

Maasstad hospital and ErasmusMC

Rotterdam, the Netherlands

No conflict of interest

What is really new

•  Difficult to search!

•  Oncology?

•  Cosmetic?

•  Reconstruction?

•  Proceedings?

Onkologisch

•  Viel passiert vor allem in der Behandlung des Melanoms

•  Chirurgisch wenig Veränderungen

•  Micrografische chirurgie auch für andere Tumoren, außer

Basalzellkarzinom und Plattenepithelzellkarzinom?

•  Wie ist die Situation in der Schweiz?

New ideas

Prassinos A1, Glusac E2, Leffell DJ3.

Melanoma in situ: Don't make the cure worse than the disease.

J Am Acad Dermatol. 2020 May 6. pii: S0190-9622(20)30825-2. doi:

10.1016/j.jaad.2020.04.168. [Epub ahead of print]

In the 2019 guidelines of care, the AAD recommended surgical margins of

0.5-1 cm for MIS [1]. They also remark that margins greater than 0.5 cm

may be necessary for MIS, lentigo maligna type. The National

Comprehensive Cancer Network and, recently, Kunishige et al. have also

recommended margins

approaching 1 cm, similar to that for invasive melanoma [2].

Recommendations for wider margins result from the tendency for

recurrence in facial MIS

Considerations

•  Micrographic controlled surgery as solution? Difficult to define healthy

skin from lentigo maligna, but MART 1 staining can help (ShinTM)

•  The authors plea for after treatment with imiquimod (In one study 95% of

patients with margin-positive MIS cleared with imiquimod)

•  Problem in the mean follow up of two years

•  How is the treatment in Switzerland ?

New Insights proceedings

Kofler L1, Kofler K2, Schulz C1, Breuninger H1, Häfner HM1.

Sentinel lymph node biopsy for high-thickness cutaneous squamous

cell carcinoma. Arch Dermatol Res. 2020 May 8. doi: 10.1007/

s00403-020-02082-1. [Epub ahead of print]

Analysis

•  720 patients with high-risk squamous cell carcinoma

•  150 patients agreed to SLNB Evetually in 101 patients, a sentinel lymph

node was successfully marked and extirpated

•  570 patients did not undergo histologic confirmation of lymph node

status and were included directly in follow-up.

•  Lymph node metastasis SLNB group (11.9%) and the observation group

(11.4%)

Considerations

•  Tumor-specific death was observed in 7.14% of the patients in the SLNB

group and 4.74% in the observation group

Inventive lower eyelid reconstruction

Chao yue1, MD, Meng Ying Duan1, MD, Ye Qin Dai1, MD, Jian Zhong

Peng1, MD Transforming the Lower Eyelid Longitudinal Incision Direction

to Conceal the Closure 2 Line: Longitudinal Incision Horizontal Closure.

J Am Acad Dermatol. 2020 Apr 29. pii: S0190-9622(20)30751-9. doi:

10.1016/j.jaad

Statement

Repairing the resulting wedge defect (Fig. 1A) using primary closure or

local flap reconstruction inevitably results in a longitudinal wound closure

line perpendicular to the lower eyelid margin and poor cosmetic results

Naevus resection of the lower eyelid

Procedure

Cosmetic result

Considerations

•  Excellent result, but two questions

•  Is the result of a primary closure really bad?

•  And was an excision as deep as this nessesary?

Pain during Mohs surgery

van Loo E1, Westerveld G2, Nelemans PJ3, Kelleners-Smeets NWJ4. Pain

in dermatologic surgery: a prospective quantitative study.

J Am Acad Dermatol. 2020 May 11. pii: S0190-9622(20)30847-1. doi:

10.1016/j.jaad.2020.05.019. [Epub ahead of print]

During Mohs surgery

•  Like college Hafner always postulates use bicarbonaat!!!!!

•  The used also bubivacain during the session

•  199 Patients were included, 163 (81.9%) with one and 36 (18.1%) with

more than one surgical 60 site

•  Patients rated their pain using the pain intensity

numeric rating scale (PI-NRS)- 11 (‘0’ indicating

no pain and ‘10’ the worst pain imaginable).

Data

•  In total, 169 of 199 (84.9%) patients reported pain (PI-NRS ≥1) during

injection of local anaesthetics, with the majority of scores on the lower

end of the spectrum (Table I). 27 Of 199 (13.6%) reported severe pain

(PI-NRS ≥6).

•  During surgery, 77 of 199 patients (38.7%) reported pain (PI-NRS ≥1)

with predominantly low scores of 1 or 2. Severe pain was reported by

8.5%

•  The risk of severe intraoperative pain was significantly increased in

patients with high pain expectation

Considerations

In conclusion, most patients report only minor pain during dermatologic

surgery under local anaesthesia. A small group experiences severe

intraoperative pain. Awareness of risk factors for severe pain helps

improving pain management and selection of candidates for pain-reducing

interventions. High-risk patients might benefit from conscious sedation

(limited to hospital setting) or oral anxiolytics.

Kosmetisch

•  Deutlich älter aber wichtig > Liposuktion der Brust anstatt Operation

•  Pionier Loek Habbema plant erneute Publikation dieses Jahr

Dermatologic Surgery 2009;35:41-52

Key messages

•  Local anesthesia

•  No visible scars

•  Reduction of volume average 50%

•  No change is shape, i.e:

–  Contraction in mid-axis

–  Extreme high patient satisfaction with adequate patient selection

Slow infiltration of TLA

Age: 25

Age: 77

lift

GENERAL DATA AND VOLUME REDUCTION in 250 patients

Age (years)

Breast Volume (mL) per breast

Supranatant Fat (mL) per breast

TLA used

(mL) per breast

% of Breast Volume

Removed

Average 46 1010 552 1890 54

Range 17-77 175-4000 80-2200 350-4700

24-87

“PTOSIS” reduction

Preoperative (151 patients)

After 6 weeks (151 patients)

After 4 months (133 patients)

Average (cm) 6.5 3.6 3.5

Range (cm) 0.8-13 0-8.5 0-8.5

Proceeding > Just want to mention

•  Although publication was back in 2016

•  We must step up from the paper sheet

Conventional Mohs’ surgery

•  Comparing the wound with a paper sheet

–  US: same scale drawing of the wound

–  The Netherlands: drawings on pre-printed forms

Example digital Mohs file

Digital Mohs file

•  Will help to make micrographic surgery more popular

•  We will integrate this Mohs file directly into a digital health care file

Example basal cell carcinoma

At this moment

•  Already an integration in one digital health care file

•  Still busy with Chipsoft® (NL)

•  Photos in the future with mobile phone

•  Bluetooth integration

•  Possible as Google app