Evolution of Excisional Surgery Practices for Melanoma in the United States.

Importance: National Comprehensive Cancer Network guidelines for melanoma have consistently recommended wide local excision as the standard of care since their inception. Although surgery with more comprehensive margin assessment (eg, Mohs surgery) has been advocated for certain subsets of melanoma, how often these techniques are used in clinical practice is uncertain.

Objective: To examine trends in the use of comprehensive margin assessment surgery for melanoma by tracking claims data for Mohs surgery.

Crescentic Modification to Island Pedicle Rotation Flaps for Defects of the Distal Nose.

Background: Island pedicle flaps based on a lateral sling of the nasalis have difficulty reaching distal nasal defects due to tethering of the muscle to its insertion point. The authors hypothesized that reach could be improved by modifying a crescentic flap to rotate around a pivot point equidistant to the flap and the defect.

Objective: To describe the design, execution, and results with a modified crescentic island pedicle rotation flap for repair of distal nasal defects after Mohs micrographic surgery.

The rule of 10s versus the rule of 2s: High complication rates after conventional excision with postoperative margin assessment of specialty site versus trunk and proximal extremity melanomas.

Specialty site melanomas on the head and neck, hands and feet, genitalia, and pretibial leg have higher rates of surgical complications after conventional excision with postoperative margin assessment (CE-POMA) compared with trunk and proximal extremity melanomas. The rule of 10s describes complication rates after CE-POMA of specialty site melanomas: ∼10% risk for upstaging, ∼10% risk for positive excision margins, ∼10% risk for local recurrence, and ∼10-fold increased likelihood of reconstruction with a flap or graft. Trunk and proximal extremity melanomas encounter these complications at a lower rate, according to the rule of 2s.