kai munte maasstad hospital and erasmusmc rotterdam, the ...€¦ · kai munte maasstad hospital...
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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