Question Mohs closure question

ckerley

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Any help would be appreciated.!. My surgeon refers to the closure as star wedge, but I'm not finding any reference to that. I'm sort of thinking just a complex closure, but possibly a rearrangement instead?
Thanks in advance!

Mohs Operative Note

Mohs Case Number: 22-273
Date of Previous Biopsy: 12/16/21
Previous Accession: S21-054865
Biopsy Photograph Reviewed: Yes

Location: left inferior helix
Preop Diagnosis: Basal Cell Carcinoma
Postop Diagnosis: Basal Cell Carcinoma
Mohs AUC Score: 9 (Appropriate - Diagnosis and Location)
Number of Stages: 8
Anesthesia: local infiltration-1% lidocaine with epinephrine and a 1:10 solution of 8.4% sodium bicarbonate (20 cc)
Anticoagulation Medication: Warfarin
-Status: Unchanged
Estimated Blood Loss: minimal
Complications: none

Surgeon and Pathologist:
Assistants:

Indications for Mohs Surgery

The patient has a tumor located on the left inferior helix. Tumors in this location are included in Area H (eyelids, eyebrows, nose, lips, chin, ear, pre-auricular, post-auricular, temple, genitalia, hands, feet, ankles and areola). Tissue conservation is critical in these anatomic locations.

Removal of the patient's tumor is complicated by the following clinical features: clinical area critical for tissue conservation.

Based on my medical judgement, Mohs surgery is the most appropriate treatment for this cancer compared to other treatments. The rationale for Mohs was explained to the patient and consent was obtained. The risks, benefits and alternatives to therapy were discussed in detail. Specifically, the risks of infection, scarring, bleeding, prolonged wound healing, incomplete removal, allergy to anesthesia, nerve injury and recurrence were addressed. Prior to the procedure, the treatment site was clearly identified and confirmed by the patient. All components of Universal Protocol/PAUSE Rule completed. Kendall Anne Morrison MD operated in two distinct and integrated capacities as the surgeon and pathologist.

STAGE 1: The area was prepped with Alcohol and Hibiclens. A rim of normal appearing skin was marked circumferentially around the lesion. The area was infiltrated with local anesthesia. The tumor was first debulked with a curette to remove clinically apparent tumor. through and through. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: There were numerous aggregates of basaloid cells. Depth of Invasion: cartilage. Perineural Invasion: absent. Scar Tissue: present.

STAGE 2: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 3: The patient was prepped in the same fashion. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 4: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 5: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 6: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and placed in 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 7: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and divided into 1 block. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: residual tumor seen. Histology: The pattern and morphology of the tumor is as described in the first stage.

STAGE 8: The patient was prepped in the same fashion as the first stage. An incision at a 45 degree angle following the standard Mohs approach was done and the specimen was harvested as a microscopic controlled layer. Hemostasis was achieved with electrocautery. The specimen was oriented, mapped and divided into 8 blocks. The section(s) were then chromacoded and processed in the Mohs lab using the Mohs protocol and submitted for frozen section. Frozen section analysis showed: No residual tumor seen. Histology: There were no malignant cells seen in the sections examined.

Final Defect Size: 4.1 cm x 2.9 cm
Depth of Final Defect: through and through

Repair Note:

Surgeon: Dr. M
Location: left inferior helix
Repair Anesthesia: local infiltration-1% lidocaine with 1:100,000 epinephrine and a 1:10 solution of 8.4% sodium bicarbonate(0 cc)
Repair Type: Star Ear Wedge Repair
Final Wound Length: 6.2 cm

The surgical defect and surrounding skin were prepped with antiseptic solution and Hibiclens. The choice of the repair was performed to reduce tension to enhance both functional and cosmetic results. A wedge excision was completed by carrying down an excision through the full thickness of the ear and cartilage with an inward facing Burow's triangle. The wound was then closed in a layered fashion. The subcutaneous tissue and dermis were closed with 3-0 Polysorb. Epidermal closure was achieved with 4-0 Nylon (simple interrupted). The final wound length wrapping around the ear was 6.2 cm. During the repair hemostasis was achieved with electrocautery. Vaseline + dry sterile dressing were applied. I reviewed verbally with the patient in detail post-care instructions. Pt was given written post-op instructions, as well. Patient is not to engage in any heavy lifting, exercise, or swimming for the next 14 days. Should the patient develop any fevers, chills, bleeding, severe pain patient will contact the office immediately. Suture removal in 7 days.
 
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