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P6712Rationale for antibiotic prophylaxis in patients with ventriculo-peritonealshunts undergoing dermatologic surgery
Khadija Aljefri, MBChB, Royal Victoria Infirmary, Newcastle upon Tyne, UnitedKingdom; James Langtry, MBBS, Royal Victoria Infirmary, Newcastle upon Tyne,United Kingdom
We have recently excised skin cancers from 2 patients with ventriculo-peritoneal (V-P) shunts for hydrocephalus. This led us to evaluate the current evidence andrecommendations for antibiotic prophylaxis in this clinical setting. A 73-year-oldman with a 13- 3 12-mm nodular BCC of the occipital scalp underwent excision ofthe BCC by Mohs micrographic surgery. Prophylactic antibiotics were not pre-scribed. An 85-year-old woman with a 6-3 6-mm nodular BCC of the right foreheadwith a long-standing V-P shunt received of intravenous antibiotics an hour beforeexcision and rotation flap closure. Neither patient developed shunt or woundinfections. Numerous guidelines exist on the antibiotic prophylaxis of infectiveendocarditis (IE) and prosthetic joint infection (PJI), mainly in dental procedures. Incutaneous surgery, the evidence is less clear and the decision is clinically made on acase by case basis. There are, however, recommendations by the American HeartFoundation and the American Academy of Orthopedic Surgery. The aim is firstly toprevent localized skin site infection and secondly to prevent haematogenoussurgical infection in high-risk individuals. Points to consider are the appearance ofthe skin (ulceration, crusting, or erythema), anatomic location (higher risk ofinfection in the flexures, trunk, and lower limbs), surgical procedure intended andstratifying the patient into risk groups, such as risk IE, PJI, and shunt infection. Theincidence of infection in dermatologic surgery is very low (0-4%) and significantlyless than that of dental surgery where oral mucosa is involved. There are noguidelines on antibiotic prophylaxis in patients with hydrocephalus shunts toprevent distant shunt infections. Ventriculoatrial (V-A) shunts are more susceptibleto infection than V-P shunts because of their connection with the vascularcompartment. 70% of shunt infections occur in the immediate postshunt insertionperiod, 90% of these episodes are caused by coagulase-negative staphylococci andshunt infection carries a mortality of 20% to 40%. In the setting of dental surgery,prophylactic antibiotics are not recommended in patients with hydrocephalusshunts because the risk of developing infection is negligible. Prophylactic antibioticsshould be given in the presence of local surgical site infection andwhen surgical siteis at higher risk of infection. In addition, prophylactic antibiotics may be consideredin the presence of a V-A shunt and when V-P shunt is within 2 months of placement.
AB222
cial support: None identified.
CommerP6818Retrospective evaluation of the safety of large skin flap and graft surgeryin the outpatient setting
Adam Schmitt, Case Western Reserve University School of Medicine, Macedonia,OH, United States; Jeremy Bordeaux, MD, MPH, University Hospitals CaseMedical Center, Orange Village, OH, United States; Xiaowei Guan, MS, CaseWestern Reserve University School of Medicine, Cleveland, OH, United States
Purpose: Our objective was to determine the rates of postoperative infection,bleeding, necrosis, and dehiscence in outpatient dermatologic surgery using largeflap and graft repairs, and to determine the relationship between these outcomesand defect location, closure type, repair size, and the use of anticoagulants,antiplatelets, or antibiotics.
Methods: Charts of patients requiring large flap ($ 30 cm2) or graft ($ 20 cm2)repair in the Department of Dermatology at University Hospitals Case MedicalCenter during a 42-month period were reviewed retrospectively. Medications,procedures, and complications were recorded.
Results: Following 154 procedures, 40% of patients were prescribed an antibiotic.Risk of infection was 7.1%. Increased flap repair size was a significant predictor forinfection (P¼.039), with the 70-100 cm2 group having the greatest association withinfection (P ¼ .047) . Postoperative antibiotic use and defect location were notsignificantly associated with infection, though repairs located on the lower limbswere marginally associated (P ¼ .057) with infection. There were no instances ofhemorrhage, and there was a 3.2% risk of hematoma. At the time of surgery, 53% ofpatients were taking at least 1 anticoagulant or antiplatelet medication, with 45% on1 agent and 8% on 2. Warfarin use was a marginally significant predictor forhematoma formation (P ¼ .061), but use of other anticoagulant or antiplateletmedication was not associated with bleeding of any type. There was a 4.5% risk ofnecrosis and a 1.3% risk of dehiscence. The combined outcome of dehiscence ornecrosis was associated with interpolation flap closure (P¼.0357) and repair size (P¼ .030). All complications resolved without sequelae.
Conclusion: The risk of complications following large flap and large graft proceduresis low. Bleeding risk was not significantly increased with continued anticoagulant orantiplatelet use, and the risk of infections fell within the accepted rate for clean-contaminated procedures, evenwithout consistent antibiotic use. Interpolation flapclosures were associated with increased risk of dehiscence or necrosis. Repair sizewas the greatest significant predictor of adverse outcomes, with infection, necrosis,and dehiscence being associated with larger flap repairs.
cial support: None identified.
CommerJ AM ACAD DERMATOL
P6202Role of surgery in treatment of keloid: Preliminary results of an onlinesurvey
Michael Tirgan, MD, Keloid Research Foundation, New York, NY, United States
Keloid disorder (KD) results in formation of benign skin tumors with variablephenotypes. KD is relatively resistant and often refractory to treatment, with veryhigh rate of recurrence to any single modality treatment. After intralesional steroidinjections, surgery is the second most commonly used treatment modality for KD.An IRB approved web-based survey was launched in November 2011. We report thepatients’ perception of the efficacy of surgery on their KD.
Methods: As of July 7, 2012, 330 consecutive unselected patients participated in thissurvey. Informed consent was obtained electronically. 196 patients (64.7%) reportedhaving had intralesional steroid injections and 103 patients (31.1%) reported theoutcome of surgery that they has at some point during the course of their illness.Patient profiles: male: 39 (37.9%), female: 64 (62.1%), African American: 41 (39.8%)African: 7 (6.8%), white 11 (10.7%), age 18-69. Triggering factors for KD weresurgery in 54 (53.5%), skin injury, cuts in 45 (44.6%), acne in 42 (41.6%), piercing in36 (35.6%), scratch in 20 (19.8%) and chicken pox in 12 (11.9%) cases. Sites of KDwere earlobes in 29 (28%), ear in 21 (20.4%), upper chest in 54 (52.4%), lower chestin 23 (22.3%), shoulders in 53 (51.5%) and neck in 19 (18.4%). Number of keloidswas 1 in 19 (18.4%), 2 in 15 (14.6%), 3 in 13 (12.6%) 4-5 in 22 (21.4%), 7-10 in 9(8.7%) and[11 in 28 (27.2%) cases.
Results: Seven patients (6.8%) reported no recurrence after surgery. In 8 patients(7.8%), KD recurred but remained smaller and in 13 patients (12.6%) it grew back tothe same size. KD recurred and grew to a larger size in 75 patients (72.8%).
Discussion: With several limitations, this study emphasizes that at least among theparticipants in this survey, surgery was ineffective in 85.4% of cases and resulted inworsening of KD in 72.8%. Limited data, especially from Asia, supports surgery as anintervention in KD of ear only. Large scale retrospective and well controlledprospective studies are urgently needed to assess the role of surgery in treatment ofKD. Lack of efficacy and worsening of KD after surgery have to be discussed withpatients before any surgical intervention.
cial support: None identified.
CommerP6211The Munich method: A variation of micrographic surgery hidden fordecades
Luis Fernando Kopke, MD, Dapele Dermatologia, Florianopolis, Brazil
Since the major change in Mohs micrographic surgery, which was the introductionof the fresh tissue technique in the 1970s, other technical possibilities ofmicroscopic control of surgical margins began to emerge. Although technicallydifferent from the original method of Mohs surgery, they were labeled as ‘‘Mohssurgery’’ and their observations published as such. Most of these technical variationsexamine peripherally the surgical margin, so that the relationship between tumorand surgical margin is not displayed. The only variation of Mohs micrographicsurgery that shows this feature is the Munich method, which remains hidden in theliterature since its appearance in the early 1970s. The Munich method is technicallydistinct from the Mohs method regarding the form of surgical excision, thepreparation of histologic slides, and the histologic interpretation of surgical margins,but has long been considered a ‘‘Mohs surgery’’ until it was further better studied.This work presents 284 cases of basal cell carcinomas operated by Munich methodof micrographic surgery observed and followed since 1994 in Brazil. All tumorswerelocated on the face, the nose being the most affected location. The mean of thelargest diameter of the tumors was 1.7 cm and the smallest diameter 1.4 cm. Mosttumors were recurrent (40% more than once) with infiltrative histologic pattern.Free margins were obtained with a maximum of 3 stages in 95% of cases. The follow-up was at least 5 years for 217 tumors and at least 2 years for the rest. Only 1 relapsewas observed, demonstrating that its efficacy is similar to the Mohs method. There isno perfect method of micrographic surgery, and both Mohs micrographic surgeryand its variations have their specific pitfalls. They all have advantages anddisadvantages depending on each clinical and surgical situation. The recognitionof other variants of Mohs micrgraphic surgery and the capacity to perform suchtechnical variations may contribute to expand the knowledge of micrographicsurgery, which, according to the very words of Frederic Mohs, means a surgicalexcision with microscopic margin control.
cial support: None identified.
CommerAPRIL 2013
