Yes, it is uncommon, but it can metastasize to lymph nodes. Regional adenectomy should be performed.

When can Mohs surgery be used for basal cell or squamous cell carcinoma?

Delicate areas that include perioral, perioccular, perinasal, ears, hands, and genitalia

What is the most common melanoma site on the skin in men? In women?

Men—back

Women—legs

What is the most common location for distant melanoma metastasis?

The lung (surgery can help relieve pain caused by metastatic melanoma to the lung, but is not a cure)

What is the most common metastasis to the small bowel?

Melanoma

What margins are recommended for a melanoma skin lesion with thickness of 1 mm?

1 cm margins are recommended; for lesions greater than 2 mm a 2 cm margin is recommended. 0.5 cm margins are acceptable for thin lentigo maligna melanomas or melanoma in situ.

Can electrocautery be used for excisional biopsy of melanoma?

No, cold knife excision should be used so as to not disturb the deep margin with burn artifact.

What types of melanoma are there?

Superficial spreading, lentigo maligna, acral lentiginous, nodular

What is the most common type of melanoma?

Superficial spreading

Lentigo maligna

What is the most aggressive type of melanoma?

Nodular, but acral lentiginous is also aggressive and presents late because of location on feet/hands.

If a melanoma lesion is less than 1 mm thickness and no lymphadenopathy is palpated, does any additional workup need to be performed?

No. Optional CXR, liver function test (LFT’s), and sentinel lymph node biopsy (SNLB) can be performed for lesions greater than 1 mm thickness. If SNLB is positive, then all the above workup and an MRI of brain and CXR should be performed. If there are palpable nodes present, a formal lymph node dissection should be performed.

Can Mohs surgery be used for melanoma?

No, never!

Can frozen sections be used to determine if margins are negative for melanoma?

No, frozen sections have no role in the management of melanoma (permanent section only).

What is the difference between a keloid and hypertrophic scar?

A hypertrophic scar does not extend beyond the borders of the original scar.

What is the treatment for a keloid?

First-line therapy for most keloids is intralesional corticosteroids. They can also be treated with radiation, silicone sheets, surgery with interferon or triamcinolone injections, and pressure garments.

What is the treatment for a hypertrophic scar?

Intralesional corticosteroids, silicone sheets, pressure garments

What is the treatment for hidradenitis?

Improve hygiene, antibiotics, surgery to remove infected tissue and apocrine sweat glands

WOUND HEALING

What is the reconstructive ladder?

It is a way of organizing approaches to reconstruction and wound healing. The first step of the reconstructive ladder is the simplest and least invasive method progressing to the most complex method at the top of the ladder.

What are the general categories in the steps of the reconstructive ladder in order from simple to complex?

Healing by secondary intention

Healing by primary intention/tertiary (delayed primary) intention

Split-thickness/full-thickness skin graft (STSG/FTSG)

Local flap

Regional flap

Distant flap

Free flap

Immune deficiency/suppression

Nutritional status/obesity

Diabetes

Smoking

Healing disorders

Age

How can you diagnose a skin infection in a burn patient?

Biopsy the skin; if bacteria are present on deep dermis, then the patient likely has an infection.

How do you obtain a sample of bone for biopsy to evaluate for osteomyelitis?

A separate incision is made, away from open wound, and bone biopsy is performed through this incision.

What is the utility of imaging in evaluating osteomyelitis?

MRI is a good modality to evaluate extent of osteomyelitis, plain film will not show osteomyelitis changes for 2 weeks, and bone scan is not specific in the face of an open wound or a fracture.

True or false: A moist environment is key for a clean wound to heal.