Dr. Marta Van Beek shared 4 surgical pearls for dermatologists.
Pearl #1: Don’t underestimate the alar groove.
Marta Van Beek, MD, MPH, executive medical director, University of Iowa Ambulatory Care Clinics; C. William Hanke Professor of Dermatologic Surgery; director, Division of Dermatologic Surgery and Cutaneous Oncology, Department of Dermatology
When repairing a Mohs defect with a flap or graft, blunting of the alar groove can cause significant disfigurement externally and a “shelf” internally that disrupts air flow with inspiration. Furthermore, small amounts of blood that may accumulate under a flap may cause hypertrophy, leading to further blunting of the internal groove and narrowing of the internal nasal valve. Patients will notice increased difficulty breathing.
To preserve the alar groove during facial reconstruction surgery, Van Beek uses a through-and-through suture. She passes the needle into the nasal vestibule and back, as if securing a button. Tightening this suture allows Van Beek to recreate the alar groove and prevent any collection of heme under the flap. The suture can be performed 1-2 times and should be narrow to avoid compromising the vascular supply to the flap pedicle.
Pearl #2: Use SOX-10 instead of MART-1 staining in Mohs micrographic surgery for melanoma.
It can be challenging to distinguish atypical keratinocytes with melanin from adjacent melanocytes on actinically damaged skin using melanoma antigen recognized by T-cell-1 (MART-1) immunostaining on frozen sections. MART-1 has additional limitations in recognizing desmoplastic melanoma.
Van Beek’s Mohs unit implemented SRY-related HMG-box-10 (SOX-10) immunostaining in 2016. A nuclear stain, SOX-10 does not stain melanophages or melanin in adjacent keratinocytes. It is equally sensitive for detecting melanoma compared with MART-1 but has much higher specificity in actinically damaged skin.
In a retrospective study of >900 cases completed between 1998 and 2024, Van Beek found that SOX-10 staining decreased the postoperative defect size and the number of stages needed to achieve negative margins. The University of Iowa helped developed the SOX-10 rapid protocol which is now available for any practice to use.
Pearl #3: Patient preferences don’t always align with the highest cure rates.
Van Beek described studies demonstrating the differences between patient and physician preferences. Patients’ values and biases are formed by their lived experiences including education, spiritual beliefs, family, peer groups, and traumatic events. Van Beek emphasized that dermatologists should strongly consider patient preferences when helping patients make treatment decisions. Patients may select treatment plans that result in a lower cure rate. However, if the plan aligns with their values and social circumstances, it is the right choice for them.
Pearl #4: Radiologic images do not detect microscopic disease.
Van Beek emphasized that current clinical imaging technology may miss evidence of microscopic disease. This is especially true for microscopic periosteal or bony invasion. The periosteum or calvarium can be frequently involved in patients who may have had an imaging report stating, “no bony invasion”. This can often be the case with squamous cell carcinoma tumors that are clinically fixed to underlying tissues. In these cases, a clinical exam can be more accurate to predict bony invasion than imaging.
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