Plastics

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=====Mohs Rotation=====

==== Attendings ====
  - Dr. Mariah Brown - Mondays, Thursdays, some Tuesdays \\    * Background: super smart, on the board of the derm society, breast cancer survivor
  - Dr. Maryam Asgari - Wednesdays \\   * Background: current endowed chair of Dermatology, recruited from Harvard
  - Dr. Fiona Zwald - Fridays \\   * Background: from Ireland, new UCH faculty currently building practice

====Background Reading ====
Rotation Info from Derm residents: https://olucdenver-my.sharepoint.com/:w:/g/personal/mary_k_hill_cuanschutz_edu/ET8R7xHCZ9VNnAjO8KJuf8EBQBpze6TzTzte-1S1QYhIbg?e=WqqvJQ

https://doi.org/10.1016/j.fsc.2018.08.002\\
A practical guide to skin cancer (Hanlon) - Actinic keratosis chapter\\
Facial Flap Surgery (Goldman, Dzubow, Yelverton)\\
Download the MOHS AUC app. You will need to put this score in your notes. Https://apps.apple.com/us/app/mohs-surgery-appropriate-use-criteria/id692790649.\\


Dr. Brown's videos: Password=Mohs_recon 

https://vimeo.com/675250176
https://vimeo.com/675579885
https://vimeo.com/675266027
https://vimeo.com/678391831
==== Start time ====
  * Typically 7:30
  * No “end time.” You stay until the last case is finished, can range anywhere from 3:30-7:30pm. Then you help write the notes. 

====Attire====
  * UCH green scrubs. No need for white coat or clinic clothes.
  * They wear loupes for everything. I would only wear them for the closures.

====General workflow====
  * You will not follow single patients. Basically everyone divides and conquers to get the work done.
  * Check the Mohs white board across from the nurse triage room to get a sense of patient flow/status 
  - Red bar next to patient’s name = consented and ready for 1st stage
  - Clr = Clear
  - Tld = Patient has been told that they are clear
  - + = stage is positive 
  - + ➔ (positive sign with arrow underneath) = positive stage and next stage has been taken

Before first stage
  * Once patient is roomed, get started
  * Consent patient - don’t forget to talk about potential nerve damage if applicable to wear the surgical site is. 
  - If patient wants valium, make sure to get the consent first.
  - If the patient is getting valium AND occuplastics reconstruction, make sure to get the occuloplastics consent too
  * Outline the biopsy site with the marking pen and any pertinent landmarks (wrinkles, vermillion border, cosmetic units, etc). Confirm the biopsy site with the patient and available photos in their packet (I’ve outlined the wrong thing a few times)
  * I like to ask the patient if they have any other spots they’re concerned about to have the attending look at them
  * Measure the site and write on the yellow sheet
  * Take pictures in Haiku
  - Label the photo “Mohs # **** preop”
  - Will need to take profile, side, and swimmer’s views for nose cases and profile side and postauricular for ear cases.
  - Will need at least 4 photos per encounter: preop, defect, closure, and a picture of the MOHS map sheet
  * Extras:
  - EYE CASES: For cases close to eyelid margin/eye itself, make the following are ordered 1)Tetracaine drops 2) Erythromycin 0.5% ointment ordered
  - VALIUM: Order valium 5 or 10mg as needed, if the patient requests it. Remember to give after consent obtained.

//In order for patients to be eligible to receive valium, confirm that someone will be with them for the duration of their visit and that they are not driving.\\ 
Document on “medications given in clinic” on Mohs face sheet//

  * After the patient is consented/marked/photographed. Get them positioned on the bed and drape with the chux. Put on the grounding pad. 
  * Clean the area then inject lido with epi (they use hibicleanse for most areas. Betadine for around anything with a hole).

Stage 1

  * If things are slow, I typically let the fellow and attending do the resections since we won’t be doing this in real life. You’ll help w hemostasis while they take care of the path
  * Sometimes they’ll curette first to debulk, other times they’ll take tissue for a debulk specimen. This will need to be noted in the notes
  * After hemostasis, numb the site again with the bupivicaine
  * We have to throw away the sharps, not the MAs. The bovie tip is a sharp.

Additional stages
  * If the path is positive, let the MA’s know that the patient is positive and they’ll set for another stage.
  * Once patient is back on the table, numb the area again with lido and let the attg know they’re ready for another stage

====Reconstruction====
  * Once path is negative, let the MA know get the patient ready for closing
  * Take a picture of the defect in Haiku. Label it: “Mohs #****, defect”
  * Measure the defect size and document it on the yellow sheet
  * Attempt to design the closure, once it’s approved you can put more lido in and get the patient draped
  * Once the attendings are comfortable with you, they’ll let you just do the closure with the MA
  * They only wear sterile gloves for the final closure.
  * Once done: measure and document the final length / diameter
  - If primary defect, just measure the length
  - If significant undermining (greater than the length of the defect) it’s considered a complex closure
  - If a flap, you measure the area under the flaps (including the undermined area)
  - Interpolation flaps don’t need measurements
  - Take a final photo: “Mohs # ****, closure”

Postop
  * Ask if attg wants abx and for how long
  * Most patients don’t get narcotics, but if the patient thinks they’ll need it, its fine
  * Put in any dermatopath orders if biopsies were taken (Diagnosis is typically “neoplasm of uncertain behavior of skin of ____”

====Charting and Path Request====
  * Typically done at the end of the day, but if you can knock some out throughout the day, that’s really helpful
  * You divide and conquer the notes with the fellow
  * They don’t like abbreviations or shorthand for notes
  * Templates:
  - AMC DERM MOHS PROCEDURE FULL 1 SITE
  - AMC DERM MOHS PROCEDURE FULL 2 SITES
  - AMC DERM MOHS SURGICAL FOLLOW-UP NOTE
  - There’s also MOHS notes for follow-up, shave biopsies, excisions, cryo, and intralesional therapy.
  * Make sure to add documentation if the debulk is positive or negative if the tissue is taken
  * They have extensive plans at the end of their note, list each point separately
  * If you did an excision, biopsy, intralesional injection, or anything that isn’t mohs on a patient - use the Derm mohs follow-up note and put in an HPI and exam.
  * Regardless of the type of patient, you need to put in a visit diagnosis under the plan tab and print the AVS when done.

For the pathology request, order "Dermatopathology Request" in EPIC. Make sure to include: the location of marking sutures, the margins, the pre-op diagnosis and include any secondary features. Be thorough.\\



====Intralesional chemotherapy====
  * Used for patients who are not surgical candidates or who have skin cancers on sites with poor surgical/healing outcomes (i.e. lower extremities)
  * Do not order medication prior to seeing the patient. Sometimes the skin cancer has resolved making an injection unnecessary or a different agent is needed due to treatment failure.
  * Once ordered, call the chemo pharmacy at ext 80570 to ensure that it is ordered correctly and ensure that it is being processed.
  * Typical medication specifics:
  - 5-FU 50mg/mL (most commonly used)
  - Bleomycin 1 unit/mL
  - Methotrexate 0.3-2mL of 25mg/mL
  - Triamcinolone 40mg/mL

====Example yellow sheet====

{{:resident:mohs.png?400|}}