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Background: We aimed to identify how Integra bilayer wound matrix has expanded facial reconstruction options after Mohs surgery due to its reliability in both single- and dual-stage reconstruction. Methods: A retrospective review of patients undergoing Mohs surgery and alloplastic facial reconstruction with Integra between 2012 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. Results: One hundred thirty patients with a median age of 76 years were included. Basal cell carcinoma was the most common malignancy (39%). One hundred forty-two lesions were treated and reconstructed same-day with Integra. Lesions most commonly involved the nose (34%) and forehead (22%). The mean postoperative defect size was 26.9 cm2. An estimated 45.5% (n = 60) of defect sites underwent single-stage reconstruction with healing by secondary intention, whereas 54.5% (n = 72) underwent dual-stage reconstruction with skin graft. Integra success rate was 90.2%. Average time to re-epithelialization was 32.2 + 7.3 days. Average time to repigmentation was 169.5 + 14.6 days. The complication rate was 12.8% (n = 17), with 12 undergoing debridement, three needing new Integra graft, and seven needing new skin grafts. Average size for successful healing without complication was 26.6 cm2. Nineteen sites (13.2%) underwent aesthetic improvement procedures, with the majority occurring after dual-stage reconstruction (n = 13). Conclusions: Integra is a reliable outpatient reconstructive option for facial Mohs defects that can increase the threshold for autologous tissue harvesting and successfully reconstruct large defects of 26.6 cm2 on average with low complication and reoperation rates.

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INTRODUCTION: Access to high-quality healthcare, including mental healthcare, is a high priority for the Department of Veterans Affairs (VA). Meaningful monitoring of progress will require patient-centered measures of access. To that end, we developed the Perceived Access Inventory focused on access to VA mental health services (PAI-VA). However, VA is purchasing increasing amounts of mental health services from community mental health providers. In this paper, we describe the development of a PAI for users of VA-funded community mental healthcare that incorporates access barriers unique to community care service use and compares the barriers most frequently reported by veterans using community mental health services to those most frequently reported by veterans using VA mental health services. MATERIALS AND METHODS: We conducted mixed qualitative and quantitative interviews with 25 veterans who had experience using community mental health services through the Veterans Choice Program (VCP). We used opt-out invitation letters to recruit veterans from three geographic regions. Data were collected on sociodemographics, rurality, symptom severity, and service satisfaction. Participants also completed two measures of perceived barriers to mental healthcare: the PAI-VA adapted to focus on access to mental healthcare in the community and Hoge's 13-item measure. This study was reviewed and approved by the VA Central Institutional Review Board. RESULTS: Analysis of qualitative interview data identified four topics that were not addressed in the PAI-VA: veterans being billed directly by a VCP mental health provider, lack of care coordination and communication between VCP and VA mental health providers, veterans needing to travel to a VA facility to have VCP provider prescriptions filled, and delays in VCP re-authorization. To develop a PAI for community-care users, we created items corresponding to each of the four community-care-specific topics and added them to the 43-item PAI-VA. When we compared the 10 most frequently endorsed barriers to mental healthcare in this study sample to the ten most frequently endorsed by a separate sample of current VA mental healthcare users, six items were common to both groups. The four items unique to community-care were: long waits for the first mental health appointment, lack of awareness of available mental health services, short appointments, and providers' lack of knowledge of military culture. CONCLUSIONS: Four new barriers specific to veteran access to community mental healthcare were identified. These barriers, which were largely administrative rather than arising from the clinical encounter itself, were included in the PAI for community care. Study strengths include capturing access barriers from the veteran experience across three geographic regions. Weaknesses include the relatively small number of participants and data collection from an early stage of Veteran Choice Program implementation. As VA expands its coverage of community-based mental healthcare, being able to assess the success of the initiative from the perspective of program users becomes increasingly important. The 47-item PAI for community care offers a useful tool to identify barriers experienced by veterans in accessing mental healthcare in the community, overall and in specific settings, as well as to track the impact of interventions to improve access to mental healthcare.

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BACKGROUND/OBJECTIVES: Despite precise surgical technique, some postoperative facial scars will depress and widen over time, likely due to weakened or inadequately replaced collagen fibers in the underlying dermis. The purpose of this study is to evaluate whether a 10,600 nm ablative carbon dioxide (CO2 ) fractional laser used early in the post-surgical setting results in improved postoperative facial scars after a single treatment session. STUDY DESIGN: A prospective randomized, comparative split-scar study was conducted on 20 subjects between the ages of 20-90. Subjects underwent Mohs surgery for nonmelanoma skin cancer of the face. Subsequent to tumor removal, subjects with a linear scar of 4 cm or greater were enrolled. On the day of suture removal, all subjects had one-half of their scar randomly selected and treated with a 10,600 nm CO2 fractional laser (energy = 10 mJ; density = 10%; spot size = 7 mm; pulse = 1). The untreated scar half served as a control. Scars were re-evaluated 12 weeks later. An independent blinded observer graded the scar halves with the Vancouver scar scale (VSS) immediately prior to treatment and 12 weeks after treatment. Subjects completed a visual analog scale (VAS) at the same time points. RESULTS: Three months after laser treatment, a significant decrease in VSS and 3 of the 4 of its individual parameters were detected in both control and treated halves of the scar. When comparing the laser group versus the control group, a statistically significant difference was not noted in VSS (P = 0.31) but a statistically significant difference in patient VAS was detected (P = 0.002). No side effects of the laser treatment were noted. CONCLUSION: Facial wounds sutured in a layered manner heal well. Patients prefer early fractional CO2 lasing of surgical scars, though use of the VSS failed to detect an objective difference between laser and control halves of scars. Conservative laser settings, a single session treatment, and VSS insensitivity for surgical scars may influence these findings.

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The term "induction" has been used to describe epidermal changes overlying a dermatofibroma (DF). Follicular induction is most often associated with DF, but can be observed in other lesions, including focal mucinosis, nevus sebaceous, seborrheic keratosis, wart, neurofibroma, and scars. Dermatofibrosarcoma protuberans (DFSP) is a malignant fibrohistiocytic tumor that may be difficult to distinguish from DF. In contrast to DF, the epidermis overlying DFSP is usually attenuated or ulcerated. Here, we report a case of DFSP exhibiting follicular induction of the overlying epidermis. This epidermal change has been rarely reported in DFSP and may present a diagnostic pitfall in superficially sampled lesions.

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Microcystic adnexal carcinoma (MAC) is an uncommon, locally aggressive, malignant cutaneous tumor with pilar and eccrine differentiation. Mohs micrographic surgery is the treatment of choice for this condition, but specific histological findings can complicate MAC removal and leave doubt as to whether the tumor has been completely removed. Here we describe the clinical and pathological characteristics of a case in which a patient with an MAC underwent multiple reexcisions because of the presence of benign subclinical syringomatous proliferations adjacent to the primary lesion. Our case raises awareness of syringomatous proliferation, a benign process histologically similar but behaviorally distinct from a primary MAC. This experience highlights the importance of continued communication between dermatopathologists and dermatologic surgeons in providing quality patient care.

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