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Figure 2. Dark-skinned female teenager before (R) and after (L) three sessions of microneedling for varicella scars. Lateral images of the face.

To our knowledge, this is the first report on PCI exclusively for varicella scars. Moreover, the patient was a Fitzpatrick skin phototype V girl with a high risk of postprocedure dyschromia, especially hyperpigmentation. In addition to being a low-cost, easily administered technique, PCI should be considered as an option when treating varicella scars in young dark-skinned women, because of its short downtime and the low risk of hyperpigmentation.

3. Fabbrocini G, Fardella N, Monfrecola A, Proietti I, et al. Acne scarring treatment using skin needling. Clin Exp Dermatol 2009;34(8):874–9. 4. Leheta T, El Tawdy A. Abdel Hay R, Farid S. Percutaneous collagen induction versus full-concentration trichloroacetic acid in the treatment of atrophic acne scars. Dermatol Surg 2011; 37(2):207–16. 5. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan Aesthet Surg 2009;2(1):26–30.

IZELDA M. C. COSTA, PHD Department of Dermatology Hospital Universitario de Brasılia—UnB Brasılia - DF, Brazil

References 1. Doddaballapur S. Microneedling with dermaroller. J Cutan Aesthet Surg 2009;2:110–1. 2. Fabbrocini G, De Vita V, Monfrecola A, De Padova MP, et al. Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes. J Dermatolog Treat 2012; [Epub ahead of print].

MARIANA C. COSTA, MD Department of Dermatology Hospital Universitario Prof. Edgard Santos - UFBA Salvador-BA Brazil

Dermoscopy to Identify Biopsy Sites Before Mohs Surgery

Nonmelanoma skin cancer (NMSC) has an incidence of more than 3.5 million cases per year in the United States. Basal cell carcinoma (BCC) accounts for approximately 85% of these cases and squamous cell carcinoma (SCC) 15%. Mohs micrographic surgery (MMS) offers the highest cure rate for BCC, with maximal tissue preservation and the lowest 5-year recurrence rate.

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Dermoscopy is a noninvasive technique that enables the in vivo examination of subsurface morphologic structures. It is used for melanoma and nonmelanoma screening to guide diagnosis and biopsy, with studies showing enhanced diagnostic accuracy and fewer lesions biopsied. Dermoscopy has been used in MMS to define the edge of lentigo maligna before resection and to

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delineate tumor margins of BCC before MMS. We describe the use of dermoscopy to identify biopsy sites that are difficult to locate; this is a problem that Mohs surgeons encounter frequently, particularly in cases in which there has been a delay between biopsy and surgery, allowing the site to heal and become inconspicuous.

(A)

Case 1 A 64-year-old Caucasian man presented to his dermatologist for a lesion on his left forehead. Shave biopsy confirmed the diagnosis of BCC on pathology. The Mohs surgeon evaluated the patient 1 month later. The biopsy site was not visible on clinical inspection (Figure 1A), and the patient could not pinpoint its location. The referring dermatologist was also unable to provide an exact description or a photograph of the biopsied site. Dermoscopy was used to help identify the site. An erythematous oval macule was located with the aid of dermoscopy. Within the macule, a remnant of ovoid nest and confluence of small-caliber vessels were identified (Figure 1B). Upon identification of the biopsy site with dermoscopy, two stages of MMS were performed to remove the BCC.

Case 2 A 64-year-old Caucasian man presented to the Mohs surgeon for an erythematous lesion on his right forehead. Shave biopsy confirmed the diagnosis of squamous cell carcinoma (SCC). The patient returned for surgical removal of the SCC more than 1 month later, at which point, he was unable to point out the biopsy site accurately. The Mohs surgeon, who had performed the initial biopsy, was not able to identify the biopsy site either (Figure 2A). Under dermoscopy, the presence of a scar and telangiectasias clearly delineated the site (Figure 2B). One stage of MMS was performed to remove the residual tumor. Histologic examination after the first stage showed no residual tumor but

(B)

Figure 1. (A) Clinical appearance of the biopsy site on initial Mohs consultation in Case 1. The circle denotes the patient’s recollection of the general area of the biopsy site. (B) Dermoscopic image. Erythematous patch was identified, clearly demarcated from the surrounding skin. Arrow is pointing to a remnant of the blue-grey ovoid nest.

showed evidence of scarring, confirming the biopsy site.

Discussion MMS offers the highest cure rate for NMSC while preserving the normal surrounding tissue. In most cases, Mohs surgeons can easily locate the tumor and the biopsy scar on clinical examination, but in certain cases, this crucial step poses a challenge. A number of factors exacerbate this difficulty. These include cases in which the initial tumor is small, the biopsy site is not visible to the patient, there is a long delay between the initial biopsy and surgery,

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(A)

TABLE 1. Dermoscopic Features of a Biopsy Site Clue

Description

Basal cell carcinoma remnants

Remnant of blue–gray ovoid nests and globules, telangiectasia, spoke wheel and leaf-like structures White-pink homogenous patch with underlying vessels; chrysalis structures are not commonly seen in early scar Hypopigmented border separating scar patch from surrounding (often actinically damaged) skin

Scar

Clear demarcation from surrounding skin (B)

the referring physician for confirmation of the biopsy site. A few reports have also described the use of gauze dermabrasion, presurgical curettage, and use of tangential lighting. A recent survey found that most surgeons preferred using photographs to identify the previous biopsy site,3 but there may be variation in photographic techniques that could make this method less optimal. Figure 2. (A) Clinical appearance of the site 1 month after biopsy. The biopsy site scar has healed. (B) Dermoscopic image. Scar and telangiectasia helped identify the surgical site.

and the site is well healed after a superficial biopsy. In the last scenario, a study has shown that 66% of clinically healed BCC biopsy sites had histopathologic evidence of residual tumor.1 The challenge in precise identification of the surgical site has several medicolegal implications. Rossy and colleagues2 reported that 9% of patients were unable to identify their surgical site, and McGinness and colleagues3 found that patients and physicians were incorrect in identifying biopsy sites 4.4% of the time. These mistakes can lead to operating on the wrong site, which may result in patient dissatisfaction and further surgery. To identify the biopsy site accurately, Mohs surgeons often rely on clinical inspection, assistance from patients and their families, photographs, and diagrams with distance measurements.4 In some circumstances, the Mohs surgeon may send the patient back to

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We have presented two cases in which location of the tumors was difficult to determine based on clinical inspection. Dermoscopy was used before MMS to determine the surgical site in both cases. In the first case, a superficial biopsy was performed, and no photograph of the site was taken. The patient saw the Mohs surgeon more than 4 weeks later, at which time the site was healed and not visible. Our second case showed that it may be difficult to identify the precise biopsy site even with photographs and the same physician performing both tasks. We have identified three dermoscopy clues (Table 1) that may assist Mohs surgeons in determining the precise location of the biopsy site. First, scar appears as a homogenous pink patch under dermoscopy, accompanied by a cluster of small caliber vessels. Early scar (

Dermoscopy to identify biopsy sites before Mohs surgery.

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