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JAK Inhibitors

Surgical Procedures

Electrosurgical Methods​

  • A good table summarizing electrosurgical methods can be found here: 31318829 (Table).

 

Common Devices Encountered in Dermatologic Surgery Patients (31318829)                                                                                      

Pacemakers and Implantable Cardiac Defibrillators

  • Modern pacemakers are less affected by electromagnetic interference, but interference can still occur.

  • Electrocautery or bipolar forceps are preferred. 

  • Monoterminal modalities are usually safe in patients with defibrillators and when used 5cm from pacemakers.  

  • If using biterminal modalities, place dispersive electrode away from the device so vector does not encompass the device. 

  • Use 5-10s bursts (1s or less may be prudent if operating directly near the device) at lowest possible setting with 10s in between to allow device to function appropriately. 

  • If surgery is being performed close to the device, consult cardiologist. 

Deep Brain Stimulators​

  • DBS may be turned off if tremor doesn't interfere with surgery. 

  • Electrocautery or bipolar forceps are preferred.

  • If monopolar necessary, use a dispersive plate and position so that the pulse generator or the lead wire are not located between the plate and surgical site.

Cochlear Implants

  • Electrocautery is preferred.

  • Avoid monoterminal electrosurgery in the head and neck region.

  • Biterminal electrosurgery should not be used within 1-2cm of implant.

  • Conservative recommendation is to use electrocautery, or biterminal electrosurgery only below the clavicles. 

Nerve Stimulators

  • Best to temporarily turn them off if possible.  If this isn't feasible, using electrocautery, or biterminal modalities (preferably bipolar forceps), with the plate positioned so that current passes as far away from the nerve stimulator as possible. 

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MOHS SURGERY

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Literature                                                                                                                                                                                                        

 

Surgical delays may be associated to tumor growth...

 

Lee J, Forrester VJ, Novicoff WM, Guffey DJ, Russell MA. Surgical delays of less than 1 year in Mohs surgery associated with tumor growth in moderately- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas: A retrospective analysis. J Am Acad Dermatol. 2022. PMID: 34499990.

SUMMARY: Compared size of tumor at time of biopsy with post-Mohs surgical defect size (which they used as surrogate for the tumor size after the time delay between biopsy and Mohs surgery).  They concluded that mod- and poorly-differentiated SCCs demonstrated a significant correlation between delay and growth of tumor, about 2-3mm per month of delay, but that SCCis, well-differentiated SCC, and BCCs did not show a correlation. 

 

There are a lot of issues with this study and broadly speaking I don't think I would use it to guide clinical care, particularly because they didn't demonstrated that these delays and the concomitant tumor growth resulted in quantifiably poorer outcomes.  Some critiques I would provide are:

- they controlled for tumor size as a categorical variable (> or < 2cm) but not a continuous variable.  

- they did not comment on how retraction of the skin around a defect that occurs after resection of a mohs layer leads to defects that are inherently larger than the specimen that is removed. 

- they didn't control for location beyond H, M, L (retraction of skin around defects is different based on location)

- they didn't discuss how early treatment may lead to larger defects given the propensity to take bigger initial stages when a fresh scar is present versus potentially smaller margins when the area is allowed to heal fully before Mohs surgery

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