Avoiding wrong-site surgery in the era of COVID-19 and face masks.

Introduction

As COVID-19 and its variants persist, universal pandemic precautions remain in place to protect both patients and health care personnel. With the implementation of necessary universal pandemic precautions, dermatologic surgeons now face the challenge of biopsy site identification utilizing photographs of patients wearing face masks. When worn properly, face masks hide anatomic landmarks and increase the risk of wrong-site surgery. Herein, we describe a “near miss” case of a patient presenting for Mohs micrographic surgery, who had biopsy site photographs while wearing a face mask.

Case report

A 63-year-old man presented to his dermatologist for a spot of concern on his right nasal sidewall. Physical examination revealed a 3-mm pink papule in that location. A gentian violet marker was used to mark the biopsy site, and a photograph was obtained with the patient’s face mask in place (Fig 1). Pathology revealed a basal cell carcinoma, and the patient was scheduled for Mohs micrographic surgery. Four weeks later, the patient presented to the dermatologic surgeon for definitive treatment. The presumed biopsy site was initially marked by a member of the surgical team (Fig 2). Prior to administering anesthesia, photographs from the initial biopsy were printed and utilized by the surgeon to identify the biopsy site. The photograph captured the initial biopsy site of the right nasal sidewall; however, the patient’s face mask obscured all anatomic landmarks. The Mohs surgeon noted a pink scar inferomedial to the initially marked site, and the referring dermatologist was called to the surgery suite for confirmation. The patient and providers agreed that the biopsy site was indeed inferomedial to the initially marked site. Additionally, the patient confirmed the biopsy site using a handheld mirror and then underwent Mohs micrographic surgery.

Fig 1

The biopsy site of the right nasal sidewall marked with gentian violet at the initial visit to the referring dermatologist. The patient was photographed while wearing his face mask, and the biopsy site photograph was uploaded directly to the electronic medical record.

Fig 2

Four weeks later, the patient arrives for Mohs micrographic surgery for basal cell carcinoma of the right nasal sidewall. The biopsy site had healed, and patient’s face mask was removed temporarily below the chin. The presumed biopsy site was incorrectly marked in gentian violet superiorly to the correct biopsy site. A superimposed red asterisk marks the correct biopsy site inferomedial to the incorrectly marked site.

Discussion

Herein represents a case of a “near miss.” Even without face masks, biopsy site identification can present a challenge for providers, especially when photographs are poorly lit, taken without fixed anatomic landmarks, or not taken at all. Risk factors associated with wrong-site surgery include, but are not limited to the following factors: Miscommunication between members of a team, lack of established safety protocols, poor description of surgical site, dependence on a single provider to correctly identify site, and misinterpreted preoperative photography. Solutions for avoidance of wrong-site surgeries have been cited in the literature and include the following: Recording measurements from fixed anatomic landmarks, asking the patient to confirm the biopsy site with a mirror, using photography and descriptive biopsy site documentation, asking the patient to take a biopsy site “selfie,” if a photograph was not originally taken, and obtaining input and verification from family members.2, 3, 4 Finally, as in our case, if the biopsy site remains unidentifiable, the referring physician should be consulted.

When face masks are worn by patients, the authors recommend the following actions to help mitigate the potential risk for wrong-site surgeries. When possible, photos of biopsy sites should be taken with the face mask lowered, exposing the nasal ala and distal nasal tip for orientation. When this is not possible, coordinated measurements should be obtained and recorded from stable structures such as the tragus, medial canthus, or medial aspect of the eyebrow with the patient at rest.

This specific case represents a “near miss” secondary to patient photography without sufficient landmarks in the era of COVID-19 and face masks. The authors aim to underscore the importance of high-quality biopsy site photography and remind readers to temporarily remove a patient’s face mask prior to photographing a biopsy site to avoid the risk of wrong-site surgery.

Conflicts of interest

None disclosed.