Episode 20

Mohs Surgery and Skin Grafts with Dr. Konstantin Grigoryan

Episode Transcript

Dr. Randy Lehman: [00:00:06] Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show focuses on the nuts and bolts of rural general surgery practice, covering topics such as practical surgical tips, rural lifestyle, finance, training, and practice models.

We have a segment called Classic Rural Surgery Stories where you’ll get a feel for how rural practice differs from urban settings. If rural surgery is your passion, this show is for you. So now that the Chloroprep has dried, let's make our incision.

Welcome back, listeners, to another episode of The Rural American Surgeon podcast. I have a special guest today, Dr. Konstantin Grigoryan. He is a dermatologic surgeon practicing in California. We went to medical school together, and he was the valedictorian of our graduating class. He did his internship and then followed me to the Mayo Clinic, where he completed his dermatology residency.

Now, he’s going to tell us all about what he’s doing. Because skin cancer is one of the most common conditions we see in rural America, and many of us are involved in its treatment, we’re going to discuss a wide range of topics related to it. Dr. Grigoryan, thank you for joining me today.

Dr. Konstantin Grigoryan: [00:01:21] My pleasure. I'm happy to be a part of this.

Dr. Randy Lehman: [00:01:25] Yeah, it’s awesome. You have a bit of a non-traditional and interesting background, and I want to start with an introduction. Tell us about your background, how you got to where you are, and what you’re doing now.

Dr. Konstantin Grigoryan: [00:01:37] Yes. A little about myself—I grew up in the former Soviet Union. My family were refugees, and we eventually settled in a small town in Kentucky called Bowling Green. I don't know if you’re familiar with it, but that's where Corvettes are made. I grew up there and later moved to Cincinnati during high school.

Both of my parents were engineers in the Soviet Union, so I naturally gravitated toward engineering. I studied electrical and computer engineering for six years but found it wasn’t what I expected. It involved a lot of project management in a corporate setting, and I felt like I wasn’t making a direct impact on people. That realization led me to go back to medical school after six years of working.

I took some prerequisite courses, applied, and was fortunate enough to be accepted. That’s where I met Dr. Lehman. I chose dermatology as my specialty, trained at Mayo Clinic in Minnesota for three years, and completed my internship in Boston, where I also met my wife. She later followed me to Mayo Clinic.

After that, I completed a one-year fellowship in Mohs micrographic surgery at the University of Washington in Seattle. Now, I practice in Sacramento, California, at the VA, which is affiliated with UC Davis. I also train residents, which I find very rewarding. In dermatologic surgery, we collaborate with other specialties, including head and neck surgeons and general surgeons, particularly in Mohs micrographic surgery cases.

Dr. Randy Lehman: [00:03:31] Yeah, thank you. Would you say that Mohs surgery makes up about 80% of your practice? How is your work divided?

Dr. Konstantin Grigoryan: [00:03:40] Mostly Mohs, but we also perform standard surgical excisions. Everything we do is outpatient under local anesthesia. I’d say around 60–80% of my cases are Mohs, with the remaining 20% being excisions.

I’m based in Sacramento, but the VA here covers all of Northern California outside of San Francisco. Many people think of California as just big cities, but it gets rural quickly once you leave urban areas. We provide care to veterans across the Sierra region up to the Oregon border, where access to specialists is limited. As a result, we see a lot of neglected tumors and cases that have, unfortunately, been mismanaged.

Dr. Randy Lehman: [00:04:29] Normally, I ask my guests why rural surgery is special to them. But in your case, you specifically chose Mohs surgery. Why is Mohs meaningful to you?

Dr. Konstantin Grigoryan: [00:04:44] There are a couple of reasons why I love Mohs surgery. First, I enjoy talking with my patients while they’re awake during the procedure. I get to learn about them and build a connection.

The second reason is the level of control. I perform the surgery, process the pathology myself, and can immediately confirm whether the cancer is fully removed. That instant gratification is incredibly rewarding. In other types of surgery, you have to wait for pathology results, and there’s always some uncertainty.

Dr. Randy Lehman: [00:05:31] That makes sense. Now, let’s talk about managing skin cancer in rural areas where Mohs surgery isn’t available. But first, walk us through what a patient can expect when they’re referred for Mohs surgery.

Dr. Konstantin Grigoryan: [00:05:51] Sure. Mohs surgery is named after Dr. Frederic Mohs, who developed the technique. He was originally a general surgeon in Wisconsin.

The key difference between Mohs surgery and standard excisions is in how the tissue is processed. Instead of traditional "bread loafing"—where only small sections of the margin are examined—Mohs surgery flattens the tissue for a complete 360-degree view of the margins. This approach allows us to take tighter margins while ensuring all cancerous tissue is removed.

Mohs is primarily used for basal cell carcinoma and squamous cell carcinoma, though more surgeons are now performing Mohs for melanoma. It is also used for rare tumors like dermatofibrosarcoma protuberans (DFSPs) and appendageal tumors.

Patients undergoing Mohs should expect to be at the clinic for a good portion of the day...

It takes a long time, usually about an hour, sometimes the last 45 minutes, to process that tissue. In the lab, we do frozen sections on it. Like I mentioned, it's sectioned so that you're able to see the complete margin.

They come in, I explain the procedure, numb them up, take a tight margin around the tumor, and I check it. If it's positive, I have a map. I draw it out, mark it on my map, and go back and repeat the process, sometimes multiple times, until the tumor is fully removed. Most people require one or two stages, but I’ve had outliers where it takes eight or nine stages. Those cases can take all day into the evening, and some patients can't tolerate it. We bring them back the next day or later in the week. After the skin cancer is gone, we figure out the best way to promote healing. Sometimes, healing occurs by second intention. Of course, there are primary linear closures, and things can get more complicated with different types of flaps—advancement flaps, rotation flaps, transposition flaps.

For more complex cases, we have interpolation flaps. One of the most utilized is a medial labial transposition flap or a forehead flap. In my practice, I find that patients don’t really love the forehead flap, so I try to avoid it when possible.

Dr. Randy Lehman: [00:09:11] So, yeah, and that’s what patients can expect. You’re saying that first, you take the specimen out, and then multiple times, you’re doing your own frozen section. But the difference is that rather than slices, you’re checking the entire margin and mapping it out. Resecting if necessary.

My question about how many typical cuts—well, you already answered that. You’re saying two is the average?

Dr. Konstantin Grigoryan: [00:09:38] My average is around 1.8 stages.

Dr. Randy Lehman: [00:09:41] But sometimes it takes much more. So, who is the best candidate? Not every skin cancer is suited for Mohs. If you have a nodular basal cell on the shoulder, that’s probably not the right case. Who benefits the most?

Dr. Konstantin Grigoryan: [00:10:06] Yes. There’s actually a kind of calculator that categorizes different body areas. The head and neck, particularly the face, benefit the most because you can’t take a bigger margin there. More aggressive pathologies also warrant Mohs, especially for transplant patients or immunosuppressed individuals, as tumors can be more aggressive in them.

Dr. Randy Lehman: [00:10:35] What about the patient’s age?

Dr. Konstantin Grigoryan: [00:10:38] Age? Of course, the younger, the better. My average patient population is around 75. But for a younger patient, I’d recommend Mohs because the cure rate is 99%, compared to 96% with excision or around 85% with electrodessication and curettage. So, for younger patients, I push for Mohs.

Dr. Randy Lehman: [00:11:05] Speaking of younger, a little distraction here—hi, Jack.

Dr. Konstantin Grigoryan: [00:11:11] I have a couple of my own, but they’re not in the house right now.

Dr. Randy Lehman: [00:11:16] It’s kind of hypocritical for me to ask my guests to stay focused when my kid is over here playing with Legos and poking his head over my shoulder. Thanks for joining us, Jack!

Alright, so we talked about aggressive cases. I want to discuss basal cell carcinoma types—nodular versus infiltrative. Do you think infiltrative basal cell carcinoma is a better candidate for Mohs than nodular?

Dr. Konstantin Grigoryan: [00:11:44] I would say so. Nodular basal cells are usually not as deep and don’t have as much subclinical spread. You can typically see the margin clinically. Infiltrative basal cells, on the other hand, don’t always have clear margins.

Dr. Randy Lehman: [00:12:04] Yeah, it’s frustrating to get a positive margin back on an infiltrative basal cell, but I don’t think I’ve ever had that happen with a nodular one. That plays a big role in my decision-making, along with location—like the nose or other sensitive areas.

Defect closure—how big of a closure will you do yourself? Are you performing transposition flaps?

Dr. Konstantin Grigoryan: [00:12:33] Yes, most Mohs surgeons perform facial reconstruction. Based on national billing data, we handle most reconstructions ourselves. Occasionally, a patient won’t tolerate a big repair. For example, I had a patient with a large nasal defect who needed a forehead flap but couldn’t tolerate local anesthesia. It turned out to be a big tumor. Throughout the day, patients may become more sensitive to anesthesia, but we can manage fairly large defects under local, sometimes several centimeters across. On the scalp, large defects can heal by granulation tissue formation.

Dr. Randy Lehman: [00:13:30] In my practice, I treat a variety of skin lesions—benign lesions, squamous cell carcinomas, basal cell carcinomas, and melanoma. For facial closures, I frequently use an inverted A-to-T forehead flap. I’ve also done nasolabial flaps and antihelix-based rim advancement flaps for the ear—they’re robust and easy. On the neck, I use rotational flaps, rhomboid flaps, or simple advancement flaps on the scalp.

Outside of these, are there any other flap techniques you’d recommend for general surgeons handling simple squamous or basal cell carcinomas in the head and neck?

Dr. Konstantin Grigoryan: [00:14:46] You mentioned most of them. Smaller defects can often be closed with an O-to-L flap. Transposition flaps, particularly the rhombic flap, are standard. For nasal defects, rotation flaps like the dorsal nasal rotation flap or bilobed flap can be very effective, as they move a significant amount of tissue by 90 degrees.

Dr. Randy Lehman: [00:15:30] A mucoid cyst on the finger—I love that little bilobed flap. Boom, closed, walk away—no defect in your nail. Long-term, it's kind of nice. I had a patient with a very large squamous of the lower lip. I did some reading. I like to put myself in the situation—what if I was the last person to deal with this—and then not actually do it and send them somewhere else? But there's a mental exercise that goes through, you know, first off, having a boundary but thinking if you were outside of the boundary.

So, you know, talking about trying to close with some sort of triangular or W-shaped flap. Do you do anything like that? Full-thickness lip stuff?

Dr. Konstantin Grigoryan: [00:16:14] Yeah. You can do a full-thickness wedge excision on the lip, up to around a third of the defect or a third of the width of the lip. You can get away with that and just do a full-thickness repair. You have to repair the mucosa, submucosal muscle, and then the skin.

You can also do interpolation flaps, which I haven’t really done for lip defects. In that case, you borrow—let’s say if it's a lower lip defect—you'll transpose, based on the superior labial artery, the top lip onto the defect, let it attach itself for three weeks, and then come in, sever the pedicle, do the flap, and set.

Dr. Randy Lehman: [00:16:56] And that’s how you do your nasolabials, right? You do? Yes. How long until you divide the nasolabial flap?

Dr. Konstantin Grigoryan: [00:17:04] Three weeks—about three weeks.

Dr. Randy Lehman: [00:17:06] Okay. How about skin grafts? Full-thickness skin graft—do you do many of those?

Dr. Konstantin Grigoryan: [00:17:13] Yeah, a lot.

Dr. Randy Lehman: [00:17:14] What's your technique for that?

Dr. Konstantin Grigoryan: [00:17:16] I've been evolving in what I do for those. Usually, for smaller defects, I'll use a preauricular donor site. And I'm talking about nasal defects usually. In my training, we would glue on a bolster with Steri-Strips, leave that in for five to seven days, and then remove it.

But lately, I’ve been having success with placing the graft and using Dermabond, just leaving that on. I instruct the patient not to peel it off—it'll fall off on its own. Once it does, they start applying Vaseline (petrolatum) until they see me in one to two weeks for follow-up.

I usually harvest my full-thickness skin graft, trying to get my depth as I remove it. I find it's easier to gauge depth inside rather than holding the tissue in my hand and trying to defat it. Then, I suture it in with 5-0 Fast Gut sutures and apply Dermabond on top.

Dr. Randy Lehman: [00:18:29] Yeah, the Dermabond—do you apply it just around the outside?

Dr. Konstantin Grigoryan: [00:18:32] I apply Dermabond over the whole thing, both on top and around the outside. It helps keep it in place.

Dr. Randy Lehman: [00:18:37] No pie-crust incision in the center?

Dr. Konstantin Grigoryan: [00:18:40] No, I don’t do that. I find they don’t really bleed that much afterward.

Dr. Randy Lehman: [00:18:45] Okay. Does that theoretically create a little fluid pocket behind it, elevating the graft and causing failure? I’ve heard that.

Dr. Konstantin Grigoryan: [00:18:58] I do simple interrupted sutures, but I know some people use running continuous sutures.

Dr. Randy Lehman: [00:19:06] Yeah. So, if you have a neck skin cancer and you’re closing primarily, do you do a three-to-one ellipse?

Dr. Konstantin Grigoryan: [00:19:17] Yeah, a three-to-one ellipse. I’ve closed some really big defects on the neck—older patients tend to have a lot more skin laxity.

Dr. Randy Lehman: [00:19:25] Right. So, how do you close it? What do you use for your two-layer closure?

Dr. Konstantin Grigoryan: [00:19:31] Typically, I use a two-layer closure. My training used Vicryl, but I find I’ve been using more Monocryl, particularly violet Monocryl. I prefer it—it’s easier to handle, more visible, and I feel it’s less reactive than Vicryl.

Dr. Randy Lehman: [00:19:51] What sizes do you use for sub-Q and skin?

Dr. Konstantin Grigoryan: [00:19:54] I usually use 4-0 when there’s not much tension, especially on the face and around the eyes. For really thin necks, I sometimes use 5-0.

Dr. Randy Lehman: [00:20:08] So, do you do a two-layer closure, both layers with the 4-0 violet Monocryl?

Dr. Konstantin Grigoryan: [00:20:13] For the subcutaneous layer, yes. For the top layer, I often use Fast Gut sutures, either 5-0 or 6-0.

Dr. Randy Lehman: [00:20:22] Do you do that as a baseball stitch or subcuticular?

Dr. Konstantin Grigoryan: [00:20:27] I do it as a baseball stitch—just a simple running stitch.

Dr. Randy Lehman: [00:20:31] And then they just put Vaseline over it, and it falls out?

Dr. Konstantin Grigoryan: [00:20:34] Just petrolatum, yeah. It’ll fall out in about a week.

And I, that's kind of how I've gotten to—basically, I look at NCCN guidelines on these margins and ways for excision. In a high-risk area, 6-millimeter margins are recommended, which would be like the forehead or ears—those end up being high-risk areas. According to their guidelines, you end up taking a pretty good-sized hole. For non-high-risk areas, maybe more of a 4-millimeter margin is used.

I talk to patients frankly about it. I'm like, "You can get a smaller defect, a smaller scar with Mohs." A lot of patients still decide to stay. My margin positivity rate—I don't know exactly what it is, but I'm sure it's in the low single digits, though not zero.

My two questions are: First, which patients should I have pathology in-house for frozen section for skin cancer? Second, is there such a thing as a good positive margin rate?

Dr. Konstantin Grigoryan: [00:23:58] Pathology in-house—so you're talking about bread loafing it? If you're bread loafing it and you're unsure about the clinical margins, a lot of times, I’m sure you see these patients where you don’t know where the skin cancer starts and ends because their skin is so bad. In those cases, it might be beneficial. But then again, you’re bread loafing and not evaluating the full margin, so it’s kind of hard to say.

In terms of the positive margin rate, I always say excision has about a 96% cure rate—so 4% of the time, there’s a small risk that not all of it is removed. Mohs has a 99% cure rate. Of course, that changes for recurrent tumors or really high-risk cases. Excision in those cases might only have a 70% cure rate, while Mohs can still have a 90%+ cure rate for recurrent tumors, like previously radiated skin.

Dr. Randy Lehman: [00:25:18] How many of these questions have right or wrong answers?

Dr. Konstantin Grigoryan: [00:25:23] I don’t think there’s always a clear right or wrong. Some cases are definitely clear-cut, but there’s also a gray area.

Dr. Randy Lehman: [00:25:38] Here’s an example from the last two weeks: a 92-year-old patient with a sizable SCC on the back. I took it out with about a half-centimeter margin and closed it up with an intermediate closure. One of the tips of the closure had an incidentally discovered SCC that extended to the edge of the inked margin.

I told the patient to come back in three months so we could check the scar. What are we really doing here? There may not be any regrowth at the scar, or the patient may not even be alive in three months. I could go back and remove more tissue, which would be clinically justified, but it’s about balancing treatment with the patient’s condition. He has other lesions, and we’re really just watching the big, problematic ones. What do you think?

Dr. Konstantin Grigoryan: [00:27:09] That’s reasonable, especially if the patient is reliable. In my practice, they’re not always reliable, and some get lost to follow-up. Then, years later, I see them with huge tumors.

Some would opt to re-excise, while others might refer the patient for Mohs. If it’s an incidental finding and a low-risk tumor, you have to consider the spectrum of squamous cell carcinoma—well-differentiated versus poorly differentiated. Their behavior can be quite different.

Dr. Randy Lehman: [00:28:03] So in that case, I just included that other little lesion in the tail end of my closure.

Dr. Konstantin Grigoryan: [00:28:15] In my practice, I often find incidental things. As a dermatologist, I can usually tell clinically what most things are. If I can, I try to include the whole thing in my tips—or avoid it altogether when possible.

Dr. Randy Lehman: [00:28:39] How do you decide whether to do a shave biopsy or a punch biopsy?

Dr. Konstantin Grigoryan: [00:28:52] Good question. Most people do shave biopsies for a lot of things since they give you a diagnosis quickly. The main distinction is depth—if you’re worried about depth, do a punch biopsy.

I’ve seen deep nodules where a shave wouldn’t get the full picture, so I had to use a punch biopsy or even a double punch. Non-pigmented lesions can mostly be shaved, while pigmented lesions may require a scoop shave. If a melanoma is suspected, the biopsy depth is critical—if greater than 0.8mm, staging changes, and you may need a sentinel lymph node biopsy. If possible, I try to excise the full lesion with a tight margin for accurate staging.

Dr. Randy Lehman: [00:31:05] So you don’t do sentinel lymph node biopsies in the clinic, obviously?

Dr. Konstantin Grigoryan: [00:31:15] No, we call it an excisional biopsy with a 1-2mm margin. If needed, we refer them to general surgery for a sentinel lymph node biopsy.

They'll do the wide local excision with the appropriate margin and the sentinel lymph node biopsy.

Dr. Randy Lehman: [00:31:30] Okay.

Dr. Konstantin Grigoryan: [00:31:31] So I try to get the whole lesion out, you know, for staging purposes.

Dr. Randy Lehman: [00:31:36] So you're just excising the scar? The general surgeon is just excising the scar then?

Dr. Konstantin Grigoryan: [00:31:40] Basically, yeah.

Dr. Randy Lehman: [00:31:42] Right, right. Okay. One other question—do you do dermoscopy at all?

Dr. Konstantin Grigoryan: [00:31:51] Dermoscopy.

Dr. Randy Lehman: [00:31:52] Dermoscopy. Sorry.

Dr. Konstantin Grigoryan: [00:31:54] I use it. I find that it can be helpful sometimes to distinguish between something that appears benign or if it looks like a basal cell versus a pigmented lesion. Is this just a lentigo, or does it have features of melanoma?

Dr. Randy Lehman: [00:32:13] So I think it was in the 1980s that the current procedural terminology was released. Now we live and die by these five-digit CPT codes. So I’ve been around ever since we've been practicing medicine. I have a couple of questions about that—maybe you know, or maybe you don’t—but there’s a set of codes called shave excision. I use those codes when I'm shaving something with the intent of completely removing it. Is that correct?

Dr. Konstantin Grigoryan: [00:32:55] I think it's correct. I'm probably not the best person to ask about billing because I work at the VA. It’s not that important for us. But if your intent is removal and you kind of know what it is, then I think shaving excision would be okay. I bill everything as a shave biopsy because I don’t know with certainty what the lesions are.

Dr. Randy Lehman: [00:33:24] For example, say you get this—maybe it's an irritated seborrheic keratosis, or it's an actinic keratosis, or something that ends up not being a full skin cancer. A lot of times, they're symptomatic, and they're in a place where, you know, you talk to them about excising it with margins or just doing a shave and letting it heal by secondary intent. That’s probably going to be an acceptable scar, depending on the size and location on the body. That’s when I use it—like 113XX, whatever the code is, rather than a shave biopsy. Anyway, I think the coders have been agreeing with me on it, so that's how I’ve been doing it. Okay, well, let’s move on to the next section of the show, which is called the Financial Corner. Do you have a money tip for our listeners?

Dr. Konstantin Grigoryan: [00:34:18] A money tip? I guess slow and steady wins the race. I’m kind of a low-risk person. I’d say I'm in the Boglehead camp. I don't know if you've heard that term before—just total stock market investments, an S&P fund, or the full stock market. Historically, it always goes up by about 7 to 8% annual returns.

Dr. Randy Lehman: [00:34:53] Yeah, so the question is—do you believe in the future of America?

Dr. Konstantin Grigoryan: [00:34:56] Or the world. Yeah, I think that’s what it boils down to. Do you think capitalism will continue working as it has for the last 100-plus years?

Dr. Randy Lehman: [00:35:09] Right. At least in the short term. And when I say short term, I mean your long term, but in the short term of the overall world.

Dr. Konstantin Grigoryan: [00:35:14] Yeah.

Dr. Randy Lehman: [00:35:15] Okay, wonderful. I've got a story. In classic rural surgery, sometimes you see those one-in-a-hundred-thousand diagnoses, even in a town of 1,200 people. I had this one guy come in with SCC on the scalp. It had been excised, but there was a positive margin. That was done by primary care about five years ago, but there was never a re-excision. Then he was seeing some quack who was giving him ozone treatment to the lesion. By the time I saw him, it was the size of a dessert plate right on the crown of the skull. And he was mostly disappointed that I wasn’t prepared to excise it in clinic at that moment.

It turned out the cancer had invaded through the skull, the dura, and into the brain. We had nothing to offer besides palliative radiation. So I sent him to oncology to coordinate care. That’s my sad, classic rural surgery story. I know you’ve had something similar—what do you do?

Dr. Konstantin Grigoryan: [00:37:19] So, you know, like your colleague you mentioned, you're not supposed to see these things in the United States, but we see them all the time at the VA.

You know, I had a patient with a huge basal cell carcinoma like this that's been growing for at least 15 to 20 years. And then a couple of scalp SCC stories. I had a patient that came in to me for Mohs. He had an SCC about maybe 3 cm in diameter, kind of necrotic appearing. He comes in, I look at it. It's overlying a scar. I'm like, "Hey, what's the scar from?" He's like, "Oh, I was in an accident 30 years ago. I had neurosurgery. They put in some hardware."

I was like, "Okay, so," you know, "let's take a look at this squamous cell." I just clean him with gauze, and the whole thing was necrotic. And I'm looking at his plate there, thinking, "Oh, this isn't good." So, we had to get neurosurgery involved, and he was sent to UC Davis, where head and neck surgery and neurosurgery had to work together because he needed a free flap since he had no vasculature there.

And then that was one case. I had another case. A guy came in with an innocuous-looking squamous cell, about a couple of centimeters in diameter, on his scalp. In the middle of it, I started Mohs, and it didn't feel immobile. It wasn't, you know, didn't feel odd. Just his history was that he's had bad squamous cells in the past. That was kind of the only red flag.

So, I started Mohs on this, and my first layer—boom—positive all the way around. My second layer—positive all the way around, positive deep. And almost every section had PNI, you know, perineural invasion. And I just kept chasing it and chasing it down to the bone. You know, I had to strip the periosteum, and starting from that small tumor, his defect ended up being about 8 to 10 cm. It was huge, just down to the bone.

Clinically, I would never have guessed that it would have been that large. And I can see how, you know, if you're just doing excisions, that can become a challenge—chasing those positive margins. Mohs was helpful, and I think it was the right thing for him. We ended up doing it over a couple of days because, you know, it just took all day. He couldn't handle it.

It takes a long time. Once you start processing large amounts of tissue, it takes a long time to process in the lab. 

Dr. Randy Lehman: [00:39:50] How did you end up closing that?

Dr. Konstantin Grigoryan: [00:39:52] Just granulating it with some Integra. He started granulating, and then we put a split-thickness skin graft on it afterward. He's going to get radiation for it.

Dr. Randy Lehman: [00:40:08] So if you have bone exposed and you granulate it, how big of a patch of bone can you get to granulate over? I've done that too, and I thought maybe this wouldn't be successful.

Dr. Konstantin Grigoryan: [00:40:19] But then it was. Yeah, surprisingly, it will heal. You know, I always say I don’t love leaving bone exposed because of the theoretical risk of emboli getting sucked in there. But if you cover it with Integra, you can get granulation from that pretty well after several weeks.

Dr. Randy Lehman: [00:40:42] Okay.

Dr. Konstantin Grigoryan: [00:40:43] Some people like to burr the bone to pinpoint bleeding, which might help with granulation. I haven't done that.

Dr. Randy Lehman: [00:40:52] Now, when you're doing your skin graft, split-thickness skin graft, right?

Dr. Konstantin Grigoryan: [00:40:56] Yeah.

Dr. Randy Lehman: [00:40:57] Do you do that in the office?

Dr. Konstantin Grigoryan: [00:40:59] No, I actually send them to the OR to get that done. I don't have the tool. Sometimes I'll harvest a graft and thin it really thin, but I don’t have a dermatome to be able to do that.

Dr. Randy Lehman: [00:41:14] It's a lot easier with anesthesia too. On the split-thickness skin graft, I mean, I think you can do it. We actually had Dr. Heller on, and we talked about split-thickness skin grafts in one of the earlier episodes. Her technique is great, but of course, always easier with anesthesia.

Dr. Randy Lehman: [00:42:07] If I excise someone and get an unexpected positive margin, and then they get referred to a Mohs surgeon, does that bother you? Would you rather they came to you in the first place, or how do you think about that?

Dr. Konstantin Grigoryan: [00:42:07] I'm happy to treat that. Better late than never. I've had patients where positive margins were just left. Some surgeons will say, "Oh, it's just a basal cell, we'll leave it," and then years later, it's a huge basal cell. I’d rather get it sent to me so we can take care of it properly.

Dr. Randy Lehman: [00:42:28] Yeah. There’s nothing wrong with re-excising, but it's about knowing how much is left. If I'm sending you someone with a positive margin, there were 19 other ones I took out successfully. I think finding a good referral relationship is key. Do you get direct referrals from rural surgeons?

Dr. Konstantin Grigoryan: [00:43:12] Not so much at the VA, but we do work with rural patients. Sometimes, it’s the wild west out there. Some surgeons will do strange things, but when they can’t handle cases, they refer them back to us, and we clean them up.

Dr. Randy Lehman: [00:43:35] I encourage rural surgeons to keep most cases in-house when possible for the patient’s convenience and the hospital system's benefit. But also, don’t be a cowboy. Have someone you regularly refer to.

Dr. Konstantin Grigoryan: [00:44:44] We collaborate a lot with different specialties. If a tumor tracks into the parotid or near the eye, I’ll call in colleagues who are more specialized. It’s good to have those relationships in any medical field.

Dr. Randy Lehman: [00:45:20] Any dermatology resources for rural surgeons?

Dr. Konstantin Grigoryan: [00:45:27] Yes. There’s a free website called DermNet NZ (dermnetnz.org). It has great dermatologic resources, images, and treatment guidelines.

Dr. Randy Lehman: [00:45:52] Yeah, put it in your favorites tab for quick reference.

Dr. Randy Lehman: [00:46:23] Let’s do a quick "How I do it." If a benign skin cyst appears, you excise it and close it in two layers, correct? If there’s a punctum, include it in the excision.

Dr. Konstantin Grigoryan: [00:46:23] Right.

Dr. Randy Lehman: [00:46:24] What if it’s infected?

Dr. Konstantin Grigoryan: [00:46:28] I don’t like excising them when infected. I usually prescribe antibiotics, plus or minus a culture, and schedule them for excision once it’s calm.

Dr. Randy Lehman: [00:46:39] I always I&D them. Do you ever just prescribe antibiotics without I&D?

Dr. Konstantin Grigoryan: [00:46:44] It depends. If it’s huge and ready to explode, yeah, I just I&D it. They'll relieve pressure for smaller inflamed areas, and I think antibiotics alone will work as well.

Dr. Randy Lehman: [00:47:00] Okay. And then, how long do you wait until you excise? Do you always recommend excision?

I always—well, for example, there are exceptions to every rule. But the vast majority of the time, if someone comes in with a cyst that's been there for 10 years and has just started hurting or became infected, I usually just drain it. If there's surrounding cellulitis, I put them on antibiotics. I usually wait six weeks and then re-excise.

It's amazing—maybe they had a 1.5-centimeter cyst for 10 years, but when they come back, it's just a tiny little pockmark, barely noticeable. But I still excise it because I believe there's an element of a sac there that could potentially cause recurrence. What do you think about that approach? How do you do it differently?

Dr. Konstantin Grigoryan: [00:47:42] I think that's a good approach. I would do the same—waiting six to eight weeks is a reasonable time frame to let things calm down. And I agree, the excision will likely be smaller if you let it cool down and return to its baseline.

Dr. Randy Lehman: [00:47:59] Yeah, sometimes I have these really large cysts—like 4 centimeters, non-inflamed—and I almost... I haven't fully moved to doing this yet, but since I've seen infected ones shrink down so much, I wonder: why not just drain it and then excise it later? It would probably shrink a lot. I don't make my excisions smaller, though. I haven't done that yet.

Dr. Konstantin Grigoryan: [00:48:23] Yeah, it's hard to say with those big ones—how much they'd shrink if they're already that large and non-inflamed. Because, you know, the sac is still there. You can dissect it out, and sometimes they're quite large.

Dr. Randy Lehman: [00:48:39] It's just such a common issue, so I thought I'd take the valedictorian’s advice. You know, why not? I've got you in front of me, man! I really appreciate you coming on. This is awesome. Do you have anything else you'd like to share with our audience?

Dr. Konstantin Grigoryan: [00:48:57] No, I think this has been great. Thanks for having me on.

Dr. Randy Lehman: [00:49:01] It's been my pleasure.

Dr. Konstantin Grigoryan: [00:49:03] Good experience. Keep doing this—I think it's really helpful.

Dr. Randy Lehman: [00:49:07] Yeah, we're trying to build a bit of camaraderie. The rural surgeon can be pretty isolated. Even if they’re trying to be a hero, they still need a community.

So, thank you for listening to this episode of The Rural American Surgeon. If you haven’t already, like and subscribe, join the Facebook group, and interact with us. We’re working to combat rural professional isolation.

See you next time on The Rural American Surgeon.