Tristan Hasbargen, PA-C: Closure Types in Mohs Surgery and More

“If you've never been to the Diversity in Dermatology conference, this is your welcome. Please come and attend. Like our organization, diversity doesn’t just mean skin of color or cultural differences. Our goal is to help round out advanced practice providers, whether they want to do more research, whether they want to do journal writing, or whether they’re making career changes... We’d love to have you,” said Tristan Hasbargen, PA-C, in an interview with Dermatology Times.

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At the 2024 Diversity in Dermatology meeting in San Antonio, Texas, Hasbargen, a board-certified physician assistant at Dermatology Associates of Tallahassee in Florida, and the publication and education chair of Diversity in Dermatology, presented tips from his session, “Welcome to Mohs! Tips to Becoming a Surgical APP & Interesting Cases.”

Hasbargen presented pearls on various types of Mohs surgery closures and where they can be used on the body, as well as anesthetic for digital blocks.

“We talked about rotation flaps, grafts, advancement flaps, and how they can be utilized on different areas of the facial area. We also talked about how a lot of skin cancers can be on the nail bed, or underneath the subungual, or squamous cell carcinomas that arise from verrucas. Talking about digital blocks, a lot of us still use 2% lidocaine, but with the shortage that happened during COVID-19, I think a lot of providers were switching it up to different medications. There have been articles about ropivacaine being a much better anesthetic for digital blocks.” said Hasbargen.

Another key topic from his session included the use of intralesional 5-fluorouracil injections and treatments for eruptive squamous cells. Hasbargen referenced a study of intralesional 5-fluorouracil injections for the treatment of eruptive squamous cells on lower legs and its resolution rates.

“We do ours a little differently than the study. We do weekly injections, about 4 to 6 injections for treatment of these, especially on the lower shin area, which can be a harder area to close. We see a lot of pathergy-type eruptions from trauma, where eruptive squamous cells will pop up. And this is a great way of treating these and it has great clinical curates,” said Hasbargen.

Tristan Hasbargen, PA-C: Hi everybody, my name is Tristan Hasbargen, I'm a PA at Dermatology Associates in Tallahassee, and I'm the journal and education chair of the Diversity in Dermatology organization.

Dermatology Times: What are your responsibilities as the journal and education chair of Diversity in Dermatology?

Hasbargen: I've been the journal and education chair since the inception of our organization. We've had 3 live conferences, and our first one was actually during COVID-19 and we did a virtual conference. My role is to help PAs and NPs get published. Right now, there are not a lot of PAs and NPs who have gotten into the research aspect and want to get journal articles published. Our goal is to try and get more and more APPs to just get more well versed in how to write journal articles, how to get published, because we see a lot of different patients, whether it's a case study or something that you're seeing a lot of patterns in; it's going to help your other providers when they evaluate and see patients too. So, we've had cases like Merkel cell case studies. I did an article on rotation flaps for those who are in the surgical aspects in dermatology. We've talked about how to orient those and how they work. And the cosmetic considerations you need to have when evaluating flaps. We've had articles written on photodynamic therapy for the treatment of pre-cancers. We've had articles on HS and some other comorbidities including depression. And so, it's just bringing a lot of insight and allowing more APPs the experience to not only see clinical patients but talk about it outside of the clinic and how to help other providers.

Dermatology Times: What pearls did you share with attendees during your session, "Welcome to Mohs! Tips to Becoming a Surgical APP & Interesting Cases?"

Hasbargen: I've been fortunate to have practiced alongside a Mohs surgeon for the past 12 years. I think I've gained some good insight. I think the 3 big takeaways from my talk for PAs or NPs who want to get involved in Mohs is to really sit down and look at all the different types of closures. A lot of closures end up being pattern recognition, in terms of the orientation. And so, in my talk, we talked about rotation flaps, grafts, advancement flaps, and how they can be utilized on different areas of the facial area. We also talked about how a lot of skin cancers can be on the nail bed, or underneath the subungual, squamous cell carcinomas that arise from verrucas. And talking about digital blocks; a lot of us still use 2% lidocaine, but with the shortage that happened during COVID-19, I think a lot of providers were switching it up to different medications. There have been articles about ropivacaine being a much better anesthetic for digital blocks. Ropivacaine has a longer duration of action in terms of anesthesia postoperatively, and it helps control hemostasis a lot longer than lidocaine. And it has less cardio-toxic effects than bupivacaine and it's still an amide-type local anesthetic. So, using ropivacaine will help post-operative anesthesia and post-operative bleeding and prevent your patients from having any complications.

Another big topic is the role of intralesional 5-fluorouracil injections and treatments of eruptive squamous cells. We utilize that a lot in our office, especially on the lower legs. But I talked about an article that was released where they did a study and showed the resolution rates. We do ours a little differently than the study. We do weekly injections, about 4 to 6 injections for treatment of these, especially on the lower shin area, which can be a harder area to close. And we see a lot of pathergy-type eruptions from trauma, where eruptive squamous cells will pop up. And this is a great way of treating these and it has great clinical curates. And patients do well with them. So generally, it's 0.4 ccs per centimeter squared. And we do it again about weekly for about 4 to 6 treatments. And it does extremely well. It can be used on the head neck area, as well as the hands. But I think we've seen the most utility on the legs, the feet, and the digits as well. So, another thing from my Mohs lecture that I think is important that I shared, so I like 2 books that I recommend. It's The Checklist Manifesto by Atul Gawande. He's a physician at Brigham and Women's Hospital and it talks about the importance of checklists. In medicine, you know to avoid wrong site surgeries during Mohs and making sure that you have the right slides and the right map associated with the right patient, the checklist is very important. I strongly recommend every provider read it. It's a great resource, great insight, it's only going to help your medical practice. It can also make you more efficient when you have checklists for you and your staff.

The second thing is having situational awareness and I preach that to all our residents or other PAs, our staff; situational awareness of what's going on not only in your room, but the room next door, etc. So, when we're doing Mohs, and we have 6 rooms going at a time, we need to know where I need to be next, or where the Mohs surgeon needs to go in terms of a closure or another layer or say hi to preoperative procedure. But it helps expedite things and ensures that we stay on time as best as we can. And the saying, "seconds turn into minutes, minutes turn into hours." And we want to make sure that we're using our time wisely, so that we can, at the end of the day, get home safely, but all of our patients have good outcomes. So, there is an article called "How to Develop the Situational Awareness of Jason Bourne," which is kind of a comedy article. But it is something that I do share with our staff, so that they are aware and have developed that situational awareness of what's going on in every room.

Hasbargen: The location was phenomenal. San Antonio, Texas, was such a great location to have a conference, the weather was beautiful, it was right on the riverwalk area. But I think the biggest thing about the conference was we really want to focus on the faculty we bring in. And we love the fact that the faculty want to be engaged with our audience, and they want to participate, not only in the lectures, but also outside of the lectures, and they want to mingle and get to know the attendance members. When I first started going to conferences, I think one of the big things is I want to know more about the faculty and about who they are. We can see them, and we know they're key opinion leaders in their field. But having them outside of the didactic learning is pretty fun. We chose some topics that aren't as talked about in other conferences, which I think is important. We talked about the social implications of burnout. We had a talk that Dr. Soung did a great lecture on rheumatology and the ANA and how to really interpret ANA readings. We had an excellent lecture by Dr. Drew Kuratis on cutaneous T-cell lymphoma. He also did an internal malignancy lecture as well as continuous signs of internal disease. That was phenomenal. Anytime you hear Dr. Shahriari, you're always going to learn a lot from her. I just love her passion and am excited to have her on faculty with us. And Dr. Kiracofe did lectures on the sexual health of women, which I thought was very big and something that's not discussed enough. And definitely, as a provider, something that I need to survey my patients more about. It's probably something that's overlooked and has some deep implications if we ignore those. So, I'm glad that she brought that up as well.

If you've never been to the Diversity in Dermatology conference, this is your Welcome. Please come and attend. We'd love to have you. We love teaching, we love interacting. We love learning about the different aspects of the dermatologic community. Like organization, diversity doesn't mean just skin of color or cultural differences. Our goal is to help round out APPs, whether they want to do more research, whether they want to do journal writing, whether they're making career changes and want to go into the pharmaceutical industry as MSLs or medical directors, our goal is to help you with all the advanced knowledge that all of our leaders have, and to get you the right information to help you succeed in your career. Please join. It's free to attend, but we'd love to have you and I'd love to see you at the next conference.