Description

Mohs micrographic surgery (MMS) is a microscope-guided tissue-sparing surgical procedure for the removal of certain skin cancers, in which 100% of the surgical margin is examined. It is the gold-standard for the treatment of high-risk and aggressive nonmelanoma skin cancer. It is an incredibly safe procedure and postoperative complications are uncommon, occurring in only 0.72% of cases. It is the most cost-effective form of skin cancer removal and has higher cure rates when compared to standard excision.

Despite the safety and tolerability of the procedure, postoperative patient concerns have been assessed in the literature with pain being the most common. Using classical pain assessment models, pain is often assessed by the patient as mild to moderate. On average pain is at its worst on POD0 of surgery, with one study finding peak pain scores between 2PM to 10PM on POD02. Studies have often demonstrated that the most painful anatomical sites are the nose, ear, forehead, scalp, periorbital region, and lip with the scalp being associated with the most postoperative pain. Those who undergo linear closure or second intent healing report significantly less pain postoperatively than those who undergo flaps and full-thickness-skin grafts with age (\<66 years), number of lesions, and consumption of narcotics for pain relief.

Specific Aims, long-term objectives, research accomplishments:

This study will hopefully provide more information to the Mohs surgery community regarding postoperative pain control.

Reducing pain improves the overall comfort and well-being of patients, leading to a better post-operative experience.

To provide patients with an alternative and potentially superior NSAID for pain control (compared to standard-of-care ibuprofen).

To provide a pain medication option that has a longer half-life with a reduction in patient breakthrough pain and the necessity of taking more frequent medication Discovering non-opioid pain control methods can help decrease the reliance on opioids, reducing the risk of addiction and other opioid-related side effects.

Managing pain effectively can help prevent post-operative anxiety and depression, contributing to better mental health outcomes Managing pain effectively can contribute to better Mohs surgery patient outcomes Advances in pain management can contribute to more personalized approaches, tailoring pain control strategies to individual patient needs

Background and Significance:

Standard of care postoperative pain control in Mohs micrographic surgery is alternating Tylenol and ibuprofen as directed on the manufactures label. Randomized controlled trials on postoperative pain in MMS. Upon literature review there have not been any studies in MMS using meloxicam as a postoperative pain alternative to standard of care. To date, acetaminophen and codeine, celecoxib, pregabalin, naproxen, aspirin, and other opioid prescriptions have been used for postoperative pain5-7

Meloxicam is approved for the treatment of osteoarthritis in the United States. At low doses it is COX-2 preferential, inhibiting prostanoid synthesis in inflammatory cells. In clinical trials, meloxicam was found to be as effective as naproxen, piroxicam, and diclofenac with few GI symptoms and lower incidence of perforation, obstruction and bleeding8. Compared to the medications listed above, oral meloxicam has the longest half-life at around 20 hours8. Given its long half-life, the investigators hypothesize that meloxicam will result in pain control over the postoperative time periods when pain is at its worst (POD0 and POD1). This will decrease the need for adding other pain control medicines, decrease break through pain, and increase patient satisfaction with postoperative pain control. Postoperative pain in MMS has been explored for decades and this pain-control alternative can be used as a useful tool for the surgeon.