Micrographic Surgeons Research Articles

53360 Low Medicaid Acceptance Rates in Multi-specialty and Private Clinics Among Mohs Micrographic Surgeons in New York City

53360 Low Medicaid Acceptance Rates in Multi-specialty and Private Clinics Among Mohs Micrographic Surgeons in New York City

A Post-COVID Population-Based Analysis of Mohs Micrographic Surgeon Distribution in the United States.

Policy changes to Mohs micrographic surgery board certification eligibility and population shifts in the wake of the COVID-19 pandemic have significant implications for the accessibility of Mohs micrographic surgeons across the United States. To examine the geographic distribution of micrographic surgery providers considering recent population trends and assess the impact of certification eligibility changes and population shifts on accessibility. Medicare claims data were utilized to identify micrographic surgery providers. Surgeon densities were calculated per 100,000 people by county and state. Population changes were analyzed using US census data. Practicing micrographic surgeons were concentrated in metropolitan and nonmetropolitan areas. Overall, 80.4% of counties lacked micrographic surgery providers, with rural areas being the most underserved. Population changes varied among states. Shifts in micrographic surgery certification requirements, US population distribution, and micrographic surgeon location emphasize challenges in accessibility, especially in rural areas across the United States.

Growing Adoption of Immunohistochemistry by Mohs Micrographic Surgeons: A National Medicare Trend Analysis.

Immunohistochemical (IHC) staining can be used alongside Mohs micrographic surgery to aid in margin assessment of subtle tumors, yet existing estimates of IHC utilization have primarily relied on survey or older data that lacks stratification. To characterize national IHC utilization trends by Mohs surgeons, stratifying by surgeon characteristics and modeling future adoption. Longitudinal analysis of 2014 to 2021 Medicare Public Use Files. In 2021, 158 of 2,058 Mohs surgeons (7.7%) used IHC as compared with 4.0% in 2014 (average annual growth rate [AAGR] +3.6%). Adoption change was highest in the Northeast (AAGR +19.9%), whereas volume growth was greatest in the West (AAGR +25.2%). Multivariable regression revealed significantly greater utilization propensity among Mohs surgeons in academics (adjusted odds ratio [aOR] 3.36), American College of Mohs Surgery (ACMS) members (aOR 2.12), and Micrographic Dermatologic Surgery (MDS)-certified surgeons (aOR 1.66). Mohs surgeons are steadily incorporating IHC into practice across all regions, with volume growth driven by higher adoption rates. Greater utilization among ACMS members, recipients of MDS certification, and those in academics suggests value of formalized training in enhancing comfort. Additional educational opportunities at conferences may aid in recognition of value and help identify solutions to address integration challenges.

41930 Comparison of Travel Distance and Time to In-Network Mohs Micrographic Surgeons Between Medicaid and Medicare Beneficiaries

41930 Comparison of Travel Distance and Time to In-Network Mohs Micrographic Surgeons Between Medicaid and Medicare Beneficiaries

Periosteal flaps allow for single stage reconstruction of larger full thickness eyelid defects: a retrospective study.

Full-thickness lower eyelid defects after Mohs micrographic surgery are frequently referred out to oculoplastic surgery for reconstruction. Reconstructive options include wedge closure with or without canthotomy/cantholysis and tarsoconjunctival sliding flaps. Defects > 50% of the eyelid margin have traditionally required the two-stage Hughes flap, leaving the patient with monocular vision for 3-6weeks until pedicle division. To demonstrate single-stage periosteal flaps performed by dermatologic surgeons can result in safe, functional, and cosmetically acceptable repairs for large full thickness eyelid defects, an institutional review board-approved retrospective study of repairs performed by two dermatologic surgeons between January 2017 and July 2021 at the University of Minnesota. Patient demographics, operative notes, and follow-up notes were reviewed. Defect and follow-up photographs were scored using a visual analogue scale to assess aesthetic results. Ten cases were included in the analysis. Six patients were male and the average age was 62years old. 8/10 were basal cell carcinoma and 2/10 were melanoma. The mean defect was 9.5cm2, with a range of 1-24cm2. The median cosmetic score was 85.8 ± 10.7. There were no serious complications reported. Mohs micrographic surgeons can safely and successfully reconstruct large, full thickness eyelid defects by periosteal flap.

Comparison of Travel Distance and Time to In-Network Mohs Micrographic Surgeons Between Medicaid and Medicare Beneficiaries.

Beltrami, Eric J. BS*; Masison, Joseph BS*; Gronbeck, Christian MD†; Feng, Hao MD, MHS† Author Information

Complex Eyelid Reconstruction: A Practical Guide for the Mohs Surgeon.

A growing body of literature suggests that Mohs micrographic surgeons can safely and successfully perform complex eyelid reconstruction. Given that up to 10 percent of all skin cancers occur on the periorbital skin, it is imperative that Mohs surgeons understand form and function to properly assess the defect and select the appropriate reconstruction method for a variety of eyelid defects. Our objective is to provide a thorough understanding of eyelid anatomy with an emphasis on form and function, provide a framework for defect analysis, and an algorithmic approach to defect analysis and appropriate selection of repair. A review of the literature on eyelid reconstruction was performed with specific reference to defect analysis and appropriately choosing repairs that are applicable to Mohs micrographic surgeons. Mohs micrographic surgeons can safely and successfully perform complex eyelid repairs. An understanding of eyelid anatomy is the first step toward the best surgical outcome, and there are various methods for reconstructing eyelid defects. Defect size, location and analysis of the anterior lamella, posterior lamella, and the canthal regions helps to create an organized operative plan.

Implementation of immunohistochemical staining among mohs micrographic surgeons

AbstractBackgroundImmunohistochemical staining has been used as part of Mohs micrographic surgery (MMS) to improve sensitivity for the detection of subtle residual tumors. It is typically used in the histopathologic detection of tumors such as malignant melanoma, extramammary Paget disease, and poorly differentiated and spindle cell neoplasms.Materials and MethodsThe study involved a questionnaire link emailed by the American College of Mohs Surgery to its members. The survey sought demographic information and asked about the use of immunohistochemistry (IHC) stains during fellowship training and in current practice as well as reasons why IHC staining is not incorporated into certain practices. The data were tabulated and analyzed.ResultsA total of 84 surveys were completed. Of these, 30 (35.7%) indicated having received training in IHC during the fellowship, whereas 54 (64.3%) did not. Currently, 32 (38.1%) respondents utilize IHC in their practice, whereas 52 (61.9%) do not. Among those who trained in IHC during the fellowship, 60% (n = 18) continue to utilize IHC, whereas among those whose fellowship did not incorporate IHC, 74.1% (n = 40) do not utilize IHC. A number of different immunostains were reportedly utilized during fellowship and in current practice. Among those not utilizing IHC, the top reasons cited were lack of sufficient volume to justify use (n = 38, 70.3%), cost of implementation (n = 38, 70.3%), the stains being time‐consuming (n = 36, 66.7%), and lack of familiarity with reading immunohistochemical stains (n = 29, 53.7%).ConclusionsThe use of IHC among Mohs surgeons appears to be rising compared to previous historical studies, but significant barriers remain to widespread implementation.

Pilot Survey of Adoption of Telemedicine in Mohs Surgery During the COVID-19 Pandemic.

The Covid-19 Pandemic prompted the widespread implementation of telemedicine across healthcare. To analyze telemedicine adoption by Mohs Micrographic surgeons (MMS) during the COVID-19 pandemic; to analyze the attitudes and perceived barriers to its long-term continuation by MMS practices. An online multiple-choice survey was distributed to members of the American College of Mohs Surgeons. 86.1% of surveyed Mohs surgeons initiated telemedicine during the pandemic surge. The most common uses for telemedicine amongst respondents were post-surgery management (77.4%), "spot checks" (60.9%), and surgical consultations (59.1%). 73.1% report patients were receptive to telemedicine. 68.6% believe that telemedicine has a place in dermatologic surgery; 49.5% plan to incorporate telemedicine into their surgical practices long-term. Physical exam limitations, fitting telemedicine into practice workflow, and patient reception/patient training were viewed as the most significant barriers to long-term implementation. While valuable use cases for telemedicine were identified with most Mohs surgeon respondents feeling that telemedicine has a place in their practices, there is uncertainty in how to implement telemedicine into the dermatologic surgery practice workflow.

Quantifying Utilization of Skin Substitutes by Mohs Micrographic Surgeons: A Cross-Sectional Analysis of Medicare Data.

Quantifying Utilization of Skin Substitutes by Mohs Micrographic Surgeons: A Cross-Sectional Analysis of Medicare Data.

A Cross-Sectional Survey of Practice Patterns Among Mohs Micrographic Surgeons in the Assessment and Management of Perioperative Hypertension.

A Cross-Sectional Survey of Practice Patterns Among Mohs Micrographic Surgeons in the Assessment and Management of Perioperative Hypertension.

Factors impacting patient ratings of Mohs micrographic surgeons: Lessons gleaned from analysis of 17,527 online reviews

Factors impacting patient ratings of Mohs micrographic surgeons: Lessons gleaned from analysis of 17,527 online reviews

Approaches to Perineural, Lymphovascular, and Single-Cell Disease.

Mohs micrographic surgeons should be adept in identifying and managing perineural invasion (PNI), lymphovascular invasion (LVI), and single-cell spread (SCS), features denoting high-risk behavior of basal cell carcinoma (BCC), cutaneous squamous cell carcinoma (cSCC) and microcystic adnexal carcinoma (MAC). The purpose of this article is to review the literature and guidelines regarding the diagnosis of PNI, LVI, and SCS in BCC, cSCC, and MAC and examine the role of advanced diagnostic studies, adjuvant therapy, and reconstructive techniques of these high-risk tumors. We performed a literature search including the following terms: PNI, LVI, SCS, BCC, cSCC, keratinocyte carcinoma, MAC, sentinel lymph node biopsy, radiation, chemotherapy, and staging. Relevant studies, case reports, and review articles were included, as well as National Comprehensive Cancer Network guidelines. Pancytokeratin immunohistochemistry may aid in the diagnosis of high-risk features of BCC and cSCC. Reconstruction of the Mohs defect should be carefully considered to allow for thorough inspection. Radiation therapy should be considered as an adjuvant treatment option for high-risk cSCC and BCC. Close surveillance for recurrence is warranted. The Mohs surgeon should be competent in identification of high-risk tumors and to understand how best to manage, further treat, and follow these tumors.

Opioid Prescribing Patterns After Micrographic Surgery: A Follow-up Retrospective Chart Review.

The abuse of opioids has reached epidemic proportions in the United States, and leftover medications are a primary source for nonmedical pain relievers. A past study at the University of Utah showed that micrographic surgeons were likely overprescribing opioids, with 35% of patients receiving a postoperative prescription. To examine the current opioid prescribing habits of the micrographic surgeons at the University of Utah compared with those in 2010. Retrospective chart review of the patient records of 4 micrographic surgeons between February and May 2017. Four hundred patient visits were reviewed. An opioid prescription was provided after 12% of encounters, 23% lower than in 2010 (p = .004). Younger patient age, increased number of stages and defect size, repair of the defect, and particular surgeons predicted opioid prescription. The percentage of patients who received an opioid prescription after undergoing micrographic surgery at the University of Utah decreased from 35% in 2010 to 12% in 2017. Reports of the minimal need of opioids after micrographic surgery, the authors' past study showing an institutional tendency to overprescribe, and reports of the national opioid epidemic likely all contributed to the decrease in opioid prescriptions at the authors' institution.

Use of Skin Biopsies Among Dermatologists.

Skin biopsies are essential to establish a diagnosis in many skin diseases. Utilization has been increasing rapidly and represents a significant health care cost. There are no benchmarks or baselines to guide the practice of skin biopsies. To create a reference data set of biopsy behavior among dermatologists. Five hundred eighty-eight dermatologists belonging to the American Dermatological Association (ADA) were surveyed. Two hundred eighty-seven responded with 128 of those providing biopsy data. The mean percentage of biopsies that were malignant was 44.5%. This varied by subspecialty with a mean of 41.7%, 57.4%, and 4.1% of biopsies performed by general dermatologists, Mohs micrographic surgeons, and pediatric dermatologists, respectively. By category or diagnosis, the biopsies were 22.7% basal cell carcinoma, 12.0% SCC, 10.2% benign neoplasms, 10.0% nevi, 8.0% actinic keratosis, 7.6% seborrheic keratosis, 7.5% inflammatory disorders, 6.1% SCC in situ, 5.3% dysplastic nevus, 5.1% benign skin, 1.5% melanoma in situ, 1.4% melanoma, 0.9% lentigines, 0.8% other malignancies, 0.6% infectious, 0.2% not otherwise specified, and 0.1% atypical lesions. There was a statistically significant difference in biopsy results between different dermatological subspecialties. These results should help elucidate dermatologic practice patterns and thus create opportunities to improve dermatologic care and reduce health care costs.

Career Trajectory and Job Satisfaction Trends in Mohs Micrographic Surgeons

Although many residents and fellows in Mohs surgery express an interest in academics, departure from academics occurs for many trainees or junior faculty. We designed a survey, issued to all American College of Mohs Surgeons (ACMS) members in 2009, to assess reasons for practice selection. A response rate of 65.0% (n=455) was obtained. Of all ACMS members, 33.9% started in academic positions, and 66.1% started in private practice. Retention rates in private practice (61.2%) were significantly higher than in academics (28.0%) (p<.001). The rationale for selection of an academic career included referral base and teaching and research opportunities. Reasons for selection of a private practice career were higher salary, autonomy over resources, and geographic flexibility. There were high rates of departure from academics early on; reasons for departure included lack of support from the academic chair and lack of autonomy over resources. Surgeons leaving academia were able to perform Mohs surgery and continue interests in research and teaching with benefits of greater autonomy over resources in private practice. Novel efforts to retain academic Mohs surgeons are needed to ensure continued success and evolution of the specialty.

Peritumoral Fibrosis in Basal Cell and Squamous Cell Carcinoma Mimicking Perineural Invasion

Perineural invasion (PI) in cutaneous basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) is linked to an aggressive course. We describe a histologic mimic for PI that we termed peritumoral fibrosis (PF). To describe the morphologic changes associated with PF and to determine the incidence of PF and PI in Mohs frozen sections of BCC and SCC. All cases of BCC and SCC that were treated by Mohs micrographic surgery (MMS) at the Skin and Cancer Center, University of Florida College of Medicine, Gainesville, Florida, and the Center for Dermatology and Skin Surgery, Tampa, Florida, during the period from January 1, 2003, to August 1, 2004, were reviewed for the presence of PI and PF. The latter was defined as the presence of concentric layers of fibrous tissue that either surround and/or were surrounded by tumor formations mimicking perineural or intraneural invasion. Seven hundred six cases of BCC and 264 cases of SCC were surveyed. Eleven cases (10 BCC and 1 SCC) with equivocal areas were destained, and immunohistochemical staining with S-100 protein was performed, proving actual PI in all of these cases. Available original hematoxylin-eosin biopsy slides were correlated with the MMS frozen sections. PF was noticed in 4.5% of SCCs and 5.8% of BCCs. The incidence of unequivocal PI was noted to be 2.6% in SCC and 2.1% in BCC. We describe a specific pattern of fibrosis noted in BCC and SCC that we called PF. It shows concentric layers of fibrous tissue surrounding and/or surrounded by tumor formations and resembles carcinomatous perineural and/or intraneural invasion. Moreover, PF was found to be a sensitive marker for PI. Mohs micrographic surgeons should be aware of this phenomenon to avoid triggering unnecessary steps in managing these cases, such as irradiation.

Mohs Tissue Mapping and Processing

BACKGROUND Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. OBJECTIVE To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. METHODS Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. RESULTS Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or “slits” are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 μm (53.9%) and less frequently at 4 μm (21.9%). CONCLUSION There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.

Mohs Tissue Mapping and Processing: A Survey Study

Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or "slits" are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 microm (53.9%) and less frequently at 4 microm (21.9%). There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.

Surgical pearl: large single sections in Mohs micrographic surgery

M ohs micrographic surgery is a highly effective surgical modality for the treatment of certain cutaneous malignancies. The “fresh-tissue technique,”1 which is currently used by most Mohs micrographic surgeons, involves the saucerization excision of a neoplasm followed by the preparation of horizontal frozen sections, sequential microscopic examination of all frozen section tissue specimens, mapping of the excised tissue, and reexcision of persistent tumor until all margins are clear. Mohs micrographic surgery, which insures maximal cure rates and the conservation of normal tissue, may also be a meticulous and time-consuming procedure. In 1998, this author and Taylor2 described a method of embedding and mounting multiple, small tissue specimens on one glass slide, which can reduce the number of glass slides used to mount frozen sections and increase the rapidity with which frozen sections can be prepared and examined during Mohs micrographic surgery. This article describes the use of large single sections, another efficient, time-saving technique for preparing histologic sections for Mohs micrographic surgery. Tissue specimens excised for Mohs micrographic surgery are typically divided into 2 or more sections before being horizontally sectioned, stained, and mounted on slides for microscopic examination. The specimen is divided so that it will fit on the cryostat chuck disk and so that the lateral and deep margins can easily be flattened into a single plane. The single-section method, originally described by Randle et al,3 saves time by omitting the division of the specimen into smaller sections, thus, reducing the number of tissue specimens that must be cut by the technician and interpreted by the surgeon. According to Randle et al,3 the single-section method is most useful for small or thin specimens (eg, eyelid tumors). Conversely, large tumors or thick specimens are typically divided into 2 or more specimens so that they may fit on the cryostat chuck and to facilitate flattening the lateral and deep margins in the same horizontal plane. This article describes a method of processing large and thick specimens by the single-section method. The first step is to aggressively remove the bulk of the tumor either by curettage, scalpel excision, or shave excision. Shave excision with a bowed half razor blade is our preferred method of debulking, which produces a thin section that is easier to flatten, freeze, and cut (Fig 1). To preserve orientation, nicks are placed at 12, 3, 6, and 9 o’clock. The tumor is removed in a thin, saucerized fashion by beveling the scalpel blade 45 degrees. The excisional specimen is then placed on a glass slide and the surface is scored with partial-thickness cuts to relax the tissue so that, as it freezes, the epidermal and deep margins can be gently flattened with forceps into the same plane that is represented by the surface of the glass slide. The 12, 3, and 9 o’clock nicks are then color-coded with dyes, the map is drawn, and the specimen (that rests on the slide) is placed into the cryostat. Optimum cutting temperature (OCT) embedding compound is poured on the tissue and the cryostat chuck, and allowed to freeze to about 24°C. After placing the slide and the tissue on the chuck, the slide is separated from the specimen by warming the slide with the thumb. At this point, the undersurface of the specimen and the epidermal margin are embedded in OCT medium in the same plane in preparation for horizontal sectioning with the microtome (Fig 2). OCT medium, if allowed to adequately freeze, may extend beyond the edges of the chuck. Thus, the diameter of the cryostat chuck is not a size-limiting factor, because specimens larger than the chuck may be successfully embedded in OCT, mounted on the chuck, and horizontally sectioned. It may also be necessary to allow larger specimens to freeze for a From the University of Cincinnati. Reprints not available from the author. J Am Acad Dermatol 2003;48:506-8. Copyright © 2003 by the American Academy of Dermatology, Inc. 0190-9622/2003/$30.00 0 doi:10.1067/S1090-9622(03)0078-6