Mohs Micrographic Surgery Research Articles

Unconventional Remedies for Squamous Cell Carcinoma: A Journey into Alternative Treatments.

Squamous cell carcinoma (SCC) is the second most common form of skin cancer and is typically found on sun-exposed skin. Risk factors include ultraviolet radiation exposure, older age, fairer complexion, smoking, and immunosuppression. SCC is a slow-growing tumor with the possibility of metastasis if not treated. The clinical presentation can range from a dry, scaly erythematous patch or plaque to a firm hyperkeratotic papule, plaque, or nodule, depending on the histological type via biopsy. The first-line therapies for SCC removal are standard excision and Mohs microscopic surgery; however, there are novel and alternative non-surgical options being considered for the treatment of SCC. This review summarizes the current guidelines for treating low-risk and high-risk SCC and discusses rare, experimental, and anecdotal non-surgical treatments for SCC in the literature.

The State of the Art of Image Guided Superficial Radiation Therapy Treatment of Non-melanoma Skin Cancer in Outpatient Dermatology Clinics in the United States and Review of the Literature.

Image guided superficial radiation therapy (IGSRT) is a novel technology which combines traditional superficial radiation therapy (SRT) with high resolution dermal ultrasound (HRDUS) to treat non-melanoma skin cancers (NMSC). Since development, IGSRT use has expanded dramatically in outpatient clinics. We review the IGSRT literature and state-of-the-art operating principles in US dermatologic practices. A literature search of electronic databases (Medline, Pubmed, Cochrane Library, Science Direct) combined with various authors' published and unpublished documents, procedures, and clinical experience with IGSRT were synthesized for this paper. Studies have demonstrated IGSRT consistently delivers high cure rates (> 99%) with low complications for early stage (stage0, I, or II) squamous cell and basal cell carcinomas. Control rates are statistically superior to non-image guided SRT and external beam radiation (XRT) as well as Mohs micrographic surgery (MMS). This improvement is attributed to invivo dermal tumor visualization via HRDUS and using an interdisciplinary approach to deliver care. IGSRT use in the dermatologic clinic for early stage NMSCs has become common practice and continues to expand. While the safety and cosmetic benefits of SRT/XRT have been long documented, IGSRT represents a significant leap forward in efficacy (statistically significant) by adding in vivo dermal tumor imaging. Results rival and appear on one study to surpass tumor control obtained with MMS. A contributing factor to the success may be the availability and use of an interdisciplinary team approach that includes dermatologists, radiation therapists, radiation oncologists, and medical physicists. The high tumor control rates, minimal side effects, favorable cosmesis, and ability to treat multiple lesions per session using IGSRT are establishing this modality as a standard first-line therapy for early stage NMSCs in dermatology clinics. IGSRT may represent the most effective option for the non-surgical treatment of early stage NMSC to date.

Dermatofibrosarcoma Protuberans With Sarcomatous Transformation Treated With Mohs Surgery Leads to Limb-Sparing Durable Remission.

Dermatofibrosarcoma Protuberans With Sarcomatous Transformation Treated With Mohs Surgery Leads to Limb-Sparing Durable Remission.

Exploring opposing arguments in the call for randomized controlled trials to demonstrate benefit of Mohs micrographic surgery for cutaneous melanoma

Exploring opposing arguments in the call for randomized controlled trials to demonstrate benefit of Mohs micrographic surgery for cutaneous melanoma

Approaches to Cheek Reconstruction following Mohs Surgery

AbstractThe native features of the cheek allow for a variety of approaches when considering reconstruction following Mohs surgery. Selecting the best approach requires consideration of deficit size and location, skin laxity, surrounding anatomy, aesthetic outcomes, and specific patient factors. Reconstruction options vary based on the zone of the cheek affected, but direct closure remains the gold standard. When direct closure is not suitable, the use of the cervicofacial advancement flap, biologic agents, or a combination of the two should adequately address the majority of cheek deficits resulting from Mohs surgery. During cheek reconstruction, great care should be taken to maintain and support the surrounding anatomy, most notably the lower eyelid. Postoperative management is mostly comprised of scar management, as immediate, urgent complications are rare. Options to address postoperative scarring range from silicone sheeting to revisional surgery, but most deficits will settle well if given adequate time and are properly cared for with noninvasive measures.

Ear Reconstruction following Mohs Micrographic Surgery

AbstractRelative to other regions of the body, the ear has a high risk of developing cutaneous malignancies that often necessitate Mohs micrographic surgery (MMS) for removal. This procedure can create defects that are immediately noticeable if left untreated. Reconstructive techniques are often needed to restore the appearance of the affected ear and its symmetrical relationship to the contralateral ear. However, achieving optimal aesthetic results can be challenging due to the subtle intricacies of the external ear. Therefore, careful planning and execution should be implemented prior to managing the acquired defect. Additionally, depending on the size and location of the defect, various options aligning with the reconstructive ladder can provide desired outcomes. The purpose of this article was to highlight and discuss the different techniques used in ear reconstruction following MMS.

Challenges and Strategies in Post-Mohs Reconstructive Surgery

AbstractFacial reconstruction following Mohs excision presents many challenges. The unpredictable nature of Mohs surgery can yield surprising deficits that require far more extensive reconstructions than originally anticipated. It is up to the reconstructive surgeon to guide the patient through the shock of the excision, initial reconstruction, definitive reconstruction, and postoperative management. It is essential to approach a post-Mohs patient with the understanding that a rushed, same-day reconstruction carries a greater risk for the patient and the outcome than that of a delayed, planned reconstruction. Considering factors beyond the deficits, such as the patient's means, health literacy, and comorbidities, is essential to ensuring a methodical reconstruction with favorable results. Often, deficits will need to be temporized until the patient is optimized and the details of the reconstruction have been established. The specifics of the reconstruction are heavily influenced by the patient's desires, understanding, and ability to participate multistage operations. Once the best suited reconstruction is selected, reviewing expectations and the possible associated contingencies is crucial for patient satisfaction. Despite the surgeon's great effort in ensuring a satisfactory reconstruction, many patients will further benefit from close follow-up and postoperative scar management. The combination of patient optimization, meticulous surgical planning, and postoperative wound management enables the surgeon to obtain favorable outcomes, even in the most unpredictable reconstructions.

Mohs Micrographic Surgery: A Brief Overview

AbstractMohs micrographic surgery (MMS) is a tissue-sparing skin cancer resection technique that involves 100% margin analysis. This procedure is performed in the outpatient setting under local anesthesia by dermatologic surgeons who act as both the surgeon and the pathologist. The technique allows for prompt reconstruction immediately after cancer clearance and offers the highest cure rate for many skin malignancies, including basal and squamous cell carcinoma, as well as more rare tumors. Mohs surgery effectively ensures cancer clearance while minimizing defect size and optimizing cosmetic and functional outcomes for patients. Herein we will discuss the evolution, procedure, and indications of MMS.

Achieving Adherence With NCCN Guidelines for Nonmelanoma Skin Cancer Regarding Peripheral and Deep En Face Margin Assessment (PDEMA).

Peripheral and deep en face margin assessment (PDEMA), formerly termed by NCCN as complete circumferential peripheral and deep margin assessment (CCPDMA), has the advantages of histologic visualization of the entire marginal surface, highly accurate resection of involved tissue, and sparing of uninvolved tissue. Owing to its highest reported cure rates, PDEMA is the NCCN-preferred treatment for dermatofibrosarcoma protuberans, high-risk basal cell carcinoma, and very-high-risk cutaneous squamous cell carcinoma. In the United States, Mohs micrographic surgery (Mohs) is the most common method of PDEMA. In Germany and some other countries, non-Mohs methods of PDEMA referred to as the Tubingen torte and muffin techniques are more widely used. The Tubingen methods of PDEMA require close communication between surgeon and pathologist. This article describes the background of both Mohs and Tubingen PDEMA, reviews what constitutes PDEMA, and provides a protocol for Tubingen PDEMA detailing critical components in a stepwise fashion using illustrative photos and diagrams. We hope to broaden understanding of the NCCN Guidelines and their rationale, align practice, and optimize patient outcomes.

Perspectives on oral benzodiazepine use for anxiety in Mohs micrographic surgery: A response to the Australian survey.

This letter responds to the recent Australian survey by Harris and Lee (Australas J Dermatol, 2024, doi: 10.1111/ajd.14361) on the use of oral benzodiazepines for anxiety management in Mohs micrographic surgery (MMS). While commending the authors' efforts, we provide additional perspectives on current practices, recent evidence and safety considerations. We highlight the alignment with U.S. practices, discuss a recent randomized controlled trial supporting diazepam's efficacy and emphasize the importance of non-pharmacological interventions. The letter also addresses the need for flumazenil availability and calls for standardized guidelines and further research to optimize patient care in MMS.

Congenital Dermatofibrosarcoma Presenting as an Atrophic Plaque

Dermatofibrosarcoma protuberans (DFSP) is a rare sarcoma that most commonly occurs on the trunk of adult patients. However, DFSP can present congenitally, and this rarity may lead to misdiagnosis or late diagnosis. The authors present a case of a congenital DFSP that was not diagnosed until the patient was 17 years old. Her tumour was successfully treated with Mohs micrographic surgery. It is important to have DFSP on the differential for atrophic plaques or violaceous to red-brown nodules, even at a young age.

Repair of a Multi-subunit Defect on the Nose and Apical Triangle Following Mohs Micrographic Surgery.

Repair of a Multi-subunit Defect on the Nose and Apical Triangle Following Mohs Micrographic Surgery.

Cutaneous melanoma in situ: a review.

Cutaneous melanoma in situ (MIS), also known as 'stage 0 melanoma', is a collection of malignant melanocytes in the epidermis and epithelial adnexa, without evidence of microinvasion to the papillary dermis. Distinct histologic subtypes include lentigo maligna (LM), superficial spreading (SS) MIS and acral lentiginous (AL) MIS. LM is the most common subtype, usually diagnosed later in life (median age at diagnosis of 66-72 years) and associated with cumulative ultraviolet radiation exposure. SS MIS is associated with intense episodes of sun exposure and is more common on the trunk and extremities. AL MIS is seen in non-hair-bearing skin. Although rare (0.6% of MIS in England), AL MIS is found in higher proportion in more pigmented skin types compared to other MIS subtypes. Most international studies between 1990-2019 report rising incidence for MIS. US data support a deceleration in the rising incidence of LM between 2016-2019. For 2013-2019 in England, the recorded incidence of LM is plateauing, while that of other MIS is rising. Definitive diagnosis of MIS is by histological examination of biopsied skin with immunohistochemistry but can be supported with dermoscopy and reflectance confocal microscopy. Surgical treatment (excision or Mohs micrographic surgery) is the gold standard. Depending on MIS subtype, other options such as cryotherapy, topical imiquimod, radiotherapy, or watchful waiting may be appropriate. The latest 5-year net survival rates in England between 2013-2015 are 98.6% for AL MIS and exceed 100% for all other MIS. This review summarises the aetiology, pathogenesis, epidemiology, diagnosis and management of MIS.

Management of Frontal Bone Exposure Following Paramedian Forehead Flap for Nasal Reconstruction.

The paramedian forehead flap is renowned for its versatility and can cover a wide range of nasal defect sizes. Most of the literature discussing outcomes of paramedian forehead flap reconstructions focuses on morbidity at the recipient site. Frontal bone exposure resulting from the use of the paramedian forehead flap is a rare but possible complication, especially when periosteum overlying the bone is damaged during surgery or during healing by secondary intention due to desiccation. In this case, a 53-year-old female underwent nasal reconstruction with a paramedian forehead flap for an extensive nasal defect after Mohs surgery and resection of residual basal cell carcinoma. She missed her postoperative follow-up visit, and her frontal bone was noted to be exposed before the division of the pedicle procedure. During the division of the pedicle, the frontal bone was burred, and a bilayer dermal regeneration matrix was applied. She underwent a split-thickness skin grafting from her thigh at 4 weeks. The graft take was 100%, and wound closure was achieved with an acceptable cosmetic outcome. The successful resolution of the complication through innovative surgical interventions highlights the importance of adaptive surgical strategies and thorough postoperative care, aiming to contribute to the existing body of knowledge and improve future clinical practices in reconstructive surgery.

Immunohistochemistry-Assisted Mohs Surgery for Invasive Eyelid and Periorbital Cutaneous Melanoma.

Prior studies describe wide local excision and "slow Mohs" outcomes for periocular melanoma. Mohs micrographic surgery (MMS) with immunohistochemistry maximizes tissue preservation and offers same-day comprehensive margin evaluation, which facilitates expedited repair, and coordination of oculoplastic reconstruction when necessary. To describe oncologic and reconstructive outcomes of invasive periocular cutaneous melanoma treated with immunohistochemistry-assisted MMS. Invasive melanoma cases affecting the eyelids or periorbital region treated with MMS between 2008 and 2018 were reviewed. Eyelid tumors and those in adjacent subunits were compared. Main outcome measures were recurrence, melanoma-specific death, and postreconstructive complications. Of 42 cases, 28 were classified as periorbital and 14 as eyelid involving. Most were T1 (37, 88.1%). There was 1 local recurrence in a patient with persistent positive conjunctival margin (2.4%). No local recurrences were observed in cases where negative Mohs margins were achieved, and no melanoma-related deaths occurred. Eyelid tumors were more likely to result in lid margin involving defects and require oculoplastic reconstruction. Eyelid complications developed in 10 cases (23.8%), and 5 (11.9%) required revision surgery. Mohs micrographic surgery for periocular melanoma results in low rates of local recurrence and melanoma-specific death. Initial tumor location can aid in reconstructive planning.

Mohs Micrographic Surgery and Wide Local Excision in Pleomorphic Dermal Sarcoma on a National Scale.

Mohs Micrographic Surgery and Wide Local Excision in Pleomorphic Dermal Sarcoma on a National Scale.

Demographics of Mohs Surgeons Performing Mohs Micrographic Surgery for Cutaneous Melanoma: A National Survey Analysis.

Demographics of Mohs Surgeons Performing Mohs Micrographic Surgery for Cutaneous Melanoma: A National Survey Analysis.

Surgical Margins of Nonmelanoma Skin Cancers in Mohs Surgery: Dermoscopy Versus Naked Eye.

Mohs micrographic surgery (MMS) offers high cure rates for nonmelanoma skin cancer (NMSC) but relies on precise margin assessment, traditionally initiated by the naked eye. Dermoscopy has emerged as a potential tool to improve margin delineation. To compare the efficacy of dermoscopic versus naked eye evaluation in marking initial MMS margins for NMSC. A multicenter, prospective study on patients with NMSC undergoing MMS was conducted. Patients were randomized into dermoscopy and naked eye groups. Statistical analysis was performed using statistical package for social sciences. A total of 127 patients were enrolled, with 63 in the naked eye group and 64 in the dermoscopy group. No significant differences in age, sex distribution, or histological subtype were found. The average number of MMS stages and accuracy of initial margins were comparable between groups. Despite its potential, the authors' study found no significant reduction in total MMS stages using dermoscopy. Novel imaging modalities or standardized dermoscopic criteria should be explored to enhance margin assessment accuracy and improve outcomes in NMSC treatment. Dermoscopic evaluation of presurgical margins does not effectively assess lateral/deep margins nor contribute to a reduction in total MMS stages. Improving the authors' understanding of presurgical margin assessment techniques can lead to better treatment outcomes for NMSC.

Predictors of psychosocial outcomes of Mohs micrographic surgery: a review.

Mohs micrographic surgery (MMS) is a highly effective treatment for skin cancers, such as squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), especially in cosmetically sensitive areas. Despite its high cure rates, the procedure's impact on psychosocial outcomes, influenced by demographic, clinical, psychological, and social factors, necessitates careful consideration. This review aims to identify and synthesize the predictors of psychosocial outcomes following MMS, thereby informing patient management strategies. A comprehensive search of the PubMed database was performed to select peer-reviewed studies in English that discuss these psychosocial aspects in MMS. The review identifies younger age, female gender, smoking, centrally located facial lesions and larger operative defects as factors associated with less favorable psychosocial outcomes. Conversely, patients with strong social support and better preoperative mental health tend to experience more favorable outcomes. This highlights the utility of integrating psychological evaluations and support mechanisms into treatment plans, promoting a patient-centered approach that considers the broader health and psychosocial needs of patients. The implications of this review are significant, suggesting that focusing on these psychosocial determinants allows healthcare providers to improve patient satisfaction and overall well-being.

Apple Vision Pro and Its Implications in Mohs Micrographic Surgery: A Narrative Review.

Mohs micrographic surgery (MMS) is a precise and effective technique for treating skin cancers, necessitating high accuracy and real-time decision-making to ensure complete tumor removal while preserving healthy tissue. The introduction of the Apple Vision Pro (AVP), an advanced mixed-reality headset, presents a potential technological advancement in surgical practice. The present investigation explores the integration of AVP into Mohs surgery, focusing on its potential to enhance preoperative planning, intraoperative guidance, and postoperative analysis. The AVP's high-resolution displays, advanced eye-tracking technology, and real-time data overlay capabilities may assist in meticulous surgical planning and execution. In the preoperative phase, AVP enables the creation and manipulation of detailed 3D models, providing comprehensive visualizations of tumor margins and critical structures. During surgery, AVP's real-time data overlay aids in precise tumor excision and spatial orientation, reducing errors and improving outcomes. Postoperatively, the AVP facilitates detailed procedural reviews and serves as a robust educational tool for surgical trainees. Despite its promising applications, challenges such as real-time resolution limitations, potential eye strain from prolonged use, and high costs must be addressed for widespread clinical adoption. This review highlights the transformative potential of AVP in Mohs surgery and underscores the need for further research to optimize integration and maximize benefits in dermatological procedures.