Effectiveness of the “Mohs and Close Technique” in Increasing the Efficiency of a Mohs Micrographic Surgery

December 2016 | Volume 15 | Issue 12 | Original Article | 1481 | Copyright © 2016

Dhwani Mehta MD,a Rebecca Jacobson MD,a Tonja Godsey,b Brian Adams MD MPH,a and Hugh Gloster Jr. MD a

a University of Cincinnati, Cincinnati, OH b UC Health, Cincinnati, OH

Abstract

INTRODUCTION: Mohs micrographic surgery (MMS) is successful and cost effective, but may be time consuming as patients are required to wait for final wound repair until margins are clear. We propose for selected cases the “Mohs and Close technique" (MCT), in which the defect is immediately repaired after tumor resection rather than waiting until margins are clear. METHODS: MCT was only performed on tumors that had clearly de ned borders, low risk histology, whose resulting defect after exci- sion required either a primary or partial closure, and whose repair wouldn’t change to a different repair option if further stages of exci- sion were necessary. Tumor data was recorded for all cases. Time elapsed from tumor resection to completion of wound closure was recorded with and without performing MCT for comparable wounds. RESULTS: MCT was performed for 456 of 898 cases. Time required without MCT was significantly longer than with MCT when only one stage was performed (P<0.001). There was no statistical difference (P=0.3358) between the two separate techniques for cases which required 2 or more stages. CONCLUSION: MCT significantly reduces the time needed for selected Mohs cases that require only one stage of excision and therefore can increase the efficiency of MMS. J Drugs Dermatol. 2016;15(12):1481-1483.

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INTRODUCTION

Mohs micrographic surgery (MMS) is a safe and cost effective procedure that provides high cure rates1 with minimal loss of normal skin. Despite its effectiveness, MMS frequently is time consuming since patients are required to wait for final wound repair until margins are determined to be free of tumor.  Most tumors treated by MMS are straightforward and do not require multiple stages to clear the tumor or complex repairs. Most MMS cases usually require only 1 stage to obtain clear margins.2,3 Ravitisiky et al found that 1.6 stages on average were required during MMS, with 72.6% of cases requiring only 1 stage.2 In another study, the average number of stages was 1.38.3 Furthermore, up to 74% of MMS cases are closed primar- ily and do not require complex repairs such as aps or grafts.3,4 Finally, the majority of the skin cancers presenting for MMS are considered to be low risk histology such as nodular basal cell carcinoma, well differentiated squamous cell carcinoma, and squamous cell carcinoma in situ.5 Given that most MMS cases require 1 stage, most defects are closed primarily, and most tumors have low risk histology, we propose the "Mohs and Close" technique (MCT) for selected cases to increase the efficiency of MMS. In this technique, the defect is immediately repaired after tumor resection rather than waiting until margins are clear.The objective of this study is to describe this technique and demonstrate that it can increase the efficiency of MMS when used for selected cases.

METHODS

Data was collected from June 29, 2012 to November 21, 2012. Cases that ful lled the following criteria were included in the study: tumors with clearly de ned borders and low risk histology, whose resulting defect after excision could be repaired either primarily or with a partial closure, and whose repair (either primary or partial closure) would not change to a different repair option (eg, a ap) if further stages of tumor extirpation resulting in a larger defect had been necessary. One Mohs surgeon performed all procedures. After determin- ing that the tumor met the above criteria, an elliptical excision was designed with a 2 mm margin around the borders of the tumor and parallel to relaxed skin tension lines. If a partial closure was anticipated, the clinically apparent borders of the tumor with a 2 mm margin of normal skin were marked with a surgical pen based on the inherent shape of the tumor.The site was then anesthetized and prepped in a sterile fashion. Prior to excision, light curettage was performed on the surface of the tumor to more clearly de ne peripheral margins. In some cases it was necessary to enlarge the excision margins based on curettage. After scoring the outlined borders with a scalpel, multiple orientation nicks were placed on the specimen and the 

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