Effectiveness of the Mohs and Close Technique in Increasing the Efficiency of a Mohs Micrographic Surgery
December 2017 | Volume 16 | Issue 12 | Editorials | 1301 | Copyright © December 2017
Sailesh Konda MD,a,b Joseph Francis MD,a,c Vishal A. Patel MDd
aDepartment of Dermatology, University of Florida College of Medicine, Gainesville, FL bDepartment of Dermatology, Loma Linda University Medical Center, Loma Linda, CA cPalm Beach Dermatology, Atlantis, FL dGood Dermatology, Torrance, CA
of Mohs Surgery Improving Wisely Quality Collaborative recently compiled Medicare data from 2305 surgeons billing for Mohs surgery, which revealed a national average of 1.7 stages per case for the head, neck, genitalia, hands, and feet regions. Mehta and colleagues noted a lower average of 1.2 in their study, which falls below the low outlier cutoff (1.28 stages/case), suggesting potential selection and “large margin” biases.1,9 While their data included all sites, only 13.6% (62/456) of tumors were on the trunk and extremities. To minimize these biases, the authors could have randomized patients to receive either MCT or MMS, used a third party to mark tumors with 2 mm margins, and blinded two Mohs surgeons with one taking layers and another doing repairs. Even if these potential biases were addressed, if a subset of low risk tumors were found to have a high percentage of clearance after one stage, should the argument be for excision instead of MCT or MMS? This would truly increase efficiency as the patient could go home immediately after excision and, more importantly, decrease utilization of costly healthcare resources. However, even with low risk tumors, 18.9% of cases required additional stages, which ultimately prolongs the time this subset of patients is waiting as a specimen could have been processing during the time is takes to remove sutures and reorient margins for an already repaired wound.Efficiency is a zero-sum game. Those of us practicing standard MMS often complete other tasks while waiting for slides (eg, taking care of other patients, medical record documentation, teaching residents, etc.). With the MCT technique, these tasks would have to be completed at the end of the day, effectively losing any efficiency gained. The argument of saving time for the patient is flawed as well. The net time saved is not nearly the large amount of time implied by the study but rather a mere 13.66 minutes, a relatively insignificant amount of time for a surgical procedure. Ultimately, “saving” time should not be a primary goal at the expense of potentially compromising high quality and cost-effective patient care.
The authors have no conflict of interest to declare.
- Mehta D, Jacobsen R, Godsey T, Adams B, Gloster H,Jr. Effectiveness of the “Mohs and Close Technique” in Increasing the Efficiency of a Mohs Micrographic Surgery. J Drugs Dermatol. 2016;15:1481-1483.
- Izikson L, Seyler M, Zeitouni NC. Prevalence of underdiagnosed aggressive non-melanoma skin cancers treated with Mohs micrographic surgery: analysis of 513 cases. Dermatol Surg. 2010;36:1769-1772.
- Dawn ME, Dawn AG, Miller SJ. Mohs surgery for the treatment of melanoma in situ: a review. Dermatol Surg. 2007;33:395-402.
- Zalla MJ, Lim KK, Dicaudo DJ, Gagnot MM. Mohs micrographic excision of melanoma using immunostains. Dermatol Surg. 2000;26:771-784.
- Eimpunth S, Goldenberg A, Hamman MS, et al. Squamous Cell Carcinoma In Situ Upstaged to Invasive Squamous Cell Carcinoma: A 5-Year, Single Institution Retrospective Review. Dermatol Surg. 2017;43:698-703.
- Luk PP, Vilain R, Crainic O, McCarthy SW, Thompson JF, Scolyer RA. Punch biopsy of melanoma causing tumour cell implantation: another peril of utilising partial biopsies for melanocytic tumours. Australas J Dermatol. 2015;56:227-231.
- Vedvyas C, Cummings PL, Geronemus RG, Brauer JA. Broader Practice Indications for Mohs Surgical Defect Healing by Secondary Intention: A Survey Study. Dermatol Surg. 2017;43:415-423.
- Ad Hoc Task Force, Connolly SM, Baker DR, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67:531-550.
- Krishnan A, Xu T, Hutfless S, et al. Outlier Practice Patterns in Mohs Micrographic Surgery: Defining the Problem and a Proposed Solution. JAMA Dermatol. 2017.